Aquatic therapy and the child with autism

By: Dang Uy Koe, ASP Chair Emeritus

WATER POWER. In aquatic therapy, children are encouraged to learn basic skills, such as holding their breath and submerging through the hoop, with the encouragement of the other children and the therapist.

Have your ever done anything fun as a family with your child with autism (CWA)? Have you ever watched him or her engage in a purposeful activity he finds genuinely fulfilling? Have you ever sat back knowing your child is having fun doing something socially acceptable, rather than just sitting and watching TV?

If you are like many parents, pressured by self-imposed demands to meet age-appropriate developmental levels, chances are, you may have overlooked aquatic therapy and the numerous benefits it can bring to not only your child, but to your entire family.

Our guest writer for this week’s Angels Talk is Cristina de Leon-Hinlo. She is the program director of Therapy Works Inc., a pioneer in the appropriate practice of aquatic therapy for children and adults with special needs.

A graduate of BS Occupational Therapy from UP College of Allied Medical Professions, she also had her masters in Business Administration (Health) from the Ateneo de Manila University.

Teacher Cris is also the founding member of Therapy Center Movement Association, proponent of Thera-Free or Libreng Therapy para sa Pilipino.

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Water has long been enjoyed recreationally by people of all ages, and persons with disabilities are no exception.

For the last half century, more and more occupational, physical and even speech therapists in Europe and the United States have been using water-based activities to help children with special needs achieve therapeutic goals and gain necessary life skills. In the last 15 years, there have been more workshops and literature available abroad regarding the benefits of treating children with autism in the water.

At Therapy Works, occupational, physical and speech therapists see in the swimming pool a great number of children who have been diagnosed with autism. These CWA have a wide range of abilities and limitations:

***All have sensory processing issues that have either been successfully or unsuccessfully addressed by land-based therapies.

***Some have self-stimulating behaviors, others have self-injurious behaviors, and yet others have no awareness of the danger that going to the deep end may bring.

***Some quickly adapt to the water and find immediate joy in being immersed.

***Others are clingy due to unfamiliarity with the new environment, yet willing to try given a little coaxing from their therapist and parents.

***Still others present with extreme fear, either due to a traumatic experience (they previously got thrown in the pool and made to learn like other children) or to a severe sensory processing issue, such as gravitation insecurity.

But all find comfort in the rhythm and routine of the session, and become secured in the structure of the session.

What is aquatic therapy?

According to the Aquatic Therapy and Rehabilitation Institute in Florida, USA, Aquatic Therapy is the “use of water & specifically designed activity by qualified personnel to aid in the restoration, extension, maintenance of quality functions for persons.”

Purposeful activities in the water have many physical, psychological, sensory, cognitive and recreational benefits.

1. The health benefits of engaging in water activities include improvement in strength, endurance, coordination, and balance.

2. It develops a positive mental attitude and promotes self-esteem, preparing the child to successfully engage in interpersonal relations;

3. It calms the child’s sensory system (examples are: reducing hyperactivity, decreasing tactile sensitivity, decreasing self-stimulatory behaviors and repetitive behaviors, etc.) so that he can cope with everyday demands;

LD is a 7-year-old child who could not communicate, had feeding problems, presented with self-injurious behaviors, such as biting himself, and pinching or slapping others. Poor attention span and impulse control were a hindrance to learning basic concepts and communication skills.

Upon first engaging in aquatic therapy, he was hesitant, fearful and in fact, threw several temper tantrums. After a few sessions, his speech therapist noted a decrease in aggressive behavior towards himself and others, an improvement in his focusing abilities, and a remarkable improvement in his ability to communicate. Furthermore, he learned how to do proper strokes by watching the therapist’s demonstrations.

4. It improves the child’s work behaviors (examples are: attention span, concentration, ability to follow instructions, etc), thereby making a more receptive learner.

5. By engaging in regular recreational activities in the water, children can have a fun activity to look forward to.

6. Lifestyle diseases, such as high cholesterol, obesity and diabetes, can be avoided.

Water works!

The properties of water, such as hydrostatic pressure, turbulence, viscosity and temperature all play a role as to why a well-planned treatment in the water is effective.

The deep pressure exerted by the water on the body is present the entire time the child is in the water, thereby providing much needed calming tactile stimulation to the child who is highly sensitive to touch.

Pressure and viscosity also help children with gravitational insecurity to have a better sense of security; any potential “fall” will not hurt as it would if they fell on the pavement.

