Abstract
This study examined water competency, including swim safety skills, among children on the autism spectrum.
Autism is a neurodevelopmental condition that is associated with social, communication, behavioral, and sensory differences and has an estimated prevalence rate of 1 in 36 children (Centers for Disease Control and Prevention, 2023). Evidence suggests that differences in sensory processing among children on the autism spectrum affect their ability to engage meaningfully in occupations such as play, school, and self-care (Ismael et al., 2018; Koenig & Rudney, 2010). In particular, caregivers report that common childhood experiences, such as swim lessons, are more challenging for their child on the autism spectrum (Caputo et al., 2018; Pan, 2010). Difficulty participating in swim lessons raises significant safety concerns, because children on the autism spectrum are at a high risk of drowning. In 2017, drowning was the third leading cause of unintentional injury death in children on the autism spectrum (Guan & Li, 2017). Moreover, in 2019, drowning was the third leading cause of unintentional injury death worldwide (World Health Organization, 2023a). Swim lessons provide an important layer of protection. Participation in formal lessons has been associated with an 88% reduction in the risk of drowning among children ages 1 to 4 yr (Brenner et al., 2009), and children who participate in swim lessons develop the water safety skills necessary to survive a fall into water (Asher et al., 1995; Weiss & Committee on Injury, Violence, and Poison Prevention, 2010). Each dollar that is invested into drowning prevention can yield returns of up to nine times, promoting public health and well-being (World Health Organization, 2023b).
Swimming and participating in swim lessons that facilitate vital swim safety skills are desired and meaningful occupations for children on the autism spectrum and their families (Carter & Koch, 2023; Mische Lawson et al., 2019; Woodson & Kemp, 2021) and have been ranked among the most enjoyed activities for children on the autism spectrum (Eversole et al., 2016). However, caregivers report that their children on the autism spectrum do not learn to swim successfully in typical swim lessons; therefore, they limit the children’s exposure to water activities to avoid the potential of drowning (Mische Lawson et al., 2019). Swim lessons for children on the autism spectrum require more one-on-one attention to ensure safety and to implement specialized coaching techniques to promote skill acquisition (Caputo et al., 2018). Given families’ desire to participate in water-based activities, as well as the lack of water exposure for children on the autism spectrum, there is a need to understand water competency skills better—including swim skills and water safety behaviors—as well as caregiver goals and child characteristics, to develop effective and tailored swim instruction for this population. Although there is no established definition, water competency is generally accepted to include swim skills of entering the water safely, getting a breath, staying afloat, changing positions, swimming a distance, and then getting out of the water (Quan et al., 2015).
Several factors have been shown to affect water competency. Children on the autism spectrum who score higher on the Sensory Profile–2 in sensory seeking acquire more swim skills than those with other sensory processing profiles (Mische Lawson et al., 2017). Researchers have also designed and demonstrated the feasibility of Sensory Enhanced Aquatics, a specialized swim program for children on the autism spectrum that individualizes swim lessons on the basis of the children’s sensory preferences (Mische Lawson & Little, 2017). Thus, determining the relationship between specific sensory characteristics and water competency is important when designing swim safety instruction.
Another factor that affects water competency is prior aquatic exposure. Typically developing children who reported negative prior aquatic experiences showed reduced swim skills during a learn-to-swim program compared with those who did not have a negative prior experience (Peden & Franklin, 2020). Similarly, prior pool experience among children on the autism spectrum is associated with better water orientation behaviors (Killian et al., 1984).
Numerous studies have identified that skilled water intervention provided by health care professionals (e.g., occupational therapists, psychologists, recreational therapists, physical therapists) is effective for teaching swim skills such as breath control, floating, and locomotion to children on the autism spectrum (Alaniz et al., 2017; Caputo et al., 2018; Ennis, 2011; Mische Lawson & Little, 2017); however, each used a different method of instruction and small sample sizes. Research describing water competency in children on the autism spectrum, factors that affect water competency, and caregiver goals for water safety is limited and may lead to interventions tailored to each child’s specific profile. The purpose of this article is to describe baseline water competency, including swim skills and water safety behaviors; identify the goals of caregivers for children on the autism spectrum; and examine the association between the child’s sensory profile, prior exposure to aquatics, and water competency.
Method
Design
This study is a cross-sectional analysis of baseline assessment data from a larger randomized controlled trial examining the efficacy of a therapeutic swim intervention (AquOTic) for children on the autism spectrum (ClinicalTrials.gov ID NCT05524753).
