It is a common belief in the ASD community that kids with Austism “love water.” While this could be an overgeneralized claim, caregivers frequently share, blog, and post web comments related to water.
Anecdotes like “he repeatedly turns on the taps to watch water run but doesn’t bother with water in a bowl,” “pours water on himself and his sister,” “he can spend hours in the tub and is often found playing with the hose,” “loves making waterfalls and swimming pools,” and “anything near water he heads right for it,” are frequently published (asd-forum.org.uk, 2008).
Interest in water may be common among people with ASD, but what kind of water? Is it still water, flowing, dripping, or swimming?
What about taking baths and showers? Surveying personal comments provided by caregivers (bbc.uk.org), baths can have appeal as the water can be engaged or manipulated. Not necessarily just for hygiene, a bath can be an opportunity to view water moving and catching the light. Showers, however, can be entirely different.
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Caregivers sometimes report opposition to showering as it may be too loud, and the beads of water can feel like “stingers” or “golf balls” on the skin (themighty.com, 2016). As far as addressing this opposition, there does not appear to be a plethora of empirical evidence specifically targeting shower/bathing.
This adaptive behavior is commonly included for interventions with other hygiene-related activities, i.e., hand washing, tooth brushing, etc. (Veazey et al., 2016). This may not be surprising considering Pituch et al. (2011) surveyed parental treatment priorities, and hygiene was not listed in the top ten.
According to the DSM 5 (American Psychiatric Association, 2013), diagnostic criteria for ASD vary from deficits in social communication and interactions to restricted, repetitive patterns of behavior. Does the latter aforementioned description help explain possible predilections to water?
Included within the diagnosis under “restricted, repetitive patterns of behavior” are two qualifiers that are plausible: “highly restricted, fixated interests that are abnormal in focus or intensity” and “hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment.”
Can the movement of water and/or light reflection of it reinforce the “visual fascination with lights or movement,” as identified as a behavioral characteristic in the diagnosis? Perhaps the need for sensory stimulation could lead people with ASD to engage in the fluidity (pun intended) of moving water.
Numerous studies have suggested the benefits of swimming for people with ASD, such as improved social skills (Mortimer et al., 2014; Pan, 2010), improved emotional responses (Caputo et al., 2018), physical fitness (Yilmaz et al., 2004), self-esteem (Napolitano, 2017), and motor abilities (Farnaz et al., 2015).
While an inherent interest in water coupled with the potential benefits of water exercise has an appeal, it is not without a caveat. Guan and Li (2017) concluded children with ASD were 160 times more likely to die from drowning than their neurotypical peers.
Couple a tendency to elope from supervised settings with an interest in water, an inability to safely navigate water could pose a significant threat. The last authors (Guan and Li, 2017) recommend swimming lessons as soon as the ASD diagnosis is made.
Other authors concur with the necessity of safety skills training regarding swimming (Alaniz et al, 2017; Lepore et al., 2007; Levy et al, 2017). Additional precautions are recommended for active supervision near bodies of water to prevent children with ASD from wandering.
While caregivers may freely share their children’s water-play (not for hygiene) behaviors, not much is disseminated regarding sensory precautions, i.e., nose plugs, earplugs, sensory deprivation gear, etc. Additionally, caregivers have reported the texture of a bathing suit and bathing caps can be potential barriers to this activity (Duquette, 2016).
Similar to any typically developing child, those with sensitivities to their eyes, ears, and nose could take similar precautions, though tolerance wearing these sensory modalities will vary across people.
What about people with ASD who are afraid of water? Is that common or as common as those with ASD having an interest with water? Phobias are not restricted to the typically developing population. Case in point, research suggests people with ASD exhibit more fears and phobias than people with other developmental disabilities or typically developing peers (Lydon et al., 2015).
This may not be surprising considering people with ASD may be more sensitive to environmental stimuli. Additionally, there appears to be a greater variety of stimuli that could occasion fear, with water being identified as a source of fear in some with ASD (Davis et al., 2007; Love et al., 1990; Rapp et al., 2005; Volkmar & Cohen, 1985). Having an interest in water cannot be overgeneralized to the entire population of people with ASD.
Previously mentioned research is suggestive of the benefits of swimming for those with ASD. Considering the literature also suggests the possibility of water being aversive, what are the options to address this aversion? Davis et al. (2007) combined cognitive behavioral therapy and behavioral analytic methods to decrease anxiety to water.
Love et al. (1990) involved the caregivers and had them model stepping towards the water source and vocalizing a lack of fear. Another intervention to address avoidance of water was reinforcing the person’s entering various depths of water (Rapp et al., 2005). Currently, some research exists; unfortunately, there appears to be a paucity of empirically validated methods to address water phobia with people with ASD.
Why? Is it because fear of water does not appear to be a priority in the treatment of ASD? Perhaps a fear of water is not something actively discouraged among caregivers. In view that wandering away from supervision is the most reported activity prior to drowning incidents for those with ASD (Guan & Li, 2017), caregiver discouragement is plausible.
So what is to be done with the potential for water activities? Encourage? Discourage? Indulge? Do we allow the child to play with water in ways different than his/her typically developing peers? How long should the caregiver allow the child with ASD to play in the tub? When do we consider the child just having fun as opposed to engaging in self-stimulatory behavior? If he/she is under stimulated, does the water help? What should be done?
