4 Skills I Love to Address in the Water
In aquatic therapy, we can address all things OT! Aquatic therapy is simply outpatient OT in a pool setting; So, all general OT skill areas can be addressed. However, the water serves as a place for us to reach new depths, literally! There are a 4 distinct skills that can be most effectively addressed in the water. These are:
motor skills
sensory processing concerns
behavior and regulation
executive functioning
Typically, OTs rely on published academic research to inform their practice. In aquatic therapy, the research is still in its early stages. So, although the research is growing, it cannot be the only source of information for us to count on-there simply isn’t enough information out there (yet!).
So, I have consolidated information from 4 sources to justify this blog post and explain why OTs have such a unique opportunity to work on the specific skills written below. Current sources include:
current aquatic therapy research
“best practice” standards and recommendations for general pediatric OTs
the therapeutic properties of the water
patient outcomes in practice
Motor Skills
Motor skills include gross motor (big body movements) and fine motor skills (movements using hands/fingers). These help our bodies to complete all the movements we need in daily life. Some common skills related to motor development include: balance, coordination, fine motor grasping and dexterity, strength, posture, range of motion, and body awareness.
When working in the water, we can do movements that we would not normally be able to do on the land (think about it…you’re probably more likely to attempt a backflip for the first time under water than attempting it in the grass). This is because the water has two things…
viscosity: viscosity is the drag we feel when moving in the water. It slows our movements down.
buoyancy: buoyancy reduces the amount of gravitational force acting on our bodies. It gives us an extra bounce creates a low impact environment to work in.
By working in the water, kiddos can practice motor plans that they are not yet independent in on the land. They have more time to correct and refine their movements and if they do make a mistake, they are in a safe and low-impact environment!
How do we progress to independence on the land?
Once kiddos are completing motor skills successfully in the water, I can start to add some new demands to the movements to build strength and progress out of the water. Here are some examples of how I may increase the difficulty of a movement:
speed: By moving at a faster speed, the resistance of a movement increases.
add a floatation device: this adjusts which areas of the body are working with or against gravity. This can also impact how much trunk control is required for a movement.
change the plane of movement: by working on movements backwards or in a horizontal plane, I can adjust which muscles are working with or against gravity.
change the depth: by changing the depth, I can adjust how much stability the water is providing and alter how quickly movements needs to be completed.
The water allows kiddos to work on movements that are too challenging in other environments. It also allows me to use different aquatic tools to naturally progress a movement from the water to the land!
2. Sensory Processing Concerns
The water creates an all-encompassing, multi-sensory environment that can help to promote sensory adaptation in other environments. The water provides both sources of calming input and sources of alerting/high energy input to align with each child’s sensory needs and preferences.
Calming input in the water:
deep pressure: the water has hydrostatic pressure, which gets more intense as depth increases (this is why our ears feel pressure when we dive). This increased pressure requires the diaphragm to work harder, which increases breathing. So, our bodies are more calm and regulated in the water because we are taking deeper breaths.
vestibular input: when we are provided with slow and linear movements, our bodies become more calm (this is why babies fall asleep while being rocked). By providing kiddos with slow, swaying motions in the pool, they can quickly become re-regulated…especially when paired with calming sounds/music.
submersion: when we submerge, all visual and auditory input is reduced or blocked entirely. Additionally, the water’s viscosity and the increase in hydrostatic pressure both provide calming input to our proprioceptive receptors. This technique provides kiddos with reduced visual and auditory “clutter” and increased heavy work and pressure. It is a calming sensory dream for many kiddos!
climbing out: climbing out of the pool requires coordinated heavy work. When we are wet and fighting the surface tension, we have added resistance (and added proprioceptive work!). This can be highly regulating for the body.
Alerting input in the water:
splashing: splashing creates visual, auditory, and tactile chaos, which can be highly alerting for our bodies. When we break the surface tension in the water, our body is given a heightened tactile experience that can amp up our regulation.
jumping in: when we jump in, we break the surface tension with the entire body. It provides us with alerting and disorganized vestibular and tactile input-which can be highly regulating for sensory seekers. Added bonus that is gives us an opportunity to work on safety skills!
spinning: since our bodies are lighter in the water, I can give kiddos a lot of amplifying vestibular input. One way I do this is by spinning kiddos at varied rhythms and angles. This can help sensory seekers get the extra input they need while I have flexibility to spin them in a way that matches their sensory preferences.
These different tools (and many more!) allow me to naturally incorporate preferred sensory input into our interventions, without completely transitioning to a new activity. Furthermore, I can incorporate sensory input into the entire session while sticking to functional and occupation-based activities.
