Abstract
Importance:
There is a critical need for therapeutic water competency (water safety and swim skills) interventions tailored to meet the needs of children on the autism spectrum, a group that is at high risk for drowning.
Objective:
To examine the effect of AquOTic on caregiver- and therapist-based water competency goals for children on the autism spectrum.
Design:
Pre–post cohort design based on a larger randomized controlled trial.
Setting:
County Board of Developmental Disabilities therapy pool.
Participants:
Children on the autism spectrum (N = 37; 28 boys) ages 5 to 9 yr were recruited from the local community.
Intervention:
AquOTic is a manualized 10-wk occupational therapy–based water competency intervention for children on the autism spectrum. AquOTic incorporates evidence-based therapeutic techniques and embeds individualized therapy (interventionist–child dyads) in a group environment.
Outcomes and Measures:
Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were completed at baseline and post intervention.
Results:
Children showed significantly higher GAS T scores and COPM Performance and Satisfaction scores post-AquOTic compared with baseline (effect size d = 2.1–2.3). All goals mapped onto the Occupational Therapy Practice Framework (4th ed.), with motor skills emerging as the most common category for both caregiver- and therapist-derived goals, followed by safety awareness in the aquatic environment and sensory functions.
Conclusions and Relevance:
Children on the autism spectrum demonstrated improved caregiver- and therapist-based water competency goals following the AquOTic intervention.
Plain-Language Summary
This study examined the effect of AquOTic, an occupational therapy–based intervention, on parent/caregiver- and therapist-based goals related to water safety and swim skills among children on the autism spectrum. Caregivers identified goals for their children, and therapists developed goals that guided the intervention. After completing the 10-wk intervention, children showed improvements in both caregiver perceptions of their performance and satisfaction with goals set as well as therapist-rated goals. Our results highlight the value and effectiveness of an occupational therapy–based water competency intervention to improve water competency among children on the autism spectrum.
This study examined the effect of AquOTic, an occupational therapy–based intervention, on parent/caregiver- and therapist-based goals related to water safety and swim skills among children on the autism spectrum.
Drowning is a leading cause of unintentional death among children on the autism spectrum (Guan & Li, 2017), and autistic individuals are twice as likely to die from drowning than the general population (Schendel et al., 2016). Hence, there is a critical need for water competency and safety training for children on the autism spectrum. Among typically developing children, traditional swim lessons have been shown to decrease the risk of drowning by 88% (Brenner et al., 2009). However, children on the autism spectrum have distinct cognitive, sensory, motor, and behavioral characteristics that often impede participation in and reduce the effectiveness of traditional swim lessons (Kemp, Nikahd, Ackerman, et al., 2024; Mische Lawson et al., 2019). Consequently, children on the autism spectrum may require therapeutic water competency interventions that combine swim technique training with comprehensive aquatic safety education. Water competency encompasses safe entry into the water, breath control, floating, changing body position, swimming a set distance, and exiting the water (Denny et al., 2021). Equally important are drowning chain of survival skills, such as understanding whistle signals, locating and seeking assistance from lifeguards, recognizing and responding to someone in distress, calling for help, and safely offering flotation to others (Szpilman et al., 2014).
A recent meta‐analysis demonstrated that, for children on the autism spectrum, participation in aquatic programs yields significant gains in motor and social functioning while also reducing repetitive behaviors (van t Hooft et al., 2024). Beyond the acquisition of vital swim skills, therapeutic aquatic interventions have been associated with improvements across a broad range of health domains, including motor proficiency, executive function, sensory processing, social communication, mental well‐being, and sleep quality (see reviews in Aleksandrovic et al., 2015; Martin & Dillenburger, 2019; Murphy & Hennebach, 2020; Shariat et al., 2024). Effective aquatic programs for autism typically consist of sensorimotor and social elements, are individualized, are structured, and involve family participation. Most programs involved 60-min weekly sessions at a 1:1 instructor-to-child ratio, with total intervention times ranging from 4 hr to 72 hr. However, these systematic reviews have highlighted substantial limitations in the existing literature; over half of the studies enrolled fewer than seven participants, many lacked rigorous control groups, standardized outcome measures were rarely used, and few interventions adhered to a manualized, evidence‐based protocol (Martin & Dillenburger, 2019; Murphy & Hennebach, 2020).
