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AquOTic! A Therapeutic Aquatic Intervention For Kids On The Autism Spectrum Podcast

AquOTic! A Therapeutic Aquatic Intervention For Kids On The Autism Spectrum Podcast
Dennis Cleary, MS, OTD, OTR/L, FAOTA, Erika Kemp, OTD, OTR/L, BCP
October 25, 2023

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Editor's note: This text-based course is a transcript of the AquOTic! A Therapeutic Aquatic Intervention For Kids On The Autism Spectrum Podcast, presented by Erika Kemp, OTD, OTR/L, BCP,​ and Dennis Cleary, MS, OTD, OTR/L.

**Please use the handout to complete the exam.

Learning Outcomes

  • After this course, participants will be able to:
    • Identify the number one cause of unintentional death for children on the autism spectrum.
    • Identify at least two tenets an occupational therapy practitioner can use in an aquatic environment to increase swim safety skills of kids on the autism spectrum.
    • List the benefits of engaging in safe swimming for families.

Podcast Discussion

Dennis: Thank you, everyone, for joining us. I am happy to be talking today to my good friend, Dr. Erika Kemp, from The Ohio State University (OSU). Tell us a little bit about yourself, your OT history, and what brought you to talk to us today about AquOTic occupational therapy.

Erika: I was always a swimmer and grew up around the pool. I was a lifeguard and a swim coach. When I started as an occupational therapist, I realized that many kids weren't able to attend regular swim lessons, but the families had a desire to go on vacation or take their kids to the pool. So around 2002, I started seeing some kids on the side. This has evolved over the last 20 years of practice.

Dennis: I remember visiting you as a rehab director up in Sandusky, Ohio, near Lake Erie. You were billing for some of these types of treatments then. Now in your role at OSU, what do you do? You're a big shot nationally as well, aren't you?

Erika: I don't know about all that, but I gradually stepped away from clinical practice and into academia. I initially worked at an OTA program, teaching pediatrics and doing fieldwork placements. Then, you called and said, "You want to move to Columbus?" I've been at OSU for the last eight years. I started doing fieldwork and doctoral capstone coordination. For the last three years, I have also been the Academic Leadership Council (ALC) Chair for the doctoral capstone coordinators. It's been a lot of fun to think about what a capstone looks like on a national level and how we make use of that. Most recently, over the last year, I've moved into the interim program director here at OSU. I've done a little bit of everything.

Dennis: Tell us about AquOTic, the pool intervention that you created.

Erika: The number one cause of unintentional death for kids on the spectrum up through age 14 is drowning due to elopement or wandering. These kids, for some reason, are drawn to water. We theorize that the water feels good on their bodies as most of them are sensory seekers. And with the properties of water, the deeper you go, the more pressure you get on your body, and the better it feels. Once kids figure that out, they seek out bodies of water anywhere they go. Many kids walk towards the deeper end without thinking about it. And actually, we see a lot of drownings happen in the typical population right in that four to six feet depth, where they realize they can't touch anymore.

Across kids of all ages, drowning is the number one cause of unintentional death up through age four, but we don't see that drop off for kids on the spectrum. In addition to elopement concerns, they don't seem to learn how to swim in typical community swim lessons. If we think about it, most of these kids have some sort of individualized education program. They learn differently, and we know that as many as 83% of kids on the spectrum have motor skill impairment. While that's not part of the DSM-IV diagnostic criteria, it is a difficulty that we see for a lot of these kids. Swimming is a motor skill, but it also has a cognitive component as well. This ties into the safety awareness piece.

Dennis: I remember when you talked to me about the statistics and how horrible that is for the kids, families, and our society. I love the name of your intervention. Do you want to talk a little bit about how you came up with it?

