Staying Afloat: A Scoping Review of the Literature on Adapted Swim Instruction

Abstract

Importance

Individuals with disabilities may require adaptations and modifications during swimming instruction.

Objective

The purpose of this scoping review is to summarize the literature on adapted swim instruction including the following: (1) identifying adapted swim strategies; (2) determining which populations have received adapted swim instruction; and (3) identifying gaps in the research.

Data Sources

Six databases were searched for records published on or before September 29, 2025, including: PubMed, Excerpta Medica Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), SportDiscus, Web of Science, and Education Resources Information Center (ERIC).

Study Selection and Data Collection

Studies were included in this review if they were peer-reviewed, written in English, focused on beginner swimming skill instruction, included participants with disabilities and/or instructors/caregivers of individuals with disabilities, and consisted of original research studies. Studies were excluded if they were not peer-reviewed, not written in English, or not focused on beginning swim instruction.

Findings

Fifty-five studies met inclusion criteria and described interventions for individuals with disabilities. Studies discussed 26 adaptive strategies utilized for swimming instruction. Two studies were Oxford Level 2 studies, indicating randomized-controlled trials and definitive observational studies.

Conclusions and Relevance

There is a lack of robust, high-quality studies on adapted swim instruction, indicating a need for future studies to strengthen the evidence base.

Plain-Language Summary

Drowning is one of the leading causes of death for children ages 0 to 4, and individuals with disabilities are at an even higher risk of death by drowning. Swim lessons are an important tool for drowning prevention but may not be tailored to support the needs of people with disabilities. Adapted swim instruction is an emerging clinical practice area for occupational therapists and other rehabilitation professionals to partner with disabled individuals and their families to support independence in swimming. This review paper describes the literature to date on adapted swim instruction strategies and describes gaps in the literature for clinicians and researchers to address. This article advocates for broader accessibility of adapted swim instruction for people with a variety of disabilities to increase their safety in home and community settings. Future research should utilize rigorous study designs such as randomized controlled trials to strengthen the literature on this important topic.

Positionality

The first author is a white woman who has been working with children and adults with disabilities for nearly 14 years. She is a licensed occupational therapist whose research focuses on developmental disability and functional rehabilitation. The second author is a white woman and licensed occupational therapist who works with children with autism. The third author is a female recreational therapist, university teaching professor, and former triathlete with 15 years of professional experience serving individuals with disabilities. Her teaching and research focus on examining how adapted sports and recreational activities influence health outcomes and quality of life for individuals with disabilities. The fourth author is a white woman and licensed occupational therapist who has an autistic family member. She specializes in clinical intervention research for autistic individuals. The fifth author is a white woman and licensed occupational therapist with extensive clinical experience with children with disabilities, former swim coach, and triathlete. She is now university professor, program director, and is engaged in aquatic therapy research.

What This Article Adds

This study identifies strategies and populations most often studied in adapted swim instruction and provides suggestions for researchers and therapists looking to advance scholarship and practice in this emerging area of intervention.

Swimming is the fourth most popular sport activity in the United States, and the ability to swim can significantly reduce the risk of drowning (Centers for Disease Control and Prevention, 2024). Drowning is a major public health concern, leading to almost 236,000 deaths worldwide in 2019 (Liu et al., 2025). Furthermore, drowning deaths continue to increase in the United States (Clemens et al., 2024). In the United States, approximately 4,500 people die each year from drowning (Centers for Disease Control and Prevention & National Center for Injury Prevention and Control, 2024). Formal swimming lessons are recognized as an important preventative strategy and are widely recommended to reduce the risk of drowning (Centers for Disease Control and Prevention, 2025; Wallis et al., 2015; World Health Organization, 2017).

Several circumstances can increase a person's drowning risk such as low socioeconomic status or racial/ethnic minority status, and disabled individuals are at an especially high risk of accidental drowning (Klosky et al., 2025). While formal swimming lessons are a vital tool for drowning prevention, the approaches used in traditional learn-to-swim swimming instruction programs may require accommodations or modifications to optimize lessons for people with disabilities (American Red Cross, 2014; Gelinas & Reid, 2000). The scientific literature has devoted relatively modest attention to drowning risk and swimming instruction among individuals with disabilities (Peden et al., 2022); a group which accounts for nearly 42.5 million people, or 13% of the civilian noninstitutionalized population in the United States (Crankshaw, 2023). Adapted swimming instruction, or approaches which promote accessibility of swim lessons, can make it possible for people with disabilities to develop swim competence and reduce their risk of accidental drowning (Carson et al., 2025).