Participants
Children were eligible for inclusion if they were between 5 and 9 yr old and had a confirmed medical diagnosis of autism from a medical or psychological professional. Children with compromised airways or uncontrolled seizures were excluded from the study. Children and families were recruited from the local community using flyers and by word of mouth. The study was approved by The Ohio State University’s institutional review board, and informed consent was obtained from all caregivers. Participating families received a $25 incentive for participating in each assessment, and the therapeutic swim intervention was provided at no charge.
Measures
Demographic information collected during the baseline visit from families included gender, age, and ethnicity. The Water Orientation Test–Alyn 1 and 2 (WOTA 1 and WOTA 2, respectively), the Sensory Profile–2 (SP–2), the Canadian Occupational Performance Measure (COPM), and prior aquatic exposure were used to assess water competency, sensory characteristics, and caregiver goals.
WOTA
We assessed water competency using both the WOTA 1 and WOTA 2 (Tirosh et al., 2008). The WOTA is based on the Halliwick concept of swim instruction for people with disabilities and is a valid and reliable measure for assessing mental adjustment and function in the water for this population (Tirosh et al., 2008). The WOTA 1 has 13 items that are scored on a 4-point scale ranging from 1 (unable to perform/lower quality) to 4 (higher skill quality), with a highest possible score of 52 (Tirosh et al., 2008). The WOTA 2 consists of 27 items that are scored on a 4-point scale ranging from 0 (unable to perform/lower quality) to 3 (higher skill quality), with a highest possible score of 81 (Tirosh et al., 2008). The assessment scores the amount of assistance required for each swim skill assessed, with higher scores representing better swim skills. The WOTA 1 assesses general mental adjustment to the aquatic environment (Items 1 and 5–7), breathing control (Items 4 and 8), and functional goals (Items 2, 3, and 9–13). The WOTA 2 assesses mental adjustment (Section A, Item 1), breathing control (Section B, Items 2–6), and functional goals (Sections C and D, Items 7–27). Mental adjustment includes skills such as entering the pool willingly, side floating with the instructor’s help, and splashing water. Breathing control includes skills such as blowing bubbles in the water and submerging the head or face in the water. Functional goals include swim skills assessing balance control, such as walking across the pool; static back float for 5 s; and submerging, touching the pool floor with both hands. For this study, we used both the WOTA 1 and WOTA 2 to provide a comprehensive and nuanced assessment of water competency. The WOTA 1 focuses on evaluating basic swim skills, whereas the WOTA 2 assesses higher level swim skills and emphasizes the quality and proficiency of these skills. The WOTA 1 and WOTA 2 have been validated with populations of children with difficulties following verbal commands or multistep instructions, similar to the characteristics of children on the autism spectrum. Interrater reliability is reported as excellent for WOTA 1 (ICC = .97) and WOTA 2 (ICC = .97), with reliability for individual items as fair to good (κ > .4; Tirosh et al., 2008). The assessor was trained on the WOTA 1 and 2 by the primary investigator, an expert in swim instruction and coaching with an extensive education in aquatic therapy. The WOTA 2 was administered with instruction adaptations to improve clarity for participants; however, the skill was not changed, and instruction modifications consisted of abbreviated verbal instructions to decrease the likelihood of verbal directions impeding the demonstration of skill. For some children, the items were administered out of order to follow the child’s lead when eliciting swim skills. These alterations were designed to address the unique language and instruction preferences of children on the autism spectrum and did not assist with swim skill performance.
COPM
The COPM is a goal-oriented, individualized, and client-centered tool that is used to facilitate the identification of issues in areas of self-care, productivity, and leisure. The COPM has been adapted for use in pediatric clinical trials for caregivers of children with disabilities (Cusick et al., 2007). The COPM is widely used in occupational therapy as an outcome measure as well as a descriptive measure of client-centered goals, highlighting its flexibility and adaptability across interventions, clients, and purposes (McColl et al., 2005). For this study, the COPM was administered by means of a semistructured interview in which caregivers were asked to identify up to five functional goals related to swim performance and water safety. Caregivers rated how well their child performed each goal (COPM – Performance) and how satisfied they were with their child’s performance (COPM – Satisfaction). Internal consistency reliability of the adapted COPM is high (.86–.88), with high content and construct validity (Cusick et al., 2007).