The AquOTic program is an occupational therapy–based manualized 10-wk swim intervention that includes evidence-based techniques such as play-based and child-led activities, task-specific training, positive reinforcement, sensory supports, and a modified Halliwick approach (Gresswell, 2015) to swim instruction (Kemp, Nikahd, Howard, et al., 2024). The AquOTic program significantly improves water competency skills of children on the autism spectrum compared with children not receiving the intervention (Kemp, Nikahd, Howard, et al., 2024). This study determined the effect of AquOTic on individualized child goals and caregiver perspectives regarding satisfaction and performance with their child’s water competency and swim skills.
Family-centered goal setting is essential for maximizing intervention effectiveness among children on the autism spectrum, because it ensures that goals are meaningful, achievable, and aligned with each family’s priorities (Watling et al., 2023). Caregivers who actively collaborate in identifying and refining treatment goals report a greater sense of competence and sustained use of intervention strategies, leading to improved outcomes among children on the autism spectrum. By embedding structured, family-driven goal setting into intervention design, we can enhance both child gains and caregiver well-being, ultimately promoting more durable and generalizable treatment effects (Watling et al., 2023).
Occupational therapy is a client- and family-centered health care profession that uses therapeutic techniques to facilitate clients’ ability to participate in their desired occupations (American Occupational Therapy Association, 2020). Swimming is a valued occupation for children on the autism spectrum (Eversole et al., 2016), requiring many underlying performance skills and client factors frequently addressed in land-based therapy. Goals set in an aquatic environment may facilitate the achievement of land-based goals. A recent review noted that aquatic therapy among children with neurodevelopmental conditions facilitated global motor and psychosocial skills (Ogonowska-Slodownik et al., 2024). However, there is a lack of research examining comprehensive caregiver and therapist goals for occupational therapy–based aquatic interventions. This study addressed this gap by using the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; American Occupational Therapy Association, 2020) to categorize aquatic goals, which may help demonstrate the therapeutic nature and value of therapeutic swim intervention. This study aimed to (1) examine the efficacy of an occupational therapy–based aquatic intervention to improve caregiver and therapist goals for improving water competency among children on the autism spectrum and (2) map intervention goals onto the OTPF–4.
Method
Research Design
This study was part of a larger randomized controlled waitlist trial that examined the effectiveness of the AquOTic intervention (ClinicalTrials.gov Identifier No. NCT05524753). This article focused on the effectiveness of AquOTic, measured by caregiver and therapist goals related to aquatic environments in the intervention group only. All study procedures were approved by Ohio State University’s institutional review board. Caregivers provided written informed consent, and children provided verbal assent prior to study participation.
Participants
A total of 37 children on the autism spectrum (ages 5–9 yr; M age = 6.95, SD = 1.42) participated in the AquOTic intervention trial (see Figure 1). We randomly assigned participants to one of three groups by using a computer-generated randomization schedule: (1) AquOTic intervention-first, (2) Waitlist Control A, or (3) Waitlist Control B. Those allocated to the AquOTic intervention-first group (n = 12) began the intervention immediately. Participants in the waitlist control groups (n = 25) served as controls for a minimum duration of 4 mo before being offered the opportunity to receive the AquOTic intervention. Children were recruited from the local community via social media, word-of-mouth referrals, and flyers distributed across the university campus and the local County Board of Developmental Disabilities. Inclusion criteria were as follows: (1) a confirmed autism diagnosis provided by a health care professional, (2) age between 5 and 9 yr, (3) normal or corrected vision and hearing, (4) intact airway function, and (5) absence of uncontrolled seizures. Children were excluded if they demonstrated swim proficiency, defined by caregiver report as the ability to float independently for 5 to 10 s or propel themselves through the water without flotation support. Families received $25 per assessment session as compensation. Participation in the AquOTic intervention was provided at no cost. During the waitlist control period, participants did not receive any aquatic programming from the research team. However, children were permitted to continue their usual aquatic activities outside of the study.