Traditional Versus Adapted Swim Instruction

Many traditional swimming instruction programs provide lessons in a controlled aquatic environment such as a pool, and lessons are designed to teach swim skills in order of increasing difficulty (Forde et al., 2020). The progression of skills can include entering the water, breath control, floatation, treading water, and fundamental strokes such as the front crawl, breaststroke, or backstroke (Forde et al., 2020; Stallman et al., 2008). Traditional swimming instruction programs focus on a bottom-up approach in which individuals gradually master simpler components before progressing to more complex components (Gelinas & Reid, 2000). Skills are presented in a linear sequence, and if a swimmer is unable to master a given skill in an early sequence, they may not be permitted to continue onto the next level of instruction (Gelinas & Reid, 2000). While this traditional approach may work well for children without disabilities, it may not be valid for children with disabilities who typically require modifications or accommodations for accessing the instructional environment or for demonstrating and mastering skills (American Red Cross, 2014; Gelinas & Reid, 2000). Teaching swimming skills to individuals with disabilities requires additional knowledge and disability-specific techniques and expertise (Conatser et al., 2000; Conatser & Block, 2001; Kraft & Leblanc, 2018). For example, working with children with diagnoses such as cerebral palsy (CP), Down syndrome (DS), or developmental coordination disorder (DCD), requires knowledge and practical experience in managing the physical aspects of these conditions (e.g., anatomical and physiological variations) (Declerck et al., 2016; Grosse, 2020; Milligan et al., 2022). Specific health factors including physical and neurological aspects of different conditions can impact children's gross motor skills, muscular strength, and endurance which are required for swimming (Forde et al., 2020).

In previous studies, swim instructors have expressed feeling under-qualified to facilitate adapted swim classes for swimmers with disabilities (Carter & Koch, 2023; Conatser et al., 2000). While the literature in adapted swim instruction is emerging, there is not a clear consensus on effective adaptations or modifications for adapted swim instruction. Thus, this scoping review aimed to map the literature-to-date on adapted swim instruction, identify which populations have received adapted swim instruction, describe the strategies used in adapted swim instruction, determine which professions have been providing adapted swim instruction, and identify gaps in the literature for future research to address.

Methods

Procedures

A five-step scoping review framework was applied as follows: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting and extracting the data from articles; and (5) collating, summarizing, and reporting the results (Arksey & O’Malley, 2005; Levac et al., 2010). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were used to guide the study selection process (Tricco et al., 2018).

Inclusion/Exclusion Criteria

Articles were included if they met the following criteria: (1) peer-reviewed; (2) written in English; (3) focused on beginner swimming skill instruction, meaning basic swimming skills such as submersion, treading water, floating, swimming on front, swimming on back, etc.; (4) included participants with disabilities, instructors of individuals with disabilities, or caregivers of individuals with disabilities; and (5) consisted of original research studies. There were no limitations on the date of publication or participant age for the articles included to reflect the emergent nature of this practice and research area. Articles were excluded if they (1) addressed competitive swimming skills (e.g., breaststroke, butterfly, front crawl, and elementary backstroke) or (2) focused on the physiological effects of drowning, aquatic therapy, or benefits of the aquatic environment without addressing beginning swimming skills.

Search Strategy

Six databases were selected for their relevance to swimming and rehabilitation sciences, including: PubMed, Excerpta Medica Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), SportDiscus, Web of Science, and Education Resources Information Center (ERIC). A university librarian proficient in scoping reviews provided consulting services to optimize the search process, ensuring that relevant databases and results were included. Search terms encompassed the following: adapted OR adaptive OR modified AND disabilities AND swimming AND instruction. The search string for PubMed used MeSH terms to facilitate relevant article retrieval. A comprehensive list of search terms by database is included in Appendix 1. The last search was conducted on September 26, 2025.