Erika: Obviously, I highlighted the O and T in the middle for the term AquOTic, a therapeutic swim intervention. It's a little bit different than where I started. When I started doing lessons, it was adjunctive to land therapy, and I was addressing land-based goals in the water with a sprinkling of swim skills and swim safety. For families, it was needed because their kids weren't learning anywhere else how to swim or how to be safe. How many family vacations can you name that don't involve a body of water? Even skiing may have a pool in the hotel or wherever you are. Many vacations involve resort/hotel pools (Disney), beaches, or other bodies of water. If a child is a sensory seeker, they're going to run to the pool anytime they can or continually dunk themselves underneath water without knowing how to come back up and take a breath. Pair that with impaired motor planning and it can be frightening for a lot of families. I decided to start a similar group when I was back in Sandusky using my high school swimmers.

Dennis: Did any of your trainers become an occupational therapist?

Erika: Yes. One of them did.

Dennis: There you go. Plant the seeds early.

Erika: Yeah, exactly. That's what we have to do. At any rate, this program has evolved over time. It is an adjunct to land therapy because we are addressing motor planning, core skills and strength, and cognitive awareness. We also do a lot of social interaction in the water with the kids. We put six kids in the water together, and they all have a one-on-one buddy interventionist.

When I found out the statistics on drowning, I felt vindicated about what I'd been trying to do over the last 20 years. Initially, I did not have the right words to support it, but now we know that in the typical population, swim lessons have been shown to significantly reduce the relative risk of drowning. We also know that parents report that kids with disabilities don't learn with typical swim instruction. So when I came here, I started working with the local Franklin County Board of Developmental Disabilities to develop this. The program has evolved organically from practice into research. My advice is to get your PhD. We need more interventional research to show that what we do works on a daily basis. 

The origin of the name is that I firmly believe this is occupational therapy in the water. We are providing individualized therapy for kids so they learn a valued and needed occupation. It's a safety public health initiative from WHO on down and is so critical for our families.

Dennis: Absolutely. I think feeding and falls are other areas we're involved in that include safety. In fact, insurance and the medical model make sure that safety is our number one priority during treatment.

How do you talk to parents about swimming or get them on board with this whole process?

Erika: We've had a wait list for this program since post-pandemic, probably around 2021. I have probably over a hundred families still waiting for us to be able to fit them in, which is amazing. We've already served at least 60 unique kids. I think parents are looking for this because they are aware that this is an issue. When we interview parents, we ask, "Why did you seek out this program?" And, "What were you hoping to get out of this?" For choosing the program, the number one answer is safety. After the program, they report their child has gained safety skills in a pool environment.

We have an educational module that we've built alongside the swim skill training, including safety skills for the pool, like walking feet, the lifeguard's role, what the whistle means, and what the red guard tube is. We have the kids hold onto the guard tube to be pulled to the edge of the pool so they understand if something were to happen, they need to grab it.

We've also added a lot of caregiver education on the drowning chain of survival. What should they do? What does drowning look like? How do they keep their kids safe? Parents and caregivers have been receptive to what we're doing, and they have had a role in helping to shape what we're doing. We use information from these questions to guide us. What do they like about the intervention? What has been most helpful for their kid? What did their kid not like about the intervention? We can also use these answers to tailor sessions to each kid and what they need.

Backing up, we put six kids in the water together in a group. However, it's individualized because we use OT and PT students as their individual buddies, and then I lead the group. We start with safety skills at the side of the pool. We use visuals as we would for classroom instruction and break things down. We use social stories for different skills. Then, we do some water adjustments all together at the edge of the pool. We introduce one swim skill a week. From there, they rotate to these individualized stations using a visual schedule. There are eight stations around the pool, and depending on the kid's level, they go to six of these eight stations. For example, if they're not ready for the deep end, they don't have to do that. At each station, their swim buddy individualizes that skill to that kid's needs and/or that kid's favorite character. We try to be as play-based and child-led as we can be while embedding these skills. OTs are masters at breaking an occupation down into individual client factors and skills that are needed. We then hide those skills in play or embed them in song. They go to the stations most applicable to their status, and we problem-solve about what's working for each kid. The skills are reinforced every week, again hidden in play and songs. Then, we come together at the end for a group game or song to give input back to the parents on how the kids did that day. We've also started adding handouts for parents on the different aspects of safety each week. In the last week of this 10-week intervention, we invite parents into the water with us and show them how to hold their child and use verbal cues that work best.

