Participation in physical activity is important for children with disabilities as it can have a positive impact on development, quality of life and future health. However, children with disabilities experience 4.5 times higher rate of physical inactivity compared to children without disabilities. Children with disabilities have more personal, social, environmental and program barriers to physical activity than their typically developing peers. Parents of children with disabilities identify lack of trained staff and programs for their children as barriers to participation in physical activity. Many physical activities require physical and social skills that children with disabilities lack. This may be particularly true for children with autism.
Participation in physical activity may be challenging for individuals with autism because of limited motor functioning, low motivation, difficulty in planning, and difficulty in self-monitoring. Furthermore, children with autism are often sensitive to auditory, visual, and tactile stimuli associated with physical activities. Evidence also suggests social deficits and the difficulties they cause contribute to physical inactivity. However, well-designed and implemented recreation programs that are a good match for children's interests can help overcome these challenges to allow children with autism to experience the many benefits of engaging in physical activity. As with programming for children with other disabilities, creating access to resources through appropriate programming, staff training, and activity modification is critical for youth with autism to successfully engage in physical activity. Swimming is one type of activity that is a good match for the needs and capacity of children with autism.
Scholars, families and professionals report that children who have autism respond to sensory experiences in everyday life activities, including recreation and play, differently than their peers. The consistent water temperature, buoyancy, relative density, viscosity, and resistance of the water provide relatively constant sensory input that may support children with autism. Additionally, water provides an even deep pressure (proprioceptive) to the entire body which is comforting to many children with autism. Swimming is a physical activity that is simultaneously calming and physically demanding. Participating in swimming can increase strength and endurance and decrease self-stimulatory movements in children with autism.
The Sensory Supported Swimming program was developed to support children with autism to be successful with American Red Cross Learn-to-Swim instruction. Funded by an Autism Speaks Family and Community Grant, the intent of the Sensory Supported Swimming program is to decrease risk of drowning, increase opportunities to engage in a lifelong sport, and increase the capacity of general recreation providers to serve children with autism. By collaborating with general recreation providers, the collaborative team of recreation and occupational therapists established a sustainable, low cost recreation swim program for children with autism.
Additionally, the Sensory Supported Swimming program provides training for general recreation providers to increase their comfort in working with children with autism and their families to promote an inclusive environment. To increase the capacity of swim instructors to work with children with autism, we recruited paid instructors from university professional programs preparing students to work with children with disabilities. We also recruited graduate students and competitive swimmers to serve as volunteer instructors to provide a high instructor/student ratio for the Sensory Supported Swimming program. All swim instructors attended training about autism and how to work with children with autism and their families. An experienced swimming instructor with expertise in autism modeled best practices to new instructors by providing lessons in the water alongside new instructors. Also, an expert was on deck at all times to support instructors and families during swimming lessons and transitions (parking lot, locker room, pool deck, etc.). Because children with autism have unique needs, we had regular meetings to discuss children's progress and problem-solve how to tailor our instruction to best serve each child.
The Sensory Supported Swimming program included several strategies for increasing physical activity for children with autism in a way that is a good match for their individual needs. Because aquatic environments can be over stimulating for children with autism, we scheduled lessons at times when the pool was quieter and less crowded. Prior to lessons, we talked with parents about how their child learns best, what supports their child needed and their child's sensory preferences. The therapists working on the project administered the Sensory Profile, a parent report questionnaire of children's sensory preferences, to gain additional insights regarding their child's sensory preferences. Because visual cues and schedules are often helpful for children with autism, we provided visual supports (including pictures) of the pool environment and swimming lesson expectations to families prior to lessons. During lessons, swim instructors worked on developing swimming skills to promote physical activity, while closely observing children's sensory preferences as they learned. We had a variety of goggles, earplugs, compression suits and other equipment for children to figure out what works best for their sensory preferences. Experimenting with equipment allowed families to purchase only what they knew would work for their child. When appropriate, we also collaborated with our local parks and recreation programs and swim teams to transition swimmers with autism from a learn-to-swim program to an inclusive swim team.
We chose the American Red Cross Learn-to-Swim program to teach swimming because of its focus on water safety instruction in addition to teaching developmental swim skills. According to the National Autism Association, 92% of parents of children with autism report that their children wander which can contribute to increased death rates by drowning. The American Red Cross Learn-to-Swim program has a strong emphasis on drowning prevention and water safety.
The Sensory Supported Swimming program builds on the notion that a family-centered teaming approach can promote physical activity for children with autism. Recreation and occupational therapists share strengths and have unique contributions for working with children with autism to promote swimming as a physical activity through the Sensory Supported Swimming program. Therapeutic recreation (TR) and occupational therapy (OT) are good collaborators for promoting physical activity as both professions use purposeful activities to enhance function and focus on the whole person within the context of the child's environment. The training similarities of the two professions allow them to "speak the same language" as they work together to provide the Sensory Supported Swimming program for children with autism.