Covidence, a web-based platform for conducting systematic and scoping reviews, was used to manage search results including data collection, automatic exclusion of duplicates, and study selection (Veritas Health Innovation, 2025). Study selection followed an iterative process of elimination based on inclusion/exclusion criteria. See Figure 1 for the PRISMA-Scr diagram. The first author, along with the third and fourth authors, independently screened all abstracts, titles, and keywords to determine whether they met inclusion criteria. Any disagreements were resolved through discussion. Abstracts marked “Yes” or “Maybe” were reviewed as full texts to determine whether they met the inclusion criteria. Excluded full-texts were agreed upon by two authors and categorized by exclusion reason (e.g., wrong study population). Hand searches of references were completed for all included full texts.

Figure 1.

PRISMA flow diagram of the study selection process. The flowchart illustrates the stages of screening and inclusion, mapping the number of unique records identified, screened, assessed for eligibility, and ultimately included in the systematic review. Managed and generated via Covidence systematic review software.

Data Charting

A list of variables of interest was created by the research team and compiled by the first and second authors into a data extraction chart including the study's origin (location of the work), study design (methodological approach), purpose (research objective), sample size (number of participants), participants age (age of study sample in years), participant disability category (conditions/diagnosis), intervention (specific approach to swimming instruction, if any), variables measured (assessments/outcomes), summary of findings (statistical results/qualitative findings), and level of evidence (Oxford level). The first and third authors independently rated each study using Oxford levels and resolved disagreements using discussion. Adapted swim strategies were extracted from each article charted in a separate table. Numerical syntheses were used to classify the types and quantities of each study design included, and the levels of evidence represented. The extracted articles were then examined in-depth to identify any text belonging to the code “adapted strategies or equipment.” If data were missing from articles, the first author contacted study authors for clarification. Extracted data were limited to what was explicitly written in each study's text.

Strategies used in included articles were extracted by the first and second authors using an inductive approach to allow patterns, themes, and categories to emerge organically from the articles rather than applying a predetermined framework. Through repeated, systematic reading of studies, the second author coded instructional methods, learner adaptations, environmental modifications, and outcome measures as they naturally appear, gradually clustering these observations into broader thematic categories. The first author reviewed, confirmed, and revised the strategies selected by the second author. This bottom-up analytic process was followed as adapted swim instruction practices in the literature proved diverse, context-specific, or under-theorized. The approach allowed the authors to capture nuances and innovative strategies that a predefined framework might overlook.

Results

For this scoping review, 55 articles were selected and summarized (Table 1) for variables of interest including the origin, study design, purpose, sample size, participant age, participant disability, intervention, variables measured, summary of findings, and level of evidence. Adapted swim strategies used in studies were organized according to frequency in Table 2. Studies originated from a total of 18 countries, with most being from the United States (n = 21) followed by Turkey (n = 7), Canada (n = 3), the Czech Republic (n = 3), Italy (n = 3), Israel (n = 3), Taiwan (n = 3), and Serbia (n = 2). There were 11 other countries represented. The most common study design was one group pretest–posttest design (n = 13) followed by pretest–posttest with control group (n = 11), multiple case (n = 11), qualitative (n = 7), single case (n = 5), observational study (n = 2), within-participant repeated measures (n = 2), mixed methods (n = 2), and randomized controlled trials (RCTs; n = 2). Studies were determined to be the following Oxford Levels: Level 2, indicating the strongest evidence outside of systematic reviews of randomized controlled trials and consisting of randomized controlled trials or observational studies with dramatic effects (n = 2), level 3, indicating nonrandomized controlled studies (n = 35), or level 4, indicating case-series or case-control studies (n = 18). The purpose of each study, details about each intervention, variables observed, and summaries of findings for each study can be located in Table 1. While participants from a variety of diagnostic categories were represented in the literature, most studies targeted autism (n = 38) followed by CP(n = 14), DS (n = 2), intellectual disability (n = 2), spinal cord injury/spina bifida (n = 2), or other (n = 2). Most interventions were conducted by swim instructors (n = 29), followed by physical educators (n = 8), healthcare students (n = 6), occupational therapists (n = 5), physical therapists (n = 4), special educators (n = 4), physiotherapists (n = 3), recreational therapists (n = 3), adapted physical activity instructors (n = 2), educators (n = 2), speech-language pathologists (n = 2), and a medical doctor (n = 1). Studies had relatively small sample sizes, with the largest number of studies reporting a sample size of 24 participants or less (n = 41) followed by sample sizes of 25 to 49 participants (n = 10), 50 to 99 participants (n = 2), and 100 or more participants (n = 2). Most studies included samples with only one diagnosis (n = 50) although some included participants from two or more diagnostic groups (n = 5). Studies included a wide variety of ages, including 0 to 4 years (n = 4), 5 to 12 years (n = 42), 13 to 17 years (n = 12), 18 to 30 years (n = 7), and 30 + years (n = 1). Note that some studies had samples with wide age ranges and therefore were counted under more than one age group. Oxford levels: level 2, indicating the strongest evidence outside of systematic reviews of RCTs and consisting of RCTs or observational studies with dramatic effects (n = 5), level 3, indicating non-randomized controlled studies (n = 22), or level 4, indicating case-series or case-control studies (n = 28).