It's amazing to see what happens when you put them in the water together. They see others doing things and then they start to do those things as well. In contrast, when I've done this individually, like a one-on-one, it's a lot easier for the kid not to participate. 

Dennis: Peer pressure is a wonderful thing sometimes.

Erika: It can be. Even the kids that you don't think are paying attention are paying attention, even the ones that are in their own worlds. They are taking in more than we realize.

Dennis: You talked about how you try to grade activities based on the child or to make the stations child-centered. Do you have kind of an assessment you start with to look at their swim skills, their ability to follow directions, and those skills, or are you working on something?

Erika: There is a little bit of both. We've been using the Water Orientation Test Alyn, the WOTA, which is the only standardized measure out there for swim skills. It allows for a min, mod, and max rating scale for these swim skills, and it's based on the Halliwick concept. This concept looks first at achieving water adjustment, bubbles, and breath control. It then moves into mastering balance, buoyancy, and stillness (floating) before moving into locomotion.

It's a great tool, but the difficulty with that tool is that it doesn't easily correspond to what the American Red Cross and some others would say corresponds to water competency. How do you know when someone is water-competent? It's more about falling into the water and resurfacing, being able to turn at least 180 degrees, being able to swim towards the side of the wall, and then getting out of a pool. This doesn't completely line up exactly with those water competence skills.

The other thing we've been working on is a water competency checklist. We've taken some of those skills and have broken them down. We also look at them on land first. We should always look at a kid on land before the water. The water is a different environment. For example, the buoyancy of the water changes a child's center of gravity and how they move. We also need to ensure how a child communicates, how well they handle different types of directions, and what their needs are before going into the water.

We also complete a COPM with all the parents and ask them what skills they want their child to gain during the 10-week intervention.

It's a combination of land-based and water-based, some standardized tools, and some old-fashioned clinical reasoning and therapist judgment.

Dennis: Are there other programs that are out there for kids with autism?

Erika: There are, but I think they're harder to find. One of the things I would love to do is empower more occupational therapy practitioners to get in the water. We have such a great skill set that lines up so well with what we do. The National Autism Association has a running list on its website of other places that do adaptive lessons. However, I think that adaptive lessons are different from what we are doing because they are not as individualized. Adaptive lessons usually follow a set curriculum. A child must do this, this, and this, before they can move on to something else.

We take a different approach. We don't have a set curriculum, and every kid's swim stroke ends up looking different depending on what their bodies can do in the water and what they're interested in. Some kids learn how to do what we call chicken, eagle, or snake on their backs first, while others do more of a frog stroke on their stomach or move into a doggy paddle. This is a big difference between what we are doing and a traditional, adaptive swim.

When parents are looking for adaptive lessons, they should ask specific questions. What is their curriculum? How do they adjust to each kid's needs? There are some great adaptive swim lesson instructors out there, and I don't want to downplay what they're doing. I just think that we're another resource that could be used. We also look at disability etiquette and how to interact with the kids and the families, whereas this is not the focus of these programs.

The other big thing to remember is that behavior is a form of communication. When these kids are in the water, we need to look for signs of frustration because we want to keep them safe and prevent submergence. We want to be aware of what we're doing with kids in the water.

Dennis: What other things do occupational therapists bring to the water for this particular population?

Erika: Understanding how these kids process sensation and movement is important. We also use the concepts of task-specific training and repetitive task practice. Kids need hundreds of reps for skill acquisition, and I believe we're a little bit more patient with that process.