UNIQUE CONTRIBUTIONS OF THERAPEUTIC RECREATION
Because of her educational preparation and clinical experience, the recreation therapist affiliated with the Sensory Supported Swimming collaborative project communicated with the general recreation providers to facilitate the project. Her knowledge of risk management issues in physical activities allowed her to negotiate cooperative agreements and ensure risk management procedures were in place. Additionally, with input from the team, the recreation therapist developed and implemented the inclusion support training for the general recreation providers. The education sessions included information about autism and how recreation providers/facilities can create a welcoming environment for families with children with autism.
UNIQUE CONTRIBUTIONS OF THERAPEUTIC RECREATION
OTs can make a unique contribution to promoting inclusive recreation with their specialty knowledge of sensory processing and motor learning. OTs have specialty knowledge in the area of sensory processing; this expertise is an asset in the Sensory Supported Swimming program to assist staff, parents and instructors in tailoring the swim instruction in a way that best matches the child's sensory processing preferences. For example, when a child's Sensory Profile indicated a preference for visual stimuli and aversion to auditory stimuli, the team would design strategies to accommodate this preference such as using visual, social stories to explain proper water safety procedures.
Tyler is a 10-year-old boy with autism who has received physical therapy services in the past and is currently receiving school-based occupational therapy, speech therapy, special education, and behavioral support services. Tyler's mom identifies many strengths for her son, including eating a variety of foods and success in school activities. Tyler's level of energy interferes with his family's routine when he gets home from school as he climbs on the furniture and disrupts family activities from 4:00 to 6:00 at night. She is also concerned that Tyler doesn't get enough sleep compared to his two sisters. She has tried compression garments during the day to calm him with some success. Mom also notes Tyler's behavior is better in the summer when he is able to be more active.
Tyler swims with his family in the summer and occasionally during the school year. Tyler's mom says he loves swimming and is comfortable in the water, but has never had formal swimming lessons due to high cost and lack of well-trained instructors. Because of his impulsivity and high energy level, she worries about his safety around water, particularly because he wanders and might enter the water without permission. Tyler is entering the Sensory Supported Swimming program at the Red Cross Learn-to-Swim Advanced Beginner level. The OTs send Tyler's mom a Sensory Profile prior to lessons and learn that he is a "seeker" of touch and movement, meaning he craves that type of sensation and will actively try to get it by climbing, spinning and touching things around him. Tyler also avoids auditory stimuli whenever possible. Tyler's response to visual stimuli is similar to other children without autism.
Knowing that the sounds of the pool environment might be overwhelming, particularly when it is crowded, the recreation therapist uses information from the Sensory Profile to schedule Tyler's lessons early in the day when there are fewer people using the pool. The collaboration of the two disciplines helps identify and provide the environment that is the best fit for Tyler. Prior to lessons, the Sensory Supported Swimming program sends Tyler's mother a visual schedule to assist with preparing Tyler to enter the pool environment and transition to swimming lessons. The program also sends videos of swim instructors performing the skills Tyler will learn so he can begin to anticipate class expectations. Because of Tyler's success in school he will participate in small group lessons (three children with an instructor and volunteer).
During lessons, Tyler wears a compression suit (youth size wetsuit) that provides him sensory input to help him maintain his attention better. The Sensory Supported Swimming program has suits available to try on, so Tyler's family does not have an added expense without knowing if it will help. Tyler's mom also asks for help finding goggles he will like as his eyes are irritated by the chlorine. Sensory Supported Swimming has many styles available so Tyler can find a pair he likes before his family purchases them. During the eight weeks of lessons, Tyler's ability to attend to lessons improves and he is able to advance through most of the skills of his Red Cross Learn-to-Swim level. Tyler will continue swimming lessons and his mom is hopeful he will be able join their local summer swim team during summer. Tyler's mom also tells his instructors that he is calmer on the days he swims and sleeps better. Collaboratively, the RT and OTs help Tyler's mom identify community swim programs that are a good fit for Tyler's sensory needs and swimming abilities. The recreation therapist, with input from the team, also creates an inclusion guide for the swimming coach of the team Tyler decides to join to aid Tyler's transition to the inclusive community program.
The authors wish to acknowledge Autism Speaks Family Community Grants as the funding agency for the Sensory Supported Swimming Program. The views expressed in this publication do not necessarily express or reflect the views of Autism Speaks or any other funding agency.
ABOUT THE AUTHORS:
Lisa Mische-Lawson, PhD, CTRS is an assistant professor and recreation therapist. Jane Cox, MS, OTR/L and Lauren Foster, OTD, OTR/L are clinical assistant professors and occupational therapists. All are faculty in Occupational Therapy Education department at the University of Kansas Medical Center, Kansas City, KS.