Table 1.

Data Extraction Chart.

Citation	Origin	Study Design	Purpose	N	Age(s)	Disability	Interventionist	Intervention - Frequency - Duration (Total Hours, if Known)	Variables Measured	Summary of Findings	Level of Evidence
Peganoff (1984)	The United States	Single case study	To determine the effect of swimming on bilateral coordination of extremities, reciprocal movement of upper extremities, balance, and self-esteem for an adolescent with CP	1	14 years	CP	OT	Aquatic occupational therapy - 2 sessions/week - 8 weeks	Range of motion, bilateral coordination, reciprocal movement of upper extremities, balance, and self-esteem	Increase of 15 degrees of right shoulder flexion and 10 degrees of right shoulder abduction, improved midline orientation of right upper extremity, improvement in reciprocal upper extremity use, improved self-esteem	Level 4
Mackinnon (1997)	England	Single case study	To determine the effect of an aquatic program on swimming and gross motor skills for a child with CP	1	8 years	CP	P	Halliwick swimming - 1 session/week - 6 weeks	Gross motor skills and swimming skills	Overall, swimming skills and gross motor skills improved, especially balance skills	Level 4
Hutzler et al. (1998a)	Israel	Pretest–posttest with control group	To evaluate the effect of an aquatic program on respiratory function and water orientation for children with CP	46	5–7 years	CP	I	Individual aquatic program - 2 × 30min sessions/week - 6 months	Vital capacity and water orientation	The treatment group had a higher vital capacity after 6 months (p = .009) and improved water orientation scores (p < .001)	Level 3
Hutzler et al. (1998b)	Israel	Pretest–posttest with control group	To describe the effects of a movement and swimming program on motor function and self-perception	46	5–7 years	CP	I	Individual aquatic program - 3 × 30min sessions/week - 6 months (36 hr)	Self-concept and water orientation skills	No difference in self-concept scores but significant difference in water orientation skills (p < .001)	Level 3
Gelinas and Reid (2000)	Canada	Observational study	To determine whether traditional learn-to-swim progressions were appropriate for children with physical disabilities	40	5–12 years	CP, SCI, developmental delay, other physical disabilities	PE	Assessment - 45 min/week - school year	Swim skills	32 children were unable to perform the front swim progression, but majority could pass the front swim test 22 children were unable to perform the back swim progression	Level 4
Yılmaz et al. (2005)	Turkey	Multiple case study	To determine the effect of constant time delay on aquatic play skills in autistic children	4	7–9 years	Autism	E	Constant time delay - 3 × 60min sessions/week - 10 weeks (30 hr)	Correct “snake,” “kangaroo,” and “cycling” behaviors	The participants needed 12–13 training sessions to correctly imitate “snake,” “kangaroo,” and “cycling” behaviors	Level 4
Getz et al. (2007)	Israel	Pretest–posttest with control group	To compare the effects of an aquatic program versus a standard exercise program on physical competence, social acceptance, and social functioning	22	3–8 years	CP	I, P	Halliwick aquatic program - 2 × 30min sessions/week - 4 months (16 hr)	Aquatic independence, physical competence, social acceptance, and social function	Significant improvement in aquatic independence for the aquatic group (p < .003). The aquatic group showed an increase in social acceptance (p < .035). There was no difference in physical competence or social function	Level 3
Özer et al. (2007)	Turkey	Pretest–posttest with control group	To determine the effect of a 14-week swimming program on competence, body awareness, and problem behaviors in children with CP	40	5–10 years	CP	I	Swimming & aquatic exercise group - 3 × 30min sessions/week - 14 weeks (21 hr)	Competence, problem behaviors, body awareness	No significant difference in problem behaviors or competence (p > .05) but significant improvement in body awareness (p < .05)	Level 3
Kuhfuss and Lucas (2010)**	The United States	Observational study	To explore the experiences of 6 YMCA swim instructors teaching autistic individuals	6	Did not specify	Autism	I	YMCA swim lessons - Varied - Varied	Instructor perceptions	Instructors stated that they used parents as resources and tailored instruction to individual needs. They cited a range of comfort levels with teaching autistic students but none said they were extremely uncomfortable. Most said students with autism made progress more slowly than other students	Level 4