Consolidated Standards of Reporting Trials (CONSORT) flow diagram of the participant selection process.
Measures
Caregivers filled out a researcher-prepared form to collect basic demographic information about the child and their family. Interventionists completed structured daily documentation after each session, recording adverse events, child-specific goals, activities completed, preferred toys, and effective cues.
Outcome Measures
Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure (COPM) is a goal-oriented, individualized, client-centered tool in which caregivers set and measure goals (Law et al., 1990). At baseline, caregivers set up to five goals for their child in collaboration with the study therapist via semistructured interviews. Goals focused on caregiver priorities of water safety and swim skills. At baseline and posttest, caregivers rated how well their child performed each goal (COPM Performance) and how satisfied they were with that performance (COPM Satisfaction) on a scale of 1 to 10, with higher scores indicating greater performance and satisfaction. The minimal clinically important difference (MCID) is defined as a change score of 2.0 points for Performance and Satisfaction scores (Law et al., 1990).
Goal Attainment Scaling
The Goal Attainment Scaling (GAS) is a standardized client-centered scale to measure progress on individual goals (Turner-Stokes, 2009). A licensed and trained therapist used caregiver goals identified through the COPM and the child’s initial standardized water competency evaluation to create three to four individualized goals for each child. For all COPM goals, the corresponding individualized GAS goals would emphasize the underlying therapeutic targets, including sensory, cognitive, or motor skills needed to reach that goal. For example, for a COPM goal of ensuring the child remains safe on the pool deck, the corresponding GAS goal established by the therapist would be establishing the habit of waiting for an adult or lifeguard’s cue before entering the pool.
These goals were tailored to each participant’s baseline skills to effectively track progress throughout the trial. Goals were quantified on a 5-point scale from –2 to 2, and levels within each goal were equally distanced. The child’s baseline performance was set at –1, with 0 representing the expected level of achievement by the end of the trial. Progressively more challenging goals were defined at 1 and 2 to capture outcomes exceeding expectations, whereas –2 indicated regression from baseline. Progress on goals was tracked weekly by the child’s interventionist throughout the 10 weekly intervention sessions. At posttest, the therapist and the child’s interventionist collaborated on the final rating of the GAS scores. After the 10-wk intervention, unweighted total T scores were calculated at baseline and post-AquOTic to measure changes in performance.
AquOTic Intervention
AquOTic is a manualized 10-wk occupational therapy–based water competency intervention tailored to the cognitive, sensorimotor, and behavioral needs of children on the autism spectrum (Kemp et al., 2023; Kemp, Nikahd, Howard, et al., 2024). The intervention takes place once weekly over a 10-wk period in a warm-water pool located at a local school serving children with developmental disabilities. Each 60-min session follows a consistent structure while incorporating personalized activities based on each child’s goals and progress. Each child is consistently paired with the same interventionist for the duration of the program, fostering a strong therapeutic relationship and enabling tailored support. In this study, sessions consisted of six child–interventionist pairs, facilitated by a licensed therapist. Interventionists were graduate students enrolled in the occupational or physical therapy doctoral program at the local university. Study interventionists completed comprehensive training in AquOTic intervention fidelity, including land- and water-based training. Interventionists completed a weekly AquOTic Fidelity Self-Checklist (see Appendix A in the Supplemental Material, available online with this article at https://research.aota.org/ajot). Weekly feedback on adherence to fidelity and daily documentation of goals was provided by the lead therapist to all interventionists. The AquOTic protocol is described in detail in Kemp et al. (2023) and Kemp, Nikahd, Howard, et al. (2024).
Power Analysis
To ensure our sample was sufficiently powered to detect a significant change in caregiver- and therapist-identified goals, we conducted a power analysis using G*Power software (Version 3.1.9.7) for two-tailed matched-pairs t tests assuming a conservative medium effect size based on prior results (Kemp et al., 2023). The input parameters for G*Power were as follows: effect size = 0.6, α error probability = .05, and power = 0.80. The total sample required was 24 participants. Therefore, the study sample of 33 participants was sufficiently powered.