SP–2
Caregivers completed the SP–2, a standardized caregiver-report questionnaire that is used to examine a child’s sensory processing patterns in the context of home-, school-, and community-based activities (Dunn, 2014). The SP–2 examines six sensory sections (auditory, visual, touch, taste and smell, movement, body position, and oral) and three behavioral sections (conduct, social–emotional, and attentional). The frequency of the child’s responses to various sensory experiences is scored using a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). The SP–2 scores are categorized into four quadrants that are based on Dunn’s (1997) model of sensory processing: registration/bystander (which refers to passive behavioral responses with a high neurological threshold), seeking/seeker (which refers to active behavioral responses with a high neurological threshold), sensitivity/sensory (which refers to passive behavioral responses with a low neurological threshold), and avoiding/avoider (which refers to active behavioral responses with a low neurological threshold).
Prior Aquatic Exposure
The caregivers of all participants completed a survey describing their child’s lifetime aquatic and water experiences, including group and private lessons and family-based water activities. Family-based water activities were limited to the prior 12 mo of exposure and converted to total exposures. For example, if a caregiver reported that they went as a family to their neighborhood pool once a week in the summer (approximately 12 wk) and took a vacation to the beach for 3 days, this was recorded as a total of 15 exposures. The total number of lessons for group lessons, private lessons, and family-based water activities were used for analysis.
Procedures and Data Collection
All participants completed the same baseline assessment after randomization at a warm-water therapy pool in the Franklin County board of developmental disabilities school. Each assessment lasted approximately 1 hr and was completed with the assessor and caregiver present. Assessments began on land (approximately 15 min) and consisted of a brief caregiver interview to gather demographics and prior aquatic exposure information while the child engaged in simple land-based play with another research team member to obtain clinical observations regarding language use, ability to follow one-step directions, and motor skill observations. Children then completed the WOTA 1 and WOTA 2, with two assessors who were blinded to group assignment: one to administer and one to score the WOTAs. The primary investigator trained four assessors on the WOTAs. Assessors were occupational or physical therapy doctoral-level students in the second or third year of their program. Assessors then practiced administration of the WOTA 1 and WOTA 2 with one neurotypical child and two neurodiverse children. The primary investigator observed these assessments, reviewed scores, and provided feedback as needed. All assessors met the agreement threshold of 80% or better. All data were entered into the REDCap data management system for scoring.
Statistical Analysis
Descriptive statistics of the sample included the frequency (and percentage) for categorical measures and the median (and interquartile range; IQR) for continuous measures, because some data were nonnormally distributed. We examined relationships between the SP–2 and prior aquatic exposure with WOTA scores, using Spearman’s correlation (ρ), and a scatterplot of one of the significant correlations was provided. Hypothesis testing was conducted using α = .05, and, given the pilot nature of this study, there was no correction for familywise error rate results. As such, we also generated effect sizes for associations that are not driven by statistical power and, therefore, do not require adjustment for the number of estimations conducted. Data were complete for all participants, and analyses were performed using SAS (Version 9.4).
Results
Participant Demographics
A total of 37 children on the autism spectrum were included in this study (Table 1). The median baseline age was 6 yr (M = 6.6, SD = 1.4, IQR = 6–7), and the majority of participants were male (n = 28; 75.7%) and identified as non-Hispanic/Latino (n = 34; 91.9%). Approximately half of the participants identified as White (n = 17; 45.9%), and the other half comprised youths who identified as more than one race (n = 10; 27.0%), Black (n = 6; 16.2%), or Asian (n = 4; 10.8%). The median number of group lessons before evaluation was 1 (IQR = 0–11). The median number of private lessons was 0 (IQR = 0–2), and the median number of family exposures to swimming was 10 (IQR = 6–24). At the baseline evaluation, the median WOTA 1 score was 37 (IQR = 28–44), and the median WOTA 2 score was 24 (IQR = 17–35).
Sample Demographics and Scores on the WOTA 1, WOTA 2, and Sensory Profile–2 and Prior Aquatic Exposure
Note. N = 37. IQR = interquartile range; max = maximum; Mdn = median; min = minimum; WOTA = Water Orientation Test–Alyn.
Water Competency
Highest median scores on the WOTA 1 included entering (Mdn = 4, IQR = 3–4) or exiting (Mdn = 4, IQR = 2–4) the pool from its edge, splashing water (Mdn = 4, IQR = 3–4), short or long arm hold (Mdn = 4, IQR = 2–4), and standing or walking in water (Mdn = 4, IQR = 4–4; Table 2). Lowest median scores on the WOTA 1 included submerging (Mdn = 1, IQR = 1–3), blowing bubbles in the water (Mdn = 2, IQR = 1–3), and holding a rope (Mdn = 2, IQR = 1–3).