The resistance water provides makes moving three times more difficult in water than on land. This provides a lot more input to the “muscle sense” or the proprioceptive system (the unconscious perception of movement and spatial orientation arising from stimuli within the body itself). Children with problems in this sensory aspect are often clumsy, do not know their own strength, play too roughly, engage in a lot of “crashing play”, are very fidgety, and hyperactive. On the other end, proprioceptive problems may also cause the child to appear limp and lethargic, have poor posture, and have problems with balancing tasks.

Engaging in well-directed activities in the water helps the child gauge his own body boundaries better, allows him to regulate the force his body exerts when playing or working on tasks (thereby avoiding hurting himself and others), and improves his posture and coordination.

Furthermore, the amount of energy required to do activities in the water helps decrease the child’s hyperactivity, resulting in a better ability to concentrate on tasks afterwards, improve sleep patterns and eating habits.

S.D. is a 5 year old female with autism who presented with a variety of sensory issues. She was extremely averse to getting her face wet, submerging her head and assuming a horizontal position necessary in propelling herself forward. She cried out in fear and would clutch at therapist or mother when her feet would leave the pool floor. (This insecurity during movement was not only present in the pool, but on land also.) She also hummed during the entire session, and had minimal verbal output.

After a year of weekly aquatic therapy, she gained enough confidence to traverse the length of the pool without assistance or floatation devices, could submerge to get objects from the floor, and could express herself in a more audible voice. Self-care skills, particularly bathing, grooming and dressing, improved greatly as well.

She also became more confident in trying different types of movement on land, such as jumping, hopping and skipping.

Engaging in activities in the water is perceived as fun and as time of shared joy for families. The child learns to look forward to therapy and it becomes a source of conversation for the family. The physiologic response to water also helps build the child’s strength, endurance and lung capacity.

Enrolling a CWA an aquatic therapy program

The success of your child’s intervention is dependent on how well your therapist is able to evaluate your child’s needs on land and in the water, and how appropriate this treatment program is in achieving your goals. Children are either referred by their developmental pediatrician or their other therapists to engage in individual or group aquatic therapy at a reputable therapy center. Children may be referred to an occupational, physical or speech therapist depending on the target skills and goals of the parents, therapists and doctors.

Responsibilities of the therapists?

1. Correctly assess the sensory and physical needs of the child as it relates to land and water.

2. Plan activities very well; should be purposeful, must improve the ability of the child to cope with daily demands, and should improve his quality of life.

Different approaches to aquatic therapy?

They can be done in an individual or group setting depending on the needs of the child and the goals of the family. Treatment plans are designed to address various areas, such as physical, social, cognitive, communication, vocational and psychological goals.

1. Individual Sessions: Children recently referred usually engage in individual sessions until there is improvement in their attention span, concentration, impulse control, frustration tolerance, ability to follow instructions, self-confidence, survival skills and propulsion skills.

2. Group Sessions: Social skills training can be engaged-in during group aquatic therapy sessions with specific skills being targeted. During group sessions, they not only have to work with the therapist, but they have to learn to engage their group mates, share toys and equipment, and experience cooperative and competitive play.

Choosing the right swimming pool

Since children with autism have a lot of sensory issues, choosing a pool is critical in the success of your program.

1. Choose a pool that has a shallow end where he can get used to being in the water, and a deep end where his skills can be challenged as he gains confidence.

2. A pool where there are only a few people is desirable so as not to be too noisy or congested.

3. Some children are sensitive to bright environments, so either choose an indoor pool with controlled lighting, have therapy earlier or later in the day, or make them wear tinted goggles to shield them from sunlight.

From aqua therapy to sport and recreational activity

Aqua therapy is the engagement in swimming as a recreational activity - progressing from individual to group. Some parents initially enrolled their children in swimming lessons with the simple goal of seeing their children engage in an activity which is fun and socially acceptable. And then they see their children bloom under the careful supervision of our swimming coaches, and some have even taken to joining competitions. B.H. is a 6-year-old male diagnosed with autism whose primary goal for aqua therapy was to improve coordination. When the therapist saw his potential, he was immediately started on a swimming program with one of our coaches. After only eight sessions, he joined a competition and came in 5th! His parents did not think he would finish as he just started and was practicing in a much smaller pool. They were gladly proven wrong. With his self-confidence buoyed by this victory, he looks forward to his swimming sessions where he now trains in an Olympic-sized pool with other children with special needs.

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While Teacher Cris and I were exchanging emails about this Angels Talk feature, I sent her a video clip of my son. It shows Gio, swimming “langoy aso” (dog style), which he instinctively learned on his own. I kidded Teacher Cris “if I enroll Gio with your therapists, can he become a Michael Phelps?” Teacher Cris need not answer that question. Gio does not have to be a Michael Phelps to make us proud of whatever new aquatic skills he will gain. Simply being in the water makes Gio happy. That makes our family happy.