Pan (2010)	Taiwan	Within-participant repeated measures design	To determine the effectiveness of a 10-week water exercise swimming program on aquatic skills and social behaviors of autistic boys.	16	6–9 years	Autism	I	Water Exercise Swimming Program - 2 × 90-min sessions/week - 10 weeks (30 h)	Aquatic skills and social behaviors	Significant improvement in aquatic skills (p < .01). Overall improved prosocial behavior and fewer negative behaviors (p < .01).	Level 3
Rogers et al. (2010)	The United States	Multiple case study	To explore whether a constant time delay procedure would be effective in teaching autistic children basic swim skills	3	4–5 years	Autism	I	Constant time delay procedure - 2–3 60–45min lessons/week - 8 sessions	Flutter kicks, front crawl arm strokes, and head turns to the side	All 3 children were able to demonstrate flutter kicks, front crawl arm strokes, and head turns to the side within 3–8 sessions	Level 4
Yilmaz et al. (2010a)	Turkey	Multiple case study	To determine the effect of most-to-least prompting on swimming skills for autistic children	3	9 years	Autism	SE, PT	Most-to-least prompting - 3 × 60min sessions/week - 10 weeks (30 hr)	Simple swim progression behaviors	The participants needed 9 sessions in order to achieve the simple swim progression skills accurately	Level 4
Yilmaz et al. (2010b)	Turkey	Multiple case study	To determine the effects of a constant time delay procedure on Halliwick rotation skills during an aquatic intervention for autistic children	3	8–9 years	Autism	E	Constant time delay with Halliwick method - 45–102 min - 8–14 sessions (3.27 hr)	Vertical and lateral rotation skills	All 3 children were able to complete vertical and lateral rotation skills, but needed varying amounts of time in order to do so	Level 4
Casey and Emes (2011)	Canada	RCT	To examine the impact of swim training on speech and respiration and ability to pass a standardized swim test	28	12–18 years	DS	I	Adapted competitive swim model - 3 × 1hr lessons/week - 12 weeks	Respiratory aspects of speech and swim skills	Swim training did not significantly impact respiratory aspects of speech (p = .19). Improved maximum phonation duration (p < .001) No improvement in initiation volume or expired mean airflow All participants could pass the Swim to Survive test after the program	Level 2
Ennis (2011)	The United States	One group pretest–posttest design	To investigate the impact of an aquatic physical therapy program on aquatic skills and quality of life in autistic children	6	3–9 years	Autism, CP, spina bifida occulta	PT	Aquatic physical therapy - 1 × 60min session/week - 10 weeks (10 hr)	Aquatic skills and quality-of-life	All children improved in aquatic skills and 4 out of 6 children improved in quality of life. Parents reported satisfaction with the program	Level 4
Fragala-Pinkham et al. (2011)	The United States	Pretest–posttest control group design	To examine the impact of a group aquatic program on swimming skills and fitness in autistic children	7	6–12 years	Autism	PT, I	Group aquatic exercise program - 2 × 40min sessions/week - 14 weeks (18.67 hr)	Swim skills, cardiopulmonary endurance, muscle endurance, mobility skills, program satisfaction	No significant differences between control group and intervention group on outcome measures but significant within-group differences for the intervention group in water skills (p = .001) and swim classification (p = .02). Parents reported high satisfaction with program, instructors, and class size	Level 3
Pan (2011)	Taiwan	Within-participant repeated measures	To investigate the effect of an aquatic program on physical fitness and swimming skills in autistic children and their siblings	7	7–12 years	Autism	I	Group aquatic exercise program - 2 × 60min sessions/week - 14 weeks (28 hr)	Cardiovascular endurance, muscle strength, flexibility, body composition, and aquatic skills	Improved strength (d = .82-1.20), flexibility (d = .64), and cardiovascular endurance (d = .23) but not BMI. Significant improvements in aquatic skills (Cohen's d between .59–1.15)	Level 2
Chu and Pan (2012)	Taiwan	Pretest–posttest with control group	To examine the impact of peer- and sibling-assisted swim lessons on interaction behaviors and aquatic skills of autistic children	21	7–12 years	Autism	PE	Peer- and sibling-assisted group swim instruction - 2 × 60-min sessions/week - 16 weeks (32 h)	Interaction behaviors and aquatic skills	Children improved in swim skills (p < .05). Peer-assisted and sibling-assisted groups showed improvement in interaction behaviors (p < .01).	Level 2