Breakdown of WOTA 1 and 2 Scores
Note. N = 37. IQR = interquartile range; WOTA = Water Orientation Test–Alyn.
Highest median scores on the WOTA 2 included entering (Mdn = 3, IQR = 2–3) or exiting (Mdn = 3, IQR = 1–3) the water and walking (Mdn = 3, IQR = 3–3) or jumping (Mdn = 3, IQR = 2–3) across the pool (Table 2). The median score was 0 on 59% of the items on the WOTA 2, and at least 80% of participants scored 0 on the following items: rhythmic exhale while moving (83.8%), exhale alternate from mouth or nose (89.2%), prone glide from wall or standing (83.8%), prone float to stand (83.8%), simple progression on the back (100.0%), freestyle (94.6%), backstroke (100.0%), and breaststroke (100.0%).
Caregiver Goals for the Water Competency Intervention
Using the COPM, caregivers identified goals that focused on 12 different categories: safety around water (n = 13), safety in the water (n = 13), locomotion (n = 13), floating (n = 9), water adjustment (n = 9), interaction with the instructor (n = 3), breath control (n = 3), submerging (n = 3), increased strength (n = 2), swimming form (n = 2), treading water (n = 1), and interaction with peers (n = 1). Therefore, the most common goals that caregivers wanted to address were safety around the water, safety in the water, and locomotion.
Relationship Between Sensory Processing and Water Competency
Higher scores on conduct processing were significantly correlated with lower scores on the WOTA 1 (ρ = −.49, p = .002) and WOTA 2 (ρ = −.39, p = .017; Table 3). The degree to which the child missed sensory input (i.e., registration/bystander) was significantly correlated with lower scores on the WOTA 1 (ρ = −.33, p = .047) and WOTA 2 (ρ = −.33, p = .045).
Spearman Correlations (ρs) and p Values Between Sensory–Behavioral Profiles, Prior Aquatic Exposure, and Total WOTA 1 and 2 Scores
Note. Bolded p values were significantly correlated at the .05 level. WOTA = Water Orientation Test–Alyn.
Relationship Between Prior Aquatic Exposure and Water Competency
More exposure to group or private lessons or to family-based water activities was correlated with higher WOTA 1 and WOTA 2 scores (Table 3). Exposure to group lessons was the only exposure significantly correlated with WOTA 1 score (ρ = .41, p = .011) and WOTA 2 score (ρ = .39, p = .017).
Discussion
This study had three aims: first, to identify baseline water competency among children on the autism spectrum; second, to examine caregiver goals for swim skill intervention; and, third, to examine factors associated with water competency, including sensory processing and prior aquatic exposure. Our results suggest that children on the autism spectrum tend to have limited water competency as measured by the WOTA. Caregiver goals were primarily targeted at water safety both in and around the pool, breath control, and locomotion. Sensory processing—specifically, higher scores on conduct processing (ρ = −.49) and low registration (ρ = −.33)—significantly correlated with lower swim skills on the WOTA. Prior aquatic exposure—specifically group lessons (ρ = .41)—significantly correlated with better swim skills. These results provide an introductory examination of water competency, caregiver goals, and factors associated with water competency among children on the autism spectrum.
At baseline, most children lacked basic water competency, including adjustment to water, breath control, the ability to float, propulsion through the water, and safety awareness. The following skills are components of broader skills needed for water competency per the American Red Cross (2023): Enter water over your head and resurface. Float or tread water for 1 minute. Turn over and turn around in water. Swim at least 25 yards. Exit the water.
Consistent with previous studies that examined the engagement of children on the autism spectrum in swim instruction or family swim exposure (Mische Lawson et al., 2019), the majority of caregivers in our sample reported that their child had never received any formal swim instruction because of a lack of access to inclusive programs and because of their child’s specific motor and sensory needs. The lack of water competency, water safety, and formal swim instruction in study participants is consistent with previous research (Mische Lawson et al., 2019; Peden & Franklin, 2020) and suggests that children on the autism spectrum would benefit from swim lessons that are provided by interventionists with training in motor and sensory adaptations and that emphasize water safety and swim skill acquisition. Using both the WOTA 1 and WOTA 2 to characterize water competency allowed us to not only capture the presence of foundational skills in novice swimmers but also evaluate the quality and execution of more advanced swimming skills. Consequently, this enhanced our findings by providing a well-rounded assessment of water competency, thus highlighting areas of strength and identifying specific aspects requiring improvement.