One area leaves little room for debate: safety. If there is a remote interest in water, swimming lessons are recommended along with active supervision when in or near water. Leisure water activities could also be used to encourage water for hygiene.
If the person with ASD has sensitivity issues related to showering, baths could be an option by allowing him/her to pour water over himself/herself for rinsing. If pouring the water is not an option, caregivers could allow him/her control over the pouring (how long to pour, when to start, the type of container holding the water, etc.). If pouring is too loud, earplugs are an option.
What if he/she engages in self-stimulatory behavior with water? An option could be to allow “free water time” in his/her schedule, being notified ahead of time with vocal and visual prompts. Additionally, provide prompts of time (vocal reminders, countdown timer) remaining for this activity to notify its conclusion and transition to another.
So, regarding the common proclivity for people with ASD to be attracted to water, can it be considered a “given?” I must defer and suggest that nothing is a given. Regardless of abilities and disabilities, an individual is unique and should be engaged as such.
References:
Alaniz M.L., Rosenberg, S.S., Beard, N.R., & Rosario E.R. (2017). The effectiveness of aquatic group therapy for improving water safety and social interactions in children with autism spectrum disorder: A pilot program. Journal of Autism and Developmental Disorders, 47, 12, 4006-4017.
American Psychiatric Association (2013). The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington VA: American Psychiatric Association.asd-forum.org.uk. (2008, August 26). Water obsession [Blog post]. Retrieved from https://www.asd-forum.org.uk/forum/index.php?/topic/18764-water-obsession/
bbc.uk.org. (2012, July 18). Are people with autism drawn to water? Retrieved from http://www.bbc.co.uk/blogs/ouch/2012/07/are_people_with_autism_drawn_t.html Caputo, G., Ippolito, G., Mazzotta, M., Sentenza, L., Muzio, M.R., Salzano, S., & Conson, M. (2018).
Effectiveness of a Multisystem Aquatic Therapy for Children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 48, 6, 1945-1956. Davis, T. E., Kurtz, P. F., Gardner, A. W. & Carman, N. B. (2007). Cognitive-behavioral treatment for specific phobias with a child demonstrating severe problem behavior and developmental delays. Research in Developmental Disabilities, 28, 546 – 558.
Duquette, M.M., Carbonneau, H., Roult, R., & Crevier, L. (2016). Sport and physical activity: Facilitating interventions with young people living with autism spectrum disorder. Physical Activity Review, 4, 40-49.
Farnaz, T., Azar, A., & Sohayl, D. (2015). The effect of basic swimming skills training on gross motor skills in autistic children (7-11 years old). Development and Motor Learning (Harakat), 7, 2, 171-185.
Guan, J. & Li, G. (2017). Injury mortality in individuals with autism. American Journal of Public Health, 107, 5, 791-793.
Lepore, M., Gayle, G.W., & Stevens, S. (2007). Adapted Aquatics Programming, 2nd ed. Champaign, IL: Human Kinetics.
Levy, K.M., Ainsleigh, S.A., & Hunsinger-Harris, M.L. (2017). Let’s go under! Teaching water safety skills using a behavioral treatment package. Education and Training in Autism and Developmental Disabilities, 52, 2, 186-193.
Love, S. R., Matson, J. L., & West, D. (1990). Mothers as effective therapists for autistic children’s phobias. Journal of Applied Behavior Analysis, 23, 379–385.
Lydon, S., Healt, O., O’Callaghan, O., Mulhern, T., Holloway, J. (2015). A systematic review of the treatment of fears and phobias among children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 2, 141-154.
Mortimer, R., Privopoulos, M., & Kumar, S. (2014). The effectiveness of hydrotherapy in the treatment of social and behavioral aspects of children with autism spectrum disorders: a systematic review. Journal of Multidisciplinary Healthcare, 7, 93-104.
Napolitano, S. (2017). Swimming as an inclusion tool for autistic subjects. Journal of Physical Education and Sport, 5, 2339-2343.
Pan, C.Y. (2010). Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. Autism, 14, 1, 9-28.
Pituch, K.A., Green, V.A., Didden, R., Lang, R., O’Reilly, M.F., Lancioni, G.E., & Sigafoos, J. (2011). Parent reported treatment priorities for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 135-143.
Rapp, J.T., Vollmer, T.R., Hovanetz, A.N. (2005). Evaluation and treatment of a swimming pool avoidance exhibited by an adolescent girl with autism. Behavior Therapy, 36, 101-105.
themighty.com. (2016, March 17). Why a shower is a big deal for my son with autism and sensory processing disorder. Retrieved from https://themighty.com/2016/03/why-a-shower-is-a-big-deal-for-my-son-with-autism-and-sensory-processing-disorder/
Veazey, S.E., Valentino, A.L., Low, A.I., McElroy, A.R., & LeBlanc, L.A. (2016). Teaching feminine hygiene skills to young females with autism spectrum disorder and intellectual disability. Behavior Analysis in Practice, 9, 2, 184-189.
Volkmar, F.R. & Cohen, D.J. (1985). The experience of infantile autism: A first-person account by Tony W. Journal of Autism and Developmental Disorders, 15, 1, 47-54.
Yilmaz, I., Yanardag, B., Birkan, B., & Bumin, G. (2004). Effects of swimming training on physical fitness and water orientation in autism. Pediatrics International, 46, 5,624-626, 2004.
This article was featured in Issue 104 –Transition Strategies For Kids With Autism
