Tips for the Pediatric Therapist: Overcoming a Child’s Fear of the Water

A blast from the past. Here is one of the 300+ aquatic articles our team has written for Advance magazine over the last 10 years. The Advance magazine archives are no longer available online, so we are preserving them here.

Byline: Andrea Salzman, MS, PT

All newborns are very sensitive to movement, especially rapid movements such as the sudden loss of support, rapid elevation of the body, or jarring of the support surface. In newborns, this manifests as a startle reflex — usually followed by a quick gasp and a cry. As the child matures, these reflexes are supposed to take a back-seat. Children are designed to adapt and no longer over-react to positioning changes. 

However, with children with gravitational insecurity and other sensory issues, sudden movements or environmental changes continue to create bodily over-reactions. 

A child who is quickly transitioned from land to water without proper preparation or handling may scream or cry out. This, quite naturally, stresses the therapist or parent, who often exacerbates the problem by reacting in a negative or overly physical manner, such as by clutching the child. Anxiety passes back and forth in a palpable and physical manner.

Water orientation should occur early in life before a child learns to fear water. The parent or therapist should attempt to control as many variables as possible to make every initial experience pleasant. This includes controlling water and room temperature, lighting, loud or unexpected noises and distractions. The initial contact with water immersion should occur with a parent or therapist who is extremely comfortable in water and who has good handling skills.

Carolyn Shank believed that it is often more the reaction to an incident than the incident itself which affects whether negative associations develop further down the line.1 She made some excellent recommendations on how to ease the transition without enabling negative associations. Her ideas were explored and expanded at a recent Aquatic Therapy University seminar.2 The resulting clinician-friendly ideas are provided here.

Orient to New Environments

Adults know what a pool looks, feels, smells and sounds like. Crowded locker rooms, noisy pump rooms, high ceilings, drafty air currents and poor acoustics are taken in stride as there is nothing novel about them.

To a child, however, a pool is often virgin territory—-full of incomprehensible newness. A parent or therapist approaching a pool visit for the first time should take a physical tour of the facility with an emphasis on orienting the child to everything. It is even quite possible that the first visit or two to the pool may never culminate in actual use of the pool. 

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It is even possible to incorporate social stories about the pool trip and to begin telling the stories at home, in the car, and in the locker-room, all in an attempt to alleviate the newness factor. Take the opportunity to observe other children enjoying themselves. Sit near the pool and let the child dictate moving closer to the edge, either in response to other children or to some toy intentionally positioned near the pool.

Use a Logical Progression 

To ease the stress of the new environment, therapists should make logical leaps when introducing water. There should be a natural progression from shallow water to deep, from a small body of water to a larger body of water and from a quiet pool to an active one. A child should not be asked to progress further down the chain until he is obviously comfortable with the existing situation.

Avoid Structural Hazards

Pools, locker rooms, and decks are full of structural hazards. The child that starts to slip on the pool deck begins to walk gingerly and fearfully. The child who falls, refuses to get up. The child who has to hurdle noodles, detour parked wheelchairs and dodge on coming traffic may just turn-tail and run. Add to this the terror of being immersed into the water by lift or other means. Even adults feel terrified at the act of being lifted like a slab of beef in a sling then swung and suspended over water. The child who is lowered into the water via a sling lift feels unbelievably unsupported and out of control. 

Even the pools themselves are full of potential hazards such as unexpected drop-offs in water depth, sudden changes in water flow from nearby jets, turbulence from nearby activity, and underwater structures such as benches, bulkheads or parallel bars. 

Take Responsive Action

When minor mishaps occur, they should be treated lightly. The child who just went beneath the surface unintentionally and is OK (but upset) should be congratulated for not drinking all the water in the pool.  

Spoken reassurances can also go a long way towards alleviating fears without giving them undue power. A comment such as “I’ll bet that scared you” or “What a fright you had” can go a long way towards sharing the moment without exacerbating its import. 

Back Off Then Re-introduce a Different Way

Finally, in the event that a child is truly unwilling or unable to make the transition from land to water, let it go. Allow the child to reestablish confidence gradually and at his own pace. When ready to reintroduce water-time, try some of these tried-and-tested suggestions from the aquatic field. 

• Social Stories. Use social stories to transition from car to building or from locker room to pool.

• Communication Board. Add structure/predictability by providing a picture schedule.  Use laminated pictures of actual items or symbol of items to provide on Velcro strip or draw pictures/write list on dry erase board.

• Timer. Use a visual timer to indicate when session will be over.

• Choice. Encourage self-help skills by allowing choices. Allow the child to help design the order or the schedule or take turns choosing activities.

• Comfort Item. Bring a favorite toy from home to pool as transition item for comfort.

• Bartering. Use “First _______, Then ______” language (first we will do what I ask, then we will do what you want).

• Mini-Pool. Fill a large tub with pool water and toys to allow play on pool deck near the pool. Once the child gets into the container, slide the entire container into the pool with the child inside.

• Swaddling. Wrap the child in a large warm towel or bath blanket and hold close to therapist’s body when entering the pool

• Slide Entry. Use a mat to create a slide leading from the pool deck to the water. Be very cautious about the child walking on a wet mat as some mats are slippery when wet.

• Safe Spot. Use toddler platform as a “safe zone” island in the water. Return to this safe place when child needs a break. Keep the child’s comfort item here as well.

• Visual Path. Create a visual pathway from the pool deck into the water to overcome stressors. Use non-skid footprints (such as those used in tubs), poly spots or other items to “lead” from the locker-room to the pool.
  

Conclusion

For many children seen in therapy, transitions are a painful part of life. Pediatric therapists see the trauma a simple change in activity can inflict on their kids… in the clinic, the community pool or at home, in the bathtub or shower. The wise clinician learns to develop strategies to make these aquatic transitions tolerable. The master clinician learns how to make them fun.3

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References

1. Shank CB. “A Child’s Fear of the Water Environment”. Children's Environments Quarterly. 1987; 4(2). Available online at: www.colorado.edu/journals/cye/CYE_BackIssues/CEVol4%282%29Contents.htm

2. Salzman A, Tvrdy J. Aquatic Sensory Integration for the Pediatric Therapy: A Distance Learning Module. Plymouth, MN: Aquatic Resources Network. 2009. Available at www.swimatu.com

3. Salzman , A. A Poolside Practicum. Part 1. PTs Can Use Aquatic Therapy to Teach Transitions in Children with Autism.