Statistical Analysis
All data were normally distributed based on the Shapiro–Wilk test. Pre- and postintervention, we compared COPM Performance and COPM Satisfaction data and GAS T scores by using paired-samples t tests. Effect sizes were reported using Cohen’s d, interpreted as 0.2 = small, 0.5 = medium, and 0.8 = large (Fritz et al., 2012). To account for multiple comparisons, we set alpha at .025 (0.05/2 measures). All analyses were completed by using SPSS (Version 29).
Qualitative Coding
All therapist-derived GAS goals and caregiver-derived COPM goals were mapped into categories based on the OTPF–4 by two licensed occupational therapists to determine which types of goals were most often addressed with this intervention. When discrepancies arose, we engaged in discussion and reached consensus, assigning each goal to the category that best reflected its primary intent.
Results
The study was conducted from August 2022 to August 2023, involving 37 children who met inclusion criteria. Two children in the AquOTic intervention group were excluded because of loss to follow-up and injury outside of the study, resulting in a total of 35 participants. Of these, two participants had COPM data but were missing GAS data at one or both time points, whereas another two had GAS data but were missing COPM data. Thus, 33 participants had complete data for both GAS and COPM across time points (see Figure 1). See Table 1 for participant demographic characteristics. All key ingredients were present >90% of the time across all sessions, as measured by the interventionist fidelity checklist. No adverse events or injuries occurred among children or interventionists during AquOTic sessions.
Participant Demographic Characteristics
Note. IQR = interquartile range.
Goal Categories
Across all participants, caregivers identified a total of 104 goals, whereas therapists identified 127. The most common category for both caregiver- and therapist-derived goals was motor skills (n = 48). Examples of motor-related goals included entering and exiting a float position, holding one’s breath, and kicking across a distance. Caregivers more frequently identified goals related to safety awareness in the aquatic environment, which were coded under mental functions (n = 24). In contrast, therapist-derived safety-related goals were more often coded under habits (n = 4) or process skills (n = 8). For example, a caregiver might identify the goal of their child’s breath control when swimming/diving on the COPM, and the corresponding therapist’s goal on GAS would be for the child to submerge to obtain items at chest depth 5 times per session using their hands while holding their breath, emphasizing the underlying sensorimotor skills needed to achieve this goal. See Appendix B in the Supplemental Material for COPM and GAS goals developed for one participant. Therapist-derived goals also more frequently addressed sensory functions (n = 14) and neuromuscular and movement functions (n = 13). Examples of sensory goals included tolerating the supine position in the water or adapting to the tactile sensation of water on the body. Neuromuscular and movement goals often emphasized developing upper-body strength to exit at the poolside or using a coordinated reciprocal kicking pattern. See Table 2 for detailed breakdown of caregiver- and therapist-identified goals by category.
Goal Categories Mapped to the OTPF–4
Note. Percentages rounded to nearest 10th. GAS = Goal Attainment Scaling; COPM = Canadian Occupational Performance Measure; OTPF–4 = Occupational Therapy Practice Framework: Domain and Process (4th ed.).
Postintervention
Children had significantly higher GAS T scores post-AquOTic compared with baseline, t(32) = 12.1, p < .001, d = 2.11. The mean change in T scores post-AquOTic was 21.21 (SD = 10.07). There were significant improvements in the scores post-AquOTic for both COPM Performance, t(32) = 13.25, p < .001, d = 2.31, and COPM Satisfaction, t(32) = 12.75, p < .001, d = 2.22. The mean change in COPM Performance scores was 3.53 (SD = 1.46) and for COPM Satisfaction was 4.62 (SD = 2.08), both exceeding the MCID threshold of 2.0 points, indicating clinically meaningful improvements (see Table 3).
Means and Standard Deviations for GAS and COPM
Note. GAS = Goal Attainment Scaling; COPM = Canadian Occupational Performance Measure.
In addition, we evaluated the relationship between change scores of COPM Performance/Satisfaction and GAS change scores by using Pearson’s correlations. Change scores across measures were significant, such that those with higher gains on GAS also showed higher gains on COPM Performance (r = .46, p = .009) and COPM Satisfaction (r = .86, p = .006).
