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Using Aquatic Therapy to Teach Transitions in the Child with Autism

Byline: Andrea Salzman, MS, PT

*Not her real name

For Lauren Anderson*, the therapy pool represents the worst day in her young son’s life.

It didn’t start out that way. Kyle was eight. It was time to learn to swim and Kyle was at least interested. The family headed out to the local therapy pool which specialized in working with the disabled and special needs population.

“It went down-hill fast,” recalls Anderson.

Kyle loved his time in the pool… in fact, he loved it so much, he could not let go of the moment. “He just kept perseverating on it,” said Anderson.

For the boy, the 15-minute aquatic assessment was a delight. It was the going-home part that started the melt-down.

“I know the instructor had worked with kids with autism before, but she kept unwittingly feeding into his cycle,” recalls Anderson. “There we were, sitting in her office, dressed, discussing his assessment, and all Kyle wanted to do was get back into the pool. He couldn’t let it go.”

The instructor left Lauren and her youngest son Grayson to give the family time to make a smooth transition, but kept checking in to see if she could be of some help. Each time she reappeared, Kyle became more and more rigid and insistent.

“He could see the pool through the large glass windows in the office. It was too much for him to understand – the water was right there and no one would let him touch it.”

There came a moment when he realized that – no matter what he said -- he wasn’t going to get what he wanted.

“That’s when Kyle made a break for the pool,” recalls Anderson. She had to give chase in order to physically restrain her little boy.

Once caught, Kyle’s world imploded. He lashed out, throwing objects, ramping up into a full-on rage. The facility called for help and the EMTs came.

So ended Day One at the therapy pool.

Tolerating Transitions

For many children like Kyle, transitions are a painful part of life with autism. Karen Reckamp, OTR/L, ATP, works with such children at Wolfson Children’s Rehabilitation in Jacksonville, Florida, and has seen the trauma a simple change in activity can inflict on her kids.

Since the Wolfson clinic leases space from the local YMCA, much that happens at the pool is out of Reckamp’s control.  She has had to develop strategies to make transitions – especially the one that happens at the end of the session – tolerable.

“I often use a dry-erase board to make a picture schedule of the day’s activities. As we complete each task, the child crosses it off.  This helps each child to understand when his or her session ends and can make transitioning out of the pool much easier.”

Yifat Cohen is a speech and language pathologist (SLP) and a Hydrotherapist for Alyn Rehabilitation Center for Children, Jerusalem, Israel. She is currently the only SLP working in the water at her facility, but she chooses to take her kids into the water for some powerful reasons.

“In my facility, hydrotherapists and physical therapists take the children into the water. Currently I am the only SLP working in the pool.” [Editor’s Note:  In Israel, you can study for a year and receive a certificate to become a Hydrotherapist].

As a SLP, she often encounters the transition roadblock in her clients and she finds the pool the perfect venue for that lesson.

“One of my patients, Maleck, did not like to go into the water from dry land. He used to cry and yell, even while having a bath at home. In order to enable his mother to have a quiet bath time with him, I decided to not give up [on the idea of the pool].”

Every pool session with Maleck would start with unceasing crying jags -- even before his little toes hit water, he was in tears. To teach Maleck to let go of his fearfulness, Yifat would take a towel, swaddle the little boy, offer him his bottle and then slowly lower him into the

92° Fahrenheit (33-34° Celsius) water. After a while he would calm down.

“It took almost two months to persuade him to come in the pool without the bottle and another month to take the towel away,” reports Yifat.

But, by the end of the year, Maleck was enjoying the pool so much he didn't want to leave and, of course, bath time at home became much easier.

Maleck had learned an important skill: the ability to tolerate change.   

Laurie Jake is a Certified Therapeutic Recreation Specialist (CTRS) and has been working as a recreational therapist for over 20 years. She has received numerous professional awards, including the Arizona Recreational Therapist of the Year.

Jake believes that one of the reasons children with autism have difficulty with change is that they are unable to distinguish relevant from irrelevant information, resulting in huge difficulties with decision-making. Such kids often cannot “make up their minds” or make a simple A-versus-B choice.

“Children with autism have a need for sameness,” reports Jake. “These children have a strong need for rituals and routine and free time is very difficult for them to manage.”

Additionally, children with autism have organizational and sequencing problems.

“These children don’t know where to start, what comes next, or when a task is finished,” states Jake. The child’s life can become one long series of tragic interruptions. She concurs with Reckamp’s use of pictures to provide a schedule for the autistic client.

“Using picture cards will often work better than verbal directions,” she suggests. In an aquatic environment these cards will need to be laminated or otherwise waterproofed. By making use of a digital camera and printer – or by hand-drawing simple renderings of activities -- any therapist can easily create a meaningful schedule for the child.

It seems a small thing, but according to Jake, “a simple strip of Velcro on a laminated card” can greatly enhance a child’s ability to be successful. And often, it’s the simple ideas that work the best with this population.


Water activities can provide autistic children with the opportunity to embrace change. It helps that pool-time seems less like “therapy” and more like fun for the children. For additional, practical ways to integrate transitions into your pool work, check-out the “How to Integrate Transition” sidebar.


How to Integrate Transition into Your Aquatic Treatment

Facing transitional traumas with your pediatric patients? Try some of these well-tested methods for working transitions into your treatment plan.

Your 2-year old patient is afraid of getting his hair wet and treats every bath-time as his own private hell.  Start your pool session in the locker room. Issue your child a colorful umbrella and then use the hand-held shower to play games such as “rain, rain, go away”.  Eventually, he may get so wrapped up in the fun of dashing through the rainstorm that he forgets to use the umbrella. Transition this technique poolside by investing in watering cans and super-soaker water-guns to make it “rain” by the pool.


Your 18-month old patient will sit beside her mother on the pool deck, but she will not leave mom, and she will not come anywhere near the pool.

Place a clean, plastic dishwashing tub full of thermoneutral (approximately 93° F) water next to mom. Put a duck or other colorful floatable into the water. Let the toddler play with her new toy next to mom. A natural moment will come when the child will lean over the tub to get at the toy. Have mom “help” her step into the basin and then to sit in the water to play. Without making it obvious, slide the entire basin over to poolside -- and right over the edge! Now, your toddler is sitting in her own miniature pool inside a much bigger pool. And it happened with minimum transitional stress.

Your 5-year old patient won’t slide into the water from the pool’s edge and screams when you try to pull him in.

Place a bucket (full of pool water) and an over-sized sponge next to him on the pool deck. Stand in the water immediately “beneath” him and tell him you forgot to take a shower that morning and you are probably a little stinky. Plug your nose, wave under your armpits, ham it up!

Take the sponge and dip it into the water. Give yourself a “shower” by ringing it out over your shoulder (or, if you are feeling especially committed to the process, your head!). After modeling this a few times, see if the little boy won’t take over shower duties. Let him scrub your arms, your back, and your face with the sponge. During this process, it will be almost impossible for him to not splash himself. Now it’s your turn to give him a shower. Once you are both sufficiently “clean” and already wet, the transition into the pool will be opaque.

Your pre-teen patient will not stop romping in the water and she ends up plowing across three lanes of lap swimmers. She refuses to get out of the pool even though the swim team needs to get in.

Teach her to play the ‘First, Then’ game. Observe what activities she likes to do most in the water (floating, bobbing, swimming while holding her breath underwater, whatever). Tell her “First you need to ____” (inserting the task you want her to practice) “and then you can ___” (inserting the activity she enjoys most). Using rewards is very effective when dealing with children and the “First, Then” game will help her understand concepts of time and task completion.

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