Dimitrijević et al. (2012)	Serbia	Pretest–posttest with control group	To examine the effect of an aquatic intervention on gross motor and aquatic skills for children with CP	13	5–14 years	CP	MD, I	Halliwick aquatic therapy - 2 × 55min sessions/week - 6 weeks (11 hr)	Gross motor skills and aquatic skills	Significant improvement in gross motor skills and water orientation skills at week 6	Level 3
Jorgić et al. (2012)	Serbia	One group pretest–posttest design	To determine the effects of a Halliwick swimming program on swimming and gross motor skills in children with CP	7	7–11 years	CP	I	Halliwick swimming program - 2 × 45min sessions/week - 6 weeks (9 hr)	Gross motor and aquatic skills	Significant improvement in gross motor skills (p = .03) and water orientation skills (p = .02)	Level 3
Yanardag et al. (2013)	Turkey	Multiple case study	To examine the effectiveness of video prompting on aquatic play skills and motor skills	3	6–8 years	Autism	SE, P	Halliwick aquatic play and exercise - 3 × 60min sessions/week - 12 weeks (36 hr)	Percentage of correct steps for each play skill	All participants increased their performance of 3 aquatic play skills with video prompting and maintained these skills at 4 weeks. At 12 weeks, gross motor skills improved	Level 4
Lawson et al. (2014)	The United States	One group pretest–posttest design	To determine whether Sensory Supported Swimming improved swim skills and physical activity of autistic children	42	4–15 years	Autism	RT, OT, I	Sensory Supported Swimming - 2 × 30min sessions/week - 8 weeks (8 hr)	Sensory profile, swim levels, parent satisfaction	All participants improved in swim skills, with 74% improving by at least one swim level. Parents reported that their child was more physically active (85%) and more interested in swimming (91.9%)	Level 3
Vaščáková et al. (2015)	The Czech Republic	One group pretest–posttest design	To identify the effectiveness of the Halliwick method on adapted swimming skills for children with CP	10	5.5 years	CP and autism	I	Halliwick adapted swimming - Unknown - 10 weeks	Gross motor skills and swim skills	Children improved in basic swimming skills overall, including children with higher spasticity	Level 3
Jull and Mirenda (2015)	Canada	Multiple case study	To investigate the effect of behavioral skill training on swim skills and instructor use of strategies	8	5–8 years	Autism	I	Instructor behavioral skills training - 1x 30min session/week - 5 sessions (2.5 hr)	Instructor use of strategies, child compliance, swimming skills	All instructors except one showed improvement in skills such as rapport-building, clear instructions, etc. Three children showed increases in compliance while others had higher baselines 18%–100% of swim skills improved by at least one level	Level 4
Kafkas and Özen (2015)	Turkey	Single case study	To investigate the effectiveness of a swimming intervention using constant time delay procedures on swimming skills for a child with autism	1	8 years	Autism	PE	Constant time delay procedure - 2-4 hr/week - 24 months (192-384 hr)	Swimming skills and physical fitness	Improved psychomotor, language, communication, and swimming abilities	Level 4
Yanardag et al. (2015)	Turkey	Multiple case study	To examine the effects of most-to-least prompting during an aquatic intervention on water exploration skills in autistic children	3	6 years	Autism	PE	Most-to-least prompting - 3 × 60min sessions/week - 6 weeks (18 hr)	Blowing bubbles, face submersion, and retrieving objects	All participants were able to achieve all 3 skills using most-to-least prompting but required a wide range of trials (as few as 2 to as many as 20 trials) depending on the child	Level 4
Pimenta et al. (2016)	Brazil	Multiple case study	To describe the effectiveness of an aquatic program for 5 participants with autism	5	9–25 years	Autism	AP	Aquatic activity program - 1 × 80min class/week - 15 weeks (20 hr)	Aquatic skills	Overall, participants improved their ability to enter and exit the pool (including showering), breath control, front crawl, and backstroke skills. Front crawl and backstroke appear to show greatest variability in skill level	Level 4