Additionally, we are writing individualized goals and tracking what we do because it is therapy. I've had our students working on video coding by watching our sessions and looking for the presence of therapeutic ingredients, like grading activities. Every time we see something therapeutic, we click a button. Another example is using water properties' force to adjust for sensation. For example, if someone needs more input, we may bounce them in the water or use the flow of the water to help them with a back float. Every time we see that, we code the presence of that. For motor learning, we may see shaping, like kicks from a bicycle kick into something more functional in the water. We're shaping the vertical position slowly into something more horizontal. For those who don't know, a vertical position is often the drowning position. When your body starts to get distressed, you often go into a vertical position using a scissor kick and it's not efficient. Remember, drowning is often silent and people may not call out or splash. It's important to have people recognize what that looks like. We are helping to shape the kids out of that position into something that will allow them to propel through the water. All of these techniques are therapeutic.

We also focus on a one-on-one relationship with the kids. We have the same person with the same kid every week, so they know what the kids like and don't like and how to push them just the right amount. The kids are usually very excited to see their swim buddies. We use positive reinforcement and let the kids try as much as they can. We don't dunk kids in the water. When they're ready, they'll go under. We use lots of goggles and other tools to help them. One example is rocks that light up under the pool to get them interested in learning what it is like under the water versus on top of the water.

I feel strongly that this is therapy and that any occupational therapy practitioner has the skill set to do this. They just need to learn how to break swimming down into steps.

Dennis: Are you looking to start training other occupational therapists to do this like other OT incentives, including Backpack Awareness and CarFit, that have gone national?

Erika: Absolutely. One of the things that we're looking at is starting a community of practice on aquatics for kids through AOTA. This will be a way for us to bring this conversation to the forefront. We have manualized the intervention via funding we received this last year. One reason for this coding of the ingredients was to manualize the intervention. We need to get that out but have not gotten to that point yet. That is definitely on the docket for us to continue to have this conversation to get more people to be able to do this.

Dennis: Absolutely, especially with a hundred people on your waiting list. You're supported by the Franklin County Board of DD. Is that just local dollars that are paying for the program, or are you starting to look at billing insurance or Medicaid?

Erika: Right now, everything is covered by the Franklin County Board of DD. They've been wonderful in supporting this research. Families are being served without having to pay for it right now. I'm not in a position where I can open a clinic just yet; however, I do believe that this is a billable service. We are doing therapeutic activities in the water and often address some self-care. Where can you see dressing and showering in real time? We can have a client step in and out of a Theraband loop to simulate the activity, or when you're at the pool, we can help them take their clothes off with their suits on underneath. We also have access to showers, so we can do some showers.

We work a lot on clients being able to tolerate water on their heads in the pool, which is also applicable to grooming. So I strongly believe that what we do is billable therapeutic activity, self-care training, and therapeutic exercise. As an example, a child uses trunk strength to hold a prone extension position to be able to climb out of the pool and to propel across the water. It's all in how you are documenting your treatment and ensuring you are not just writing "swim lessons." One of my biggest pet peeves is when someone says, "You're just doing swim lessons." No, it's therapy with an amazing outcome of drowning prevention.

While much of what I discussed is individualized with a buddy, I think that it's possible to do it in a group with OTAs and an OT together or even splitting up minutes somehow creatively.

We also got research funding from the American Occupational Therapy Foundation, which ended in the summer of 2023. We'll hopefully be putting out a preliminary analysis showing that it worked, that all the kids improved in swim skills, and that goals were met according to parental perception and satisfaction. We just applied for additional funding. We'll see what that looks like and if we can continue to put this out as a manualized intervention with evidence that occupational therapy can help fill this gap in programs out there.

Dennis: Way to go, Dr. Kemp. It's great that it is out there. Obviously, safety is a huge factor when we're talking to families and funders, and you also discussed the ADL improvements. What are some other benefits that you've seen?

Erika: Most of our goals are centered around safety on the pool deck as well as in the pool water. They are also learning to listen to a lifeguard or an adult, understand and recognize depth safety, and then also water skills like back float and locomotion.

We also have goals for core strength, bilateral reciprocal movements, and motor planning types of things. We do a lot of prone extension and fine motor activities. For example, they may monkey crawl along the edge of the pool to get clothespins, and monkey crawl back to clip them on. There's a lot of stuff that we can do.