Sensory processing challenges among children on the autism spectrum affect their ability to participate in water-based activities (Caputo et al., 2018; Mische Lawson et al., 2017). The results of this study indicate that the children’s WOTA 1 and WOTA 2 baseline scores (swim skills) are associated with their sensory processing profiles. Past aquatic interventions have been shown to help regulate children on the autism spectrum who are sensory-sensitive or avoidant (Mische Lawson et al., 2017). This study adds that scores on conduct processing (example items in this domain include “rushes through coloring, writing, or drawing,” “takes excessive risks,” and “can be stubborn and uncooperative”) and low registration (example items in this domain include “needs help to find objects that are obvious to others,” “loses balance unexpectedly when walking on an uneven surface,” and “seems oblivious within an active environment”) are correlated with lower swim skills. This suggests that understanding a child’s sensory profile may help tailor the intervention to their specific learning styles. Given that prior research has shown that low registration is strongly correlated with attention among children on the autism spectrum (Crasta et al., 2020, it is probable that attention affects water competency, and, therefore, facilitation of attention may also be a critical component of tailoring therapeutic swim lessons for children on the autism spectrum.
Similar to prior research (Killian et al., 1984), the results of this study suggest that previous water exposure (group or private lessons and family-based water activities) was associated with greater water competency on the WOTA 1 and WOTA 2. However, children on the autism spectrum have inconsistent exposure to water through swim lessons or family participation (Mische Lawson et al., 2019), and negative aquatic exposures may further affect participation and/or create fear (Peden & Franklin, 2020). Caregivers report that children demonstrate increased swim skill acquisition when positive aquatic experiences occur and the instructor demonstrates positive character traits (Mische Lawson et al., 2019). It is crucial, therefore, that families have access to therapeutic swim lessons that support positive and safe experiences with water and swim activities.
Limitations
Given the cross-sectional design of baseline data for a larger randomized controlled trial, this study only identifies water competency or water safety and sensory processing cross-sectionally; therefore, we did not assess changes that were due to therapeutic swim intervention. The sample in this study was recruited through flyers and word of mouth in a midwestern urban area, which limits the generalizability of baseline data and overall diversity. Additionally, the diagnosis of autism was based on medical or psychological reports provided by the parents, and the lack of additional autism diagnostic confirmation is a limitation. Finally, we acknowledge the relatively small sample size of 37 participants and the number of analyses conducted across all the sensory profile subscales, increasing the risk of Type I error in hypothesis testing; however, effect size estimation (i.e., correlations) is not affected.
Future Work
Given the lack of basic water competency (breath control, floating, swim strokes, etc.) among children on the autism spectrum and the high incidence of unintentional drowning in this population, future work should develop and assess a therapeutic swim intervention targeted at teaching swim safety skills. Additional investigation into child characteristics related to swim skill gains and types and amounts of water exposure will assist in understanding how to best meet this population’s unique learning styles to develop these life-saving skills.
Implications for Occupational Therapy Practice
The findings of this study have the following implications for occupational therapy practice: Occupational therapy practitioners should be aware of the high incidence of unintentional drowning in children, particularly those identified as on the autism spectrum. Practitioners may want to engage in conversations with families to discuss the importance of water competency and swim safety for each family and to investigate opportunities in their communities for positive water exposure experiences. A child’s sensory differences and prior exposure to aquatic activities may affect their water competency and must be taken into account while designing water competency interventions for children on the autism spectrum. Our results highlight the need for water safety and swim skills intervention that are tailored to meet the sensory and environmental needs of children on the autism spectrum.
Conclusion
This study further contributes to the literature describing the lack of basic swim safety skills in children on the autism spectrum. It also highlights the desire of caregivers to see their children develop swim safety both in and around bodies of water. Our preliminary evidence suggests that children’s sensory characteristics and prior aquatic exposure affect their water safety and water competency. These results are consistent with prior literature that reporting that children on the autism spectrum tend to lack water competency and water safety, especially if they have not previously been exposed to water, demonstrate low sensory registration, or high conduct processing. Despite the fact that drowning remains a leading cause of unintentional death among children on the autism spectrum, aquatic programs for this population are limited. Therapeutic swim lessons and Tier 1 swim programs in the local community, designed to meet the unique needs of children on the autism spectrum, are an important strategy to reduce drowning and increase participation in aquatic activities.
Footnotes
Acknowledgments
We acknowledge the contributions of graduate students Jenna Berg and Meredith Whisenhunt. This study was funded by an American Occupational Therapy Foundation Intervention Research Grant (2022IRGKEMP) and the National Center for Advancing Translational Sciences (Grant UL1TR001070).