Zverev and Kurnikova (2016)	Russia	One group pretest–posttest design	To evaluate the feasibility and effectiveness of a group adapted aquatic program for children and adolescents with CP	13	5–17 years	CP	AP	Group aquatic balance program - 2 × 45min sessions/week - 6 months (36 hr)	Parent/child satisfaction, balance and mobility, and swim skills	Parents and children shared no negative responses in ratings. Children improved significantly in balance and mobility measures (p = 0.000). Children increased in swimming levels (p = .011)	Level 4
Aherne and Coughlan (2017)	Ireland	Qualitative	To evaluate the suitability of an aquatics program for adults with	4	39–57 years	Intellectual disabilities	I	Halliwick aquatics program - 8–12 sessions, 30–45 min/session - 2 months (4-9 hr)	Service staff perceptions	Participants reported effects of the aquatics program on their mood and physical states. Facilitators included having support, encouragement within their organization, staff member attitudes, personal characteristics, and enjoyment. Barriers included time constraints, lack of resources, health conditions, disability impairments, and the propensity for things to go wrong. Strengths included frequency of sessions, 1:1 staffing ratio, positive relationships, consistency, and staff feedback. Needs included poor wellbeing, poor social connection, a need for more activity, difficulty with advocacy and understanding, and need for continued aquatic programming	Level 4
Alaniz et al. (2017)	The United States	One group pretest–posttest design	To examine the effect of aquatic therapy on swim skills and social skills in children with autism	7	3–7 years	Autism	OT, SLP	Group aquatic therapy program - 60 min/week - 24 weeks (24 hr)	Swim skills and social skills	Improved overall swim skills (p < .001) Improved breath control (p < .001) Improved ability to change positions (p < .05) Improved propulsion skills (p < .05) No improvement in navigation, exiting the pool, back float skills, or social skills	Level 3
Lawson et al. (2017)	The United States	One group pretest–posttest design	To determine if autistic children with various sensory preferences acquired swim skills differently in adapted swimming	83	4–17 years	Autism	HS	Sensory Enhanced Aquatics - 1 × 30min lesson/week - 8 weeks	Sensory profile and swim skills	Sensory seekers had the highest frequency of total swim skills. Across categories, water safety skills were demonstrated less frequently than water orientation, front stroke, and backstroke skills. Bystanders, avoiders, and sensors addressed water safety more than seekers	Level 3
Levy et al. (2017)	The United States	Multiple case study	Using behavioral strategies to teach underwater submersion to children with autism	3	4–8 years	Autism	I	Behavioral strategies - 1 × 30min session/week - 1 year (26 hr)	Submersion of head under water	Children needed 18–27 lessons to demonstrate underwater submersion without resistance	Level 4
Sato and Haegele (2017)	The United States	Qualitative	To describe the experiences of kinesiology students participating in an adaptive aquatics training with individuals with developmental disabilities	100	2–22 years	Intellectual disabilities	PE	Adapted aquatics training - 3–5 × 30–35 swim lessons/week - Varied (30 hr)	Student perceptions	3 themes: (1) ethical/unethical treatment of students with disabilities—students had difficulty keeping accurate data on the intervention which they viewed as unethical; (2) conflict of parents’ and students’ interests—some parents had unrealistic desires for their child although they did care; (3) medical and gender sensitivity—some students had seizures during the lessons and it was difficult to manage, especially if they were a different gender	Level 4
Caputo et al. (2018)	Italy	Pretest–posttest control group design	To evaluate the effectiveness of a multisystem aquatic therapy program, CI-MAT, with autistic children	26	6–12 years	Autism	I	Multisystemic aquatic therapy (CI-MAT) - 1–2 45min sessions/week - 10 weeks (7.5–15 hr)	Autism symptoms, adaptive behavior, and swim skills	Improved autism symptoms (p < .05) Higher daily living scores but not any other adaptive behavior (p < .01) Improved swimming skills (p < .0101)	Level 3