Families also see gains in sensory processing. For instance, many parents have anecdotally told us that their kids sleep better, particularly the night of swimming and the couple nights after. Unfortunately, we do not have formal data on that, but I would say greater than 50% of families tell us this.

We also see improved social skills. We see families connect with other families, and the kids make friends with each other. In fact, we have seen many long-term friendships come out of our group, which was totally unexpected.

Also, families feel more comfortable with other recreational activities. These kids now have their own thing they can go to, like their siblings who have soccer, softball, or whatever. Now this kid has something they can go to do. After they graduate, we've also been able to push kids to try other activities like adaptive swim teams, adaptive synchronized swim, Special Olympics, and even typical swim teams.

Dennis: Participation is a good thing. I used to do a lot of aquatic therapy with autistic adults. They swam five nights a week in succession for a month. The sleep data showed great improvement, as you also mentioned.

Erika: Swimming is great for all kids with disabilities. We're focused on autism simply because it's a big issue, but we also have kids with cerebral palsy, Down syndrome, and developmental disabilities. Most of these kids don't learn to swim in typical lessons, and they benefit from this type of approach. 

Dennis:  What is the difference between helping somebody learn to swim safely in a pool versus a larger body of water, like Lake Erie, which we both love? I would argue the greatest of all the Great Lakes.

Erika: One of the biggest differences is that you can't see if you open your eyes. One of the things that we encourage is that the kids go underwater without goggles. Another difference is the waves and the currents in a lake. Many community rec centers have lazy rivers that are great to use for practice. Again, kids on the spectrum seek that feeling on their bodies, or they find the jets in the pool. The other thing is that in a pool, you can push off of the bottom to resurface. In lakes and ponds, it's more of a gradual entry before it gets deep, but it can really drop off quickly, and they may not be able to reach the bottom.

Dennis: I live near Lake Michigan now, and it's dangerous due to the riptides.

Erika: Yes. A tip that I give families is to dress their kids in neon-colored swimsuits (blue, yellow, or pink), particularly if they're going to a lake. They will stick out more than if they wear a pale blue swimsuit. And if they have multiple kids, I recommend that they dress them in the same color swimsuits. 

Dennis: Good tip. Are there success stories that you want to share? 

Erika: There are two big profiles that I see. One is the kid who is afraid to go anywhere near the water. They don't understand what it's going to feel like. The other is the kid who seeks the water and dive bombs underneath. We've had real success with both of these types of kids. We don't limit our intervention to verbal kids. We have kids that are nonverbal, minimally verbal, or have intellectual disabilities, and they all make progress. They don't all make the same amount of progress. For some, it takes longer to learn skills, but they all do make progress.

We had one girl who was nonverbal and did two sessions (about 20 sessions). She was probably eight or nine when she started. Now, she swims on the synchronized swim team, which is amazing, and she loves to go to the pool. It brightens her day, and her parents love to take her.

We had another child who did so well that he joined a typical swim team. It's so fun to watch him do freestyle and backstroke. He can't quite figure out breaststroke just yet, but he is on a typical swim team at a normal YMCA. This has been a great opportunity for social participation.

Another girl is non-verbal and uses a device to talk. After three summers, she's just now able to lift her feet up off the ground, starting to kick, and is starting to put her face near the water.

These examples go to show that every kid can learn. We need to figure out what each kid needs. I think these are some of the questions we're hoping to be able to answer with some of these bigger research projects. For example, how do we figure out how much intervention each child needs, who can start right away in a group, who could benefit from parent-child interaction, and who could benefit from positive water exposure before actual instruction?

I even had a kid that ended up swimming for his college.

Dennis: As a former swim team dad with 5:30 AM practices, it is great for kids and parents to have a group to belong to and bond with.

Erika: Yes. It is so powerful to have a sense of belonging. It is also great that kids and parents have something that they enjoy doing together.

Dennis: Is there a preferred age for your program?