Discussion
This study demonstrated that the AquOTic intervention program resulted in significantly enhanced performance and satisfaction on caregiver-based and therapist-based individualized water competency goals among children on the autism spectrum. These findings contribute to a growing body of evidence supporting the effectiveness of therapeutic water competency intervention for this population (Shariat et al., 2024; van t Hooft et al., 2024). Both caregiver- and therapist-identified goals encompassed motor swim skills, cognitive water safety skills and habits, neuromuscular functions, and sensory tolerance, with consistent improvements observed across all domains following participation in AquOTic. This suggests that the intervention successfully addressed a broad range of skill areas prioritized by both families and therapists. This finding is important because swimming and water play are highly desired occupations for families of individuals on the autism spectrum, with autistic children enjoying swimming significantly more than neurotypical children (Eversole et al., 2016; Mische Lawson et al., 2019). However, autistic children with higher scores on the conduct processing sensory domain and hyporesponsive sensory profile often show limited swim skills (Kemp, Nikahd, Ackerman, et al., 2024). In addition, the high rate of drowning and elopement among autistic children further underscores the need for evidence-based therapeutic swim instruction.
Although prior therapeutic swim interventions have also shown improvements in swim skills and sociomotor functioning, most studies do not use a manualized approach with strict adherence to intervention fidelity and often have small sample sizes (Murphy & Hennebach, 2020; Shariat et al., 2024). In contrast, the AquOTic trial used an adequately powered sample size, an interventionist fidelity checklist, and daily documentation of goals. This methodological rigor of the AquOTic trial enhanced the reliability and generalizability of our findings. The mean change in COPM scores post-AquOTic exceeded the MCID threshold, supporting the clinical relevance and family-centeredness of the AquOTic program.
This study focused on caregiver- and therapist-based goals as outcome measures and adds to the growing body of literature supporting the effectiveness of AquOTic in improving water safety skills as well as basic swim skills (Kemp et al., 2023; Kemp, Nikahd, Howard, et al., 2024). In the same sample of children, compared with the control children, participation in the AquOTic intervention significantly improved swim skills as measured by the standardized Water Orientation Test–Alyn, with large effect sizes, and highest gains in water comfort and breath control (Kemp, Nikahd, Howard, et al., 2024). In the current study, caregivers identified fewer goals (n = 104) than therapists (n = 127). In some cases, families provided only a single, broad goal (e.g., “safety” or “swim”), which was too general to track meaningful progress and often encompassed multiple underlying components. Therefore, during GAS establishment, additional goals were created to address the underlying skills needed, thereby enabling measurable progress within the broader category. During coding, it became evident that many goals contained both a primary and a secondary target. For example, the goal “child will assume a back float with ears submerged for 10 s with one hand support from buddy at low back” was coded as a primary motor skill (achieving the back-float position) but also included a secondary sensory target (tolerating water on the ears). Secondary targets were not coded for this project, but their presence highlights the multidimensional nature of goals in aquatic therapy. Overall, the goals established closely paralleled those typically addressed in land-based occupational therapy, including improvements in strength, bilateral coordination, sensory tolerance, safety habits, and the development and refinement of motor and process skills (Crasta et al., 2024). These findings emphasize the importance of thorough goal establishment and collaborative planning prior to initiating intervention to ensure that goals are both meaningful and measurable.
The combined use of COPM and GAS in this study is recommended in pediatric trials, because these are the most commonly used client- and family-centered individualized measures (Calder et al., 2018; Mathews et al., 2020). Family-centered practice is widely recognized as a best practice in pediatrics. Centering intervention planning around parent- or caregiver-identified goals is a key principle of this approach and has been associated with improved child and family outcomes, as well as enhanced quality of life. (Calder et al., 2018; Watling et al., 2023). In the current study, the use of these measures ensured that the family’s priorities guided the focus of the intervention. The COPM follows a standardized administration process that emphasizes collaborative goal setting, wherein caregivers prioritize goals and rate their perceptions of their child’s performance and their satisfaction with these goals (Law et al., 1990). In our study, information from the COPM, along with baseline evaluations of the child’s swim skills and sensory profile, was used by the therapist to set goals with the GAS. The GAS is designed to meaningfully capture small increases in functional performance in a standardized framework, focusing on a child’s goal performance as rated by the therapist (Turner-Stokes, 2009). The use of GAS-informed clinical decision-making promoted individualization of the AquOTic sessions, weekly monitoring of the child’s progress, and adaptation of the intervention based on goal achievement progress. There was a significant improvement in COPM and GAS scores post-AquOTic, which highlights the effectiveness of AquOTic in enhancing family-centered goals.
