If there were already a tidy, laminated protocol telling pediatric therapists exactly how to integrate water competency into aquatic therapy, you and I wouldn’t be having this conversation.
But there isn’t.
Not by a long shot.
Across the literature, no standardized, consensus-backed guideline exists for embedding water competency skills into medically necessary aquatic therapy for children with disabilities — not for ASD, not for CP, not for Down syndrome, and not for neuromotor delay.
Yes, we have the Halliwick Concept, and yes, we have tools like the Humphries’ Assessment of Aquatic Readiness (HAAR), and even newer profession-specific practice models like the AqOTic framework for occupational therapists [7], but each of these respected systems focuses on participation, sensory-motor development, or aquatic skill readiness within therapy.
None offers a roadmap for embedding survival-oriented water-competency micro-skills while still maintaining fidelity to CPT codes, therapeutic goals, and ethical scope of practice.
Even the American Academy of Pediatrics, long a leader in drowning prevention, offers guidance on swimming lessons for children with disabilities but does not describe how water competency should interface with therapy practice.[4]
And although recent qualitative studies have captured the real-world barriers (accessibility, cost, sensory overload, instructor preparedness) none have proposed a uniform method for integrating water safety foundations into rehabilitation. [5–6]
So we are in familiar territory:
Therapists are already doing the work; the literature just hasn’t caught up.
Below is what the evidence does support, and what any future protocol must hold if it is to honor both therapeutic rigor and drowning-prevention urgency.
I am suggesting that the time is right to develop a framework (for the time being, let's call it Foundational Aquatic Safety Techniques & Skills™ or FAST Skills™ as shorthand)
I am suggesting that the time is right to develop a framework (for the time being, let's call it Foundational Aquatic Safety Techniques & Skills™ or FAST Skills™ as shorthand)
Working Definition of Foundational Aquatic Safety Techniques & Skills™ (FAST Skills™) - The intentional integration of foundational, developmentally appropriate water-safety micro-skills into therapeutic activities, designed to improve a child’s orientation, breath control, postural security, hazard awareness, and capacity to make safe choices in aquatic environments — without providing swimming instruction and without altering the clinical goals, therapeutic documentation, or skilled nature of aquatic therapy.
Key Considerations for Building an Integrated Framework: FAST Skills™
1. Clinical & Therapeutic Alignment
Before we talk about water competency, we talk about clinical objectives — because the therapy must remain therapy.
The good news: survival swimming skills mirror therapeutic targets in the following and more:
- Breath control = respiratory and motor coordination
- Rotational control = postural reactions
- Vertical-to-horizontal transitions = balance, motor planning
- Calm recovery and self-orientation = sensory regulation and executive function
These overlap directly with findings from the systematic review on aquatic therapy and neurodevelopmental disorders [1] and are emphasized across Halliwick literature and related scoping reviews. [2–3]
In other words, embedding safety-related movement patterns into therapy does not distort the therapy.
It reinforces it.
Validated tools such as HAAR provide an objective way to track both therapeutic progression and aquatic readiness. [3]
The therapist’s job is to maintain fidelity to evidence-based aquatic therapy methods while intentionally pairing these methods with survival-oriented elements. The research gives us the ingredients. It simply hasn’t written the recipe. [2–3]
2. Individualization & Developmental Readiness
Children with ASD, CP, Down syndrome, and neuromotor delays bring profoundly diverse sensory, motor, and cognitive profiles. [5–6]
Any integrated water competency framework must:
- respect developmental readiness
- avoid pushing safety skills before the child has the sensory or motor foundation
- track progress according to both therapeutic and aquatic benchmarks [1–3]
This mirrors the AAP’s warnings that water exposure must match a child’s developmental stage, particularly regarding submersion, cold exposure, and task demands. [4]
3. Caregiver Education & Family Alignment
This one may be the most important. Parents often misunderstand what “water ability” looks like in their child, especially in ASD populations. [6] Evidence shows families frequently overestimate skills, underestimate risk, and lack access to adaptive lessons. [5–6]
Any framework must include:
- caregiver training
- reinforcement of water safety rules
- clarification that competency is not a one-time milestone
- realistic discussion of supervision and environmental risk [4]
Families must understand that water competency is layered, progressive, and not a replacement for supervision.
4. Safety and Medical Considerations During Therapy
The AAP reminds us that water ingestion, submersion tolerance, thermoregulation and pool chemical exposure are troublesome concerns for disabled or medically fragile children. [4]
These must be addressed directly within the framework:
- warm-water parameters
- limited forced submersion
- clear infection-control measures
- therapist qualifications and emergency readiness
The framework must protect safety and avoid substituting swimming lessons for therapy.
5. Program Structure & Dosage
One of the more glaring gaps in the evidence: There is no standardized dosage for aquatic therapy, let alone for water competency integration. [2]
Different programs vary dramatically in:
- frequency
- duration
- instructional strategies
- progression criteria
Any framework should define:
- minimum practice opportunities for competency behaviors
- progression pathways that do not derail therapeutic progress
- methods for layering motor and safety tasks in evidence-based ways
Again, the literature gives no firm answers, only direction. [1–2]
6. Instructor and Therapist Training
Rehabilitation professionals and swim instructors alike report gaps in confidence and skill when working with children with disabilities. [5]
Therapists need training in:
- embedding water competency without drifting into swimming-instruction territory
- disability-specific readiness and safety cues
- balancing therapeutic goals with safety-oriented elements
Instructors need training in:
- communication
- sensory regulation
- adaptive equipment
- behavior strategies
This is echoed across qualitative studies in both provider groups. [5–6]
7. Outcome Measurement
We cannot claim a framework is preferred if we cannot measure its impact.
Evidence endorses the use of tools consistent with ICF domains — body function, activity, and participation — to evaluate both therapy progress and aquatic readiness. [1]
But the biggest gap is here:
No long-term studies have measured whether integrating water competency into therapy actually reduces drowning risk.
The need is openly stated across drowning-prevention literature. [1][4]
Any framework we build must include measurable outcomes and push toward the longitudinal data the field is missing.
8. Ethics, Billing & Scope of Practice
Therapists must document therapeutic goals, not swimming ability.
But legitimate therapeutic interventions can include skills that meaningfully enhance water safety — if they are tied to neuromotor, sensory, or functional objectives. [1–3]
A framework must spell out:
- how CPT 97113 (aquatic therapy) supports water-competency-adjacent movements
- how to avoid misrepresenting swimming instruction as therapy
- how to document medical necessity while capturing safety benefits
Done correctly, the integration is ethical, defensible, and evidence-informed.
9. Accessibility & Equity
Finally, no framework can ignore the profound disparities identified across the literature:
- sensory-unfriendly pool environments
- lack of adaptive programs
- cost barriers
- transportation challenges
- cultural perceptions of disability and recreation [5–6]
A framework must be usable in:
- community pools
- private clinics
- hospital therapy centers
- school-based programs
or we risk building something clinically elegant but practically irrelevant.
Where the Field Must Go Next
To develop a real, replicable, ethical framework, the field needs collaborative input from:
- pediatric PTs and OTs
- aquatic therapy specialists
- drowning-prevention experts
- families and caregivers
- adaptive aquatics instructors
Therapists are already doing fragments of this work. The research simply hasn’t codified it yet.
But the evidence is clear:
This isn’t mission creep. It’s mission critical.
Water competency belongs in therapy — and kids with disabilities can’t afford for us to wait.