Erika: Yes. This has evolved over time. I see kids start to be more independent around the age of six; however, we take kids as young as five and as old as 10 in our group. The sweet spot seems to be between six to eight years of age. In a typical population, most kids learn to swim around the same time frame or maybe a little bit earlier. The important thing seems to be for them to have positive water experiences before that age. This includes going with their family to zero-entry pools and getting used to splashing and what it feels like on their body. We are looking at doing some more parent-child kinds of things for those younger kids because they seem to benefit from that. Kids who are older may take longer for them to learn, especially if they haven't had that exposure over time.

Dennis: Currently, your intervention is once a week for 10 weeks. Is that your ideal level of intervention?

Erika: I like once a week, and we're in the water anywhere from 45 to 60 minutes, depending on how the day is going. Ten weeks seems to be a good amount of time for parents to commit to. Then, we usually take some time off, like a month, depending on where the holidays and sort of things fall, and then we can start up again. Twice a week might work, but once a week is working right now. Families typically miss one or two sessions. A minimum dose, from the research and from our anecdotal evidence, seems to be at least eight hours or eight weeks of intervention.

When looking at how many rounds are needed, I think we need about a year. There's not anything solid out there about how many sessions typical people need to learn how to swim, so we're going against a non-existent benchmark. As mentioned, I also think kids need a break between sessions. So we typically have kids at not more than three sessions a year for 30 lessons with a couple of months off between each before we decide the next steps.

Dennis: You stated that you have seen a level of improvement in all the kids you have treated. Do you have video evidence at the beginning and end of the 10 weeks? 

Erika: Yes, definitely. We have video evidence as well as the assessments that we're doing. We have tried to do blinded assessments before and after, but then I also have had their primary swim buddy administer the assessment. We definitely see better performance with their familiar buddy than we do an unfamiliar buddy. 

Dennis: Where can OTs start if they are interested in this program? Can they just take a class at Ohio State? Do you have a class on aquatics yet?

Erika: It's in development.

Dennis: Aha. There you go.

Erika: It is in development here, but if they are in Florida, Dr. Tana Carson at Florida International University is also doing work in drowning prevention and has a course for her students. Also, I'm happy to talk to anyone who has that interest and help them understand what they would need to do. I think revisiting swim instruction is a great way to think about the skills kids need to learn to swim and then apply that OT hat and activity analysis. Hopefully, in the next year, we'll have some sort of externally-facing continuing education course very soon that people can sign up for through Ohio State. People can also look out for our community of practice. We're hoping to get that up and running by springtime to meet with like-minded people.

Dennis: Would the first step be to get certified as a lifeguard? 

Erika: I think certification as a lifeguard would go a long way to help people recognize what a drowning position looks like. I think those classes are readily available through the American Red Cross or through a local YMCA. The second step would be to become a swim instructor. There are multiple certifications out there for that, again through the YMCA and the Red Cross. Swim America is another place to get a swim instructor certification. Once you have those skills, then you can apply your OT hat to each individual kid to help them achieve these milestones through an individualized evaluation.

Dennis: It helps families feel like we're competent if we have at least that very basic level. And if something happens to "Junior," you could intervene pretty quickly to make sure that they're safe. Have you thought about liability insurance?

Erika: I carry my own liability insurance on top of what the university has. Additionally, the university is in contract with Franklin County for the pool usage, and a lot of that is covered there. If you're a private practitioner and going to be at the community pool during open swim time, it is important to find out who carries the liability. If you're there during the lifeguarded time, It is important to know your responsibility as the therapist. If you're going to contract for a hotel pool or another entity, make sure they are aware of where you're doing your intervention. Looking at community swim lessons, we need to be mindful of the ratio of participants to instructors. This is why having additional certifications can be helpful.

Dennis: Are you starting to see students come to Ohio State because of the aquatics opportunities that are available?

Erika: Interestingly enough, I have had a couple come, which is just so cool.

Dennis: Yeah, absolutely.

Erika: I just love thinking that there are people out there who would also like to have their hobby become their job. It's so freeing to be able to swim and work with a group of people who are not able to access this. I'm so thankful that you made the connection between Franklin County and me when I first started here.

Dennis: It's funny how these little things come around.

Erika: It is so true.

