an inTeRlink feature
and the role of Aquatic Therapy in Recreational Therapy
Laurie Jake CTRS, CEDS
Imagine a world
where you did not see, hear, smell, feel and taste the way
everyone else does. Imagine a world where lights and sounds
bombard your senses and frighten you. This is often the world
that children with autism live in.
Autism is a lifelong neurological and biological developmental disability that
begins at birth or during the first three years of life. Current prevalence
rates indicate an incidence of about 2 in 1000. Although the cause is still
unknown, Autism appears to be associated with some hereditary factors. The
risk of Autism is three times more likely in males and is not isolated to any
one race, culture or socioeconomic group.
The Diagnostic Statistical Manual of Mental Disorders (DSM IV, l994) places
Autistic Disorder under the broader category of Pervasive Developmental Disorders,
which includes Autistic Disorder, but also Rett's Disorder, Childhood Disintegrative
Disorder, Asperger's Disorder, and PDD not otherwise specified.
Autism has numerous treatment implications for recreational therapy because
of the significant impact on an individual’s lifestyle. The main features
of Autism include severe delays in language development, inconsistent pattern
of sensory responses, uneven patterns of intellectual functioning with peak
skills in some areas and significant deficits in others, and marked restriction
of activity and interests. Beyond the public perception of Dustin Hoffman’s
performance in the movie Rain man, most people understand very little about
this complex disorder that affects every aspect of an individual’s life.
Socially, children with Autism may lack awareness of others, have severe anxiety
around others, experience difficulties with reciprocity, and significant difficulties
with socialization. A child with Autism will usually lack any kind of a social
smile or eye contact. They lack ‘normal’ responses to people, they
may laugh and giggle inappropriately or cry and tantrum easily. The usually
have poor play skills, and spend time alone rather than with others. They show
little interest in making friends and usually lack the ability to form personal
attachments. Often children with Autism lack spontaneous or imaginative play.
They do not imitate others' actions and they don't initiate pretend games like
Autism involves many cognitive consequences including; problems with verbal
commands, problems with verbal concepts and explanations, literal and concrete
understanding, delayed processing, and problems with communicating. Children
with Autism often focus on detail and have trouble with choices. They are unable
to distinguish relevant from irrelevant information, which results in significant
difficulty making decisions. They have trouble understanding cause and effect
relationships and are usually not able to understand the concept of time.
Children with Autism have a strong need for sameness and they usually have
a very hard time with any changes or transitions. These children have a strong
need for rituals and routine and free time is very difficult for them to manage.
Children with Autism often have low muscle tone, self-injurious behavior, and
unusual sleeping patterns. Autism is associated with various kinds of neurobiological
symptoms, which may include unusual reflexes and high rates of seizure disorder.
Children with Autism have significant sensory and perceptual problems, including
inconsistent response to sounds. They are very distractible and will over or
under react to stimuli. They usually dislike certain textures. They may have
a strong sensory need to smell or lick and they have a great deal of trouble
screening sounds and processing words.
The lifestyle of children with Autism includes many challenges due to their
organizational and sequencing problems. These children don’t know where
to start, what comes next, or when a task is finished. This creates significant
difficulties with organizing their day or their activity involvements.
Recreational therapy interventions can help address many of these affected
life areas. Recreational therapy can play a primary role in enhancing the quality
of life and productivity of a child with Autism. According to the American
Therapeutic Recreation Association, Recreational therapists offer individuals
with disabilities the opportunity to resume normal life activities and to establish/re-establish
skills for successful social integration.
Among the range of interventions that a recreational therapist might choose,
one unique and very successful alternative for individuals with autism is aquatic
therapy. Water activities provide autistic children with proprioceptive and
tactile input. Children with Autism have significant sensory difficulties,
and are very distractible. These children over or under react to stimuli in
their environment and have very strong reactions to certain textures. The warm
water provides a safe and supported environment, which not only supports the
children, but also provides them with hydrostatic pressure that surrounds their
body in the water. This pressure actually soothes and calms the children, providing
the necessary sensory input they crave.
Aquatics activities are a fun and enjoyable experience that have many physical,
psycho social, cognitive, and recreational benefits. Research continues to
support the concept that water is the ideal medium in which to exercise or
rehabilitate the body. Water provides an environment, which reduces body weight
by 90%, decreasing stress or impact on the body. Warm water also reduces spasticity
and relaxes muscles.
For children with Autism aquatic therapy can focus on therapeutic play-based
functional movement, improving range of motion, helping to facilitate neurodevelopmental
growth, improved body awareness, increased balance, sensory integration, mobility
skills and most importantly, having fun. The Aquatic Therapy and Rehabilitation
Institute defines Aquatic Therapy as "The use of water and specifically
designed activity by qualified personnel to aid in the restoration, extension,
maintenance and quality of function for persons with acute, transient, or chronic
disabilities, syndromes or diseases". Clients with Autism present an interesting
opportunity for recreational therapists to use aquatic therapy interventions
as part of their overall treatment plan.
Due to their communication difficulties, children with Autism respond better
to visual cues and specific tangible rewards. Often using picture cards to
explain what you are requesting the child to do will work much better than
verbal directions. In an aquatic environment these cards will need to be laminated
or somehow waterproofed. Using a digital camera or simply using hand-drawn
pictures, the aquatic recreational therapist can place these pictures in a
sequence for the child. A simple strip of Velcro on a laminated card can greatly
enhance the child’s ability to be successful during aquatic therapy interventions.
Another way to ensure a more positive response is to use the ‘First,
Then’ concept. When asking the child to complete a task reinforce the
concept of positive consequences using the phrase “fist you need to___,
then you can___”. Using rewards is very effective when dealing with children
and this also aids in understanding the concepts of time and task completion
that children with Autism may have difficulty with.
Children with Autism present significant safety risks when in the pool. Their
lack of response to verbal commands, and their distractible nature can present
great challenges for even the most careful therapists. It is essential to maintain
intense supervision of these clients at all times, particularly in an aquatic
environment. Another factor to consider when providing aquatic therapy is the
high rate of seizure disorder that is common in children with Autism.
There are many important considerations when choosing aquatic therapy as an
option for working with children with Autism. The therapist must evaluate the
water temperature and the distractions in the aquatic environment. Because
these children are very sensitive to sensory input, the water temperature must
be warm and comfortable, or the child will not respond favorably.
Lighting is another important factor. Children with Autism are very sensitive
to light and have been known to react poorly to certain types of lighting,
especially bright florescent lights. Noise can be an additional factor as most
pool environments are noisy.
Recreational therapists who choose to add aquatic therapy as an intervention
approach for their clients with Autism can realize a great many benefits, but
proper planning is essential.
Resources for more information about Autism:
www.icdl.com (Interdisciplinary Council on Developmental Learning Disorders)
www.canfoundation.org (Cure Autism Now)
Resources for additional aquatic info:
www.atra-tr.org (ATRA's Aquatic Therapy Treatment Network)
www.atri.org (Aquatic Therapy and Rehabilitation Institute)
www.usswim.org (click programs then click adapted, for info on adapting strokes
www.aquaticnet.com (Aquatic Resources Network)