Our findings also underscored the value of occupational therapy–based swim intervention for children on the autism spectrum. Notably, all caregiver- and therapist-identified goals mapped onto OTPF–4 categories, reinforcing that AquOTic is well aligned with the established scope and domain of occupational therapy practice. The AquOTic program’s key ingredients include child-led techniques, play-based activities to elicit motor skills, modeling, grading, shaping, motor repetition, visual schedules, sensory accommodations, active child engagement, child–therapist therapeutic relationship, reinforcements, use of water properties to reinforce tactile/proprioceptive input, and caregiver education on drowning prevention (see Appendix A in the Supplemental Material). These core therapeutic principles allowed for individualization and adaptation of the intervention to the child’s needs while maintaining adherence to intervention fidelity. A recent systematic review of aquatic interventions in autism noted that most programs were offered by trained therapy professionals (van t Hooft et al., 2024). Occupational therapy practitioners are uniquely qualified to deliver such interventions, given our expertise in promoting participation in meaningful occupations, including swimming and water play, while simultaneously addressing underlying client factors such as sensory processing, motor, and social skills. This positions occupational therapy as a vital contributor to both safety and participation outcomes for autistic children in aquatic environments.
Limitations and Future Directions
Although this study showed large effect sizes for pre- to postintervention for the AquOTic group, a primary limitation was the lack of COPM and GAS outcome measures in the control group. Lack of blinding on GAS scoring was also a significant limitation. Future studies with blinded assessors are needed to validate these findings. In addition, given that most goals were focused on motor skills, there is a need for future studies incorporating motor outcome measures. There were no long-term follow-up evaluations, which limits our ability to make interpretations on skill maintenance. Further studies with long-term outcome evaluations are needed to examine the retention and progression of water competency over time. Future randomized controlled trials incorporating both quantitative and qualitative data collection from families of children on the autism spectrum are needed to holistically understand the impact of therapeutic swim interventions. Another limitation was the lack of baseline characterization measures such as autism levels, IQ, and verbal ability. Future studies with comprehensive child and family characterization will allow for more nuanced analysis of treatment response and enable further individualization of the intervention to better meet the diverse needs of children across the autism spectrum.
Implications for Occupational Therapy Practice
The results of the AquOTic trial highlight the following practice implications: Aquatic occupational therapy can effectively support caregiver- and therapist-identified goals related to water competency of children on the autism spectrum. Engaging caregivers in clinical decision-making is essential to tailoring interventions that align with family needs and priorities. Therapists should integrate caregiver goals with assessments of a child’s sensory, motor, cognitive functioning, and baseline swim skills to guide individualized intervention planning. The COPM is a valuable tool for identifying caregiver priorities, whereas the GAS offers a clinically relevant method for tracking progress and adapting interventions to support goal achievement. This study supports the scope of occupational therapy practice in facilitating meaningful participation in aquatic environments for children on the autism spectrum.
Conclusion
This study examined the effectiveness of a manualized occupational therapy–based intervention to improve caregiver- and therapist-identified goals related to water competency of children on the autism spectrum. Following the 10-wk AquOTic intervention, children demonstrated significant improvements in GAS T scores and COPM Performance and Satisfaction scores, exceeding the threshold for a minimally important clinical difference. These findings highlight the clinical relevance of occupational therapy in supporting meaningful participation in aquatic environments. The results underscore the importance of incorporating caregiver perspectives into goal setting and using individualized, evidence-based approaches to promote water competency among children on the autism spectrum.
Footnotes
Acknowledgments
The deidentified dataset will be made available upon request to the corresponding author.