Dennis: I am assuming that you've had capstone students that have helped?

Erika: Absolutely. I had a student from Marquette University this last summer, and I've had students from our own program doing this. I love to help capstone students get the opportunity to be involved in interventional translational research. They help with some of the data analysis and exposure to why it is important to collect the data. They also get to be in the water and get some of those hands-on skills. One of my other favorite things is mentoring students, and that's the whole reason that I moved into academia. I want to help make better practitioners. If any capstone students are listening, please reach out.

Dennis: How many years have you guys been doing this? 

Erika: We started in 2019.

Dennis: Then, the global pandemic happened.

Erika: Yes, and we picked up again in early 2021. I've been working at the county for eight years and have a great relationship with them. They keep their pool at 90 degrees, so it's great for little bodies but a little hot for the grownups. The pool deck is at 85 degrees, and the humidity is anywhere from 60 to 70%. So it can be pretty rough some days.

Dennis: Have you had any of your students start up an aquatics program after graduation?

Erika: Yes, I have had a couple. One in Chicago is working for a private practice, and she's been doing some groups. One is down in the Carolinas, also working for a private practice. We've also had a few private practices, at least one here in Columbus, that's going to be doing some aquatics using this methodology. I'm excited to know that I have had an effect on getting people to think differently about aquatic therapy and its use. It's a great adjunctive to land therapy and drowning prevention. 

Dennis: You go, Dr. Kemp. That's pretty cool. I assume the people who are working for the private practice clinics are probably billing for it directly?

Erika: Some of them are doing it on a cash, fee-for-service basis. I know that even in that model, some county DD waiver money is helping pay for some of that. I do believe that some of the other private practices that I mentioned are billing units, whether that's for early intervention units or private Medicaid. Again, I do think that it is billable, and I think it's all about how you frame what you are doing. This includes things like motor planning, multi-step direction following, social interaction/participation, ADLs, and cognitive/safety awareness.

Dennis: Have you been talking with other organizations about their interest in funding?

Erika: I think the developmental board of disabilities in your area is a good first choice. I've also seen Autism Speaks fund different projects. There is also some funding for drowning prevention right now. In fact, the NIH is calling for interventions specific to drowning prevention for all individuals, not just individuals with disabilities. I think we're going to see more and more interest in this topic across ages and from neurotypical to those with disabilities. I think we need to be creative and think about other nonprofit organizations in the community.

Opportunities may exist to offer inclusive lessons to individuals who can't afford regular swim lessons. Let's be honest, swim lessons cost money, even at your local community center. So how can you maybe partner with your local community center to offer this at a low cost and then look at nonprofits in your area to help fund this type of intervention? This may be especially if you're in a private practice where you have the freedom to be able to work with different payer sources. How can you think outside of traditional medical insurance to be reimbursable? I think that one of the cool things about OT is that we have the skill set to do that and to think about serving populations. We can then take that business plan that you had to write back in your master's or doctorate course.

Dennis:  I think there's lots of opportunity as well with partnering with children's hospitals. Many of them have pools, and they may be able to partner with an academic program to deliver this program. 

Erika: School districts often also have pools. Can you take your kids there for therapy? If you have an ADL or a strength goal, it's a perfect time to work on that. Where I am located, there is a successful program where therapists bring kids for therapy during the day, and then our program is during after-school hours. I think getting creative about how we provide this to kids is important.

Dennis: This may be a great idea for extra treatment in the summer. 

Erika: Yeah, that's a great idea. 

Dennis: There are many options. Dr. Kemp, way to go with all of your work in this area.

Erika: Thank you.

Dennis: You are making a difference in the profession. I appreciate our chat today, and I know I've learned a lot. Any other last-minute advice you have for people?

Erika: Get in the water and take that first step. You never know what'll come of it.

Dennis: Well, Dr. Erika Kemp from the Ohio State University, thank you so much for your time today.

Erika: Thank you. It was good to talk to you.


Please refer to the outline and handout.