3. Regulation and Behavior
In order to address behaviors and regulation, we have to build co-regulation skills with kiddos. Co-regulation involves creating connection with a trusted adult then developing the ability to appropriately manage stressful and non-preferred scenarios when given guidance from said adult. In order for OTs to build co-regulation skills, in the water we can:
maintain a proximity to the child that is comfortable for them (and adjust if needed)
mirror the child’s actions to encourage reciprocal play
create an inviting and functional play space that is child-led
tailor interactions to support preferred sensory input
By working in the swimming pool, there is more flexibility to implement each of these strategies. I can adjust proximity at a greater range because I can provide kiddos with sufficient equipment to move independently and further away from me if they are needing space. I can naturally mirror kiddos because I am physically in the pool with them and already at their eye level. We are sharing the exact same, large, sensory space which allows me to naturally replicate a child’s actions to help build connection. While working in the water, I can also create an inviting play space by setting up provocations using multiple locations in the pool (such as the steps, the deep end, the ladder, the edge of the pool, etc.) This allows for an engaging space that may require distinct sensory adaptations and functional mobility skills…talk about a natural, multi-faceted intervention. Lastly, I can use the sensory properties of the water mentioned above to ensure kiddos are receiving the sensory input that regulates them most.
Ultimately, by adjusting my body language and using this flexible play space to its full potential, I have natural opportunities to build co-regulation skills with kiddos. Kiddos are typically highly motivated in the water, so we are able to work on these skills in a positive and child-led way. Co-regulation is all about building a trusting and understanding relationship. So, why not work on this during a fun, motivating, and highly sensory activity that a therapist, parent, and child can all engage in together?
4. Executive Functioning
Executive Functioning (EF) involves the higher level thinking skills we are required to do as human beings. Some common EF skills include: planning, problem-solving, time-management, sequencing, self-control, and attention. OTs often address these skills by incorporating functional, sequential routines into their interventions.
When a kiddo participates in swimming, there are many additional routines/tasks required of them to adequately prepare to swim and transition into the pool. Kiddos must: get their swim gear on, pack a swim bag, pick their favorite toys, use the restroom, etc. Then, once they are ready to swim, they must understand how and when they can enter a pool safely. Once in the water, they must develop an understanding of their own ability level as well as where/when/how to get assistance with swimming if needed.
These additional requirements and safety skills allow me to naturally incorporate many routines and functional skills into our aquatic interventions. The swimming pool is highly motivating, so kiddos often participate in these interventions phenomenally! Furthermore, I can naturally tailor the demands of these skills to best fit the child’s functional level. For example, once a kiddo is safe entering and swimming in the pool, we may start practicing jumping in the water to add additional safety measures. Or, if a kiddo has limited experience with swimming, we may start simply with learning how to how the stair railing when entering the water.
Conclusion
So, now you know. Although we can address many OT skills in the aquatic setting, these four are my favorites as a practitioner. This is because we can utilize the tools that the swimming pool provides for us to work on these skills in a natural and motivating way. Reach out to Emily if you have questions about how your child might do in the water!
References:
Agostoni, E. , Gurtner, G. , Torri, G. , & Rahn, H. (1966). Respiratory mechanics during submersion and negative‐pressure breathing. Journal of Applied Physiology, 21, 251–258. doi: 10.14814/phy2.15475
Aquatic Therapy University. (2012). Aquatic sensory and motor integration for the pediatric therapist. (Continuing Education Lecture and Manual). https://www.atuseminars.com/product-page/aquatic-sensory-motor-integration-forpediatric-3-hr-w-manual
Center on the Developing Child. (n.d.). What is executive functioning and how does it relate to child development? Harvard University. https://developingchild.harvard.edu/resources/what-is-executive-function-and-how-does-it-relate-to-child-development/
Greenspan, S. & Wieder, S. (n.d.) Basic principles of floor time. International Council on Development and Learning. https://sa1s3.patientpop.com/assets/docs/61721.pdf
Tisser, A & Freedman, C. (2021). Totally treatment-pediatric aquatic therapy course. (Continuing Education PowerPoint Slides). Swim Angelfish. https://swimangelfish.com/therapist-training/
Warwick, T. (2023). Creating connections to better understand challenging behavior in children. (Continuing Education Lecture and PowerPoint Slides). Occpationaltherapy.com. https://www.occupationaltherapy.com/ot-ceus/course/creating-connections-to-betterunderstand-9564
Wood, V. (2022). Co-regulation. OT Toolbox. https://www.theottoolbox.com/co-regulation/