Kemp, E., and Cleary, D. (2023). AquOTic! A therapeutic aquatic intervention for kids on the autism spectrum podcast. OccupationalTherapy.com, Article 5650. Available at www.occupationaltherapy.com

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dennis cleary

Dennis Cleary, MS, OTD, OTR/L, FAOTA

Dr. Dennis Cleary has over 25 years of experience as an occupational therapist.  Dennis’ clinical practice has been primarily with children and adults with intellectual disabilities to encourage their full participation in all aspects of life at home, work, and in the community. He has had faculty positions at The Ohio State University and Indiana University. As a researcher, he has been on teams that have received over seven million dollars in grants from state and federal agencies, including a National Institutes of Health multisite trial of the Vocational Fit Assessment, an age-appropriate transition assessment, which he co-created. He has numerous publications and national and international presentations. Dennis is passionate about increasing the role of Occupational Therapy in transition-age service with the goal of improving outcomes and quality of life for all. 


erika kemp

Erika Kemp, OTD, OTR/L, BCP

Erika Kemp is the Doctoral Capstone Coordinator and Director of Clinical Education for The Ohio State University’s entry-level occupational therapy doctorate program.  She has experience as a clinician in pediatric outpatient and school-based settings as well as adult acute care.  She has been the academic fieldwork coordinator for an OTA program as well as MOT and OTD programs and is passionate about shortening the gap between practice and academia.

Related Courses

AquOTic! A Therapeutic Aquatic Intervention For Kids On The Autism Spectrum Podcast
Presented by Erika Kemp, OTD, OTR/L, BCP, Dennis Cleary, MS, OTD, OTR/L, FAOTA
Course: #6166Level: Introductory1 Hour
Kids on the autism spectrum are particularly vulnerable to drowning incidents. Occupational Therapy practitioners have a unique skill set to help autistic kids and their families learn to swim and be safe around the water. This is part of the Continued Learning Podcast series.

Educating Future Occupational Therapists Podcast
Presented by Erika Kemp, OTD, OTR/L, BCP, Dennis Cleary, MS, OTD, OTR/L, FAOTA
Course: #5618Level: Intermediate1 Hour
An overview of the myriad ways practitioners can become involved in the education of future occupational therapists will be discussed in this podcast. The types of student rotations, responsibilities of practitioners, and the benefits gained by the practitioner, site, student, and ultimately the profession as a whole will be reviewed. This is part of the Continued Learning Podcast series.

What’s Culture Got To Do With It? OT Practice With Pediatric Clients From Diverse Communities Podcast
Presented by Cristina Reyes Smith, OTD, OTR/L, Dennis Cleary, MS, OTD, OTR/L, FAOTA
Course: #5690Level: Introductory1 Hour
The meaning in occupational engagement is rooted in the client's cultural heritage. Occupational therapy practitioners must be aware of and sensitive to any client's culture, but it is especially important for pediatric practitioners at this formative stage of life. This is part of the Continued Learning Podcast series.

Evaluation And Treatment Of Cerebral Visual Impairment Podcast
Presented by Karen Harpster, PhD, OTR/L, Dennis Cleary, MS, OTD, OTR/L, FAOTA
Course: #5995Level: Introductory1 Hour
On the podcast, we will discuss the role of the occupational therapist in the evaluation and treatment of children with cerebral visual impairment (CVI). We will discuss how CVI affects performance in activities of daily living. This is part of the Continued Learning Podcast series.

Promoting Participation and Mental Health in Children and Youth: Every Moment Counts and ESSA (Every Student Succeeds Act) Podcast
Presented by Susan Bazyk, PhD, OTR/L, FAOTA, Dennis Cleary, MS, OTD, OTR/L, FAOTA
Course: #5753Level: Intermediate1 Hour
Occupational therapy's role in mental health promotion, prevention, and intervention when working with all children and youth -those with and without disabilities and/or mental illness- in schools and community settings will be explored. It will include Every Moment Counts’ initiatives and opportunities with ESSA, Every Student Succeeds Act. This is part of the Continued Learning Podcast series.

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