Battaglia et al. (2019)	Italy	Multiple case study	To understand the impact of the CI-MAT swimming program on locomotion, object control, and social behavior in autistic individuals	3	11–15 years	Autism	I	Multisystemic aquatic therapy (CI-MAT) - 2 × 45–50min sessions/week - 12 weeks (18–20 hr)	Social behavior and gross motor skills	Overall, improved gross motor skills and all participants improved in at least one of the object control skills. Participants improved in awareness of others and social eye contact	Level 4
Lawson et al. (2019)	The United States	Qualitative	To understand the swimming experiences of children with autism and their families	12	6–18 years	Autism	RT, HS	General swimming experiences - N/A - N/A	Perceptions of autistic children and their parents	Swimming was a meaningful activity for all families. Safety was a primary concern because children can be impulsive and unpredictable. Autistic traits impacted family swim experiences. Bonds with instructors were important for learning to swim. Parents shared a range of swim skills learned through lessons and preferences children had. Families shared difficulty accessing adapted swim lessons. Families described swimming as therapeutic	Level 4
Lawson and Lisk (2019)	The United States	One group pretest–posttest design	To understand the feasibility of measuring heart rate and perceived exertion during swim lessons	16	4–15 years	Autism	RT, HS	Sensory Enhanced Aquatics - 1 × 30min lesson/week - 7 weeks	Heart rate and perceived exertion	Only one out of 16 children could accurately report perceived exertion, and instructors had to report this instead. Instructors had difficulty manually taking pulses	Level 3
Zanobini and Solari (2019)	Italy	Pretest–posttest control group design	To determine the impact of an aquatic program on social skills, autistic behaviors, and aquatic skills in autistic children	33	3–8 years	Autism	SE	Water as a Mediator of Communication Program - 1 × 30min session/2 weeks - 24 weeks (6 hr)	Autistic behaviors, social skills, and swimming skills	Autistic behaviors decreased (p < .01), social skills improved (p = .049), and aquatic skills improved (p < .02)	Level 3
Gajić et al. (2020)	Bosnia and Herzegovina	One group pretest–posttest design	To determine the effect of the Halliwick method on swim skills, motor skills, and functional independence for children with CP	30	5–18 years	CP	I	Halliwick method - 1 × 60min session/week - 1 year (52 hr)	Swim skills, gross motor skills, functional independence skills	Swimming skills improved (p < .001) except for saggital rotation. Gross motor skills improved (p = .003) as well as functional independence (p = .006)	Level 3
Güeita-Rodríguez et al. (2021)	Spain	Mixed methods study	To determine the impact of an aquatic program on perceived competence, social acceptance, aquatic skills, and quality of life and to explore aquatic therapy experiences of parents of autistic children	6	6–12 years	Autism	PT	Water Specific Therapy Halliwick Sessions - 2 × 60min sessions/week - 7 months (56 hr)	Perceived competence, social acceptance, aquatic skills, quality of life, parent perceptions	Perceived social competence and social acceptance were significant (p = .026, r = .64), quality of life effect size was moderate (r > .3) in physical and social health and large (r > .5) in school functioning. The effect of the program on aquatic skills was large (r > .5). Themes included meaning of aquatic therapy, patterns of behavior and activities changes, and social communication/social interaction	Level 3
Johnson et al. (2021)	The United States	One group pretest–posttest design	To determine the impact of a swimming program for autistic children on child behaviors and parental psychological health	10	5.5–11 years	Autism	I	Individual swim lessons - 1 × 30min lesson/day - 12 lessons (6 hr)	Children's challenging behaviors, parent positive thinking, parent psychological wellbeing, parent anxiety	Parent positive thinking, psychological wellbeing, and anxiety improved with small effect sizes. Challenging behaviors decreased (d = 0.07–0.45). Parents were satisfied with instructors	Level 3
Munn et al. (2021)	The United States	One group pretest–posttest design	To determine the effectiveness of an adapted swim program for children and adolescents with autism	86	3–18 years	Autism	I	iCanSwim - 1 × 45–60-min lesson/day - 5 days (3.75-5 hr)	Swim skills	Of the 42 participants who started as nonswimmers, 22 increased to the beginner swimmer level Of the 36 who started as beginner swimmers, 17 increased to the intermediate swimmer level. The 6 swimmers who started at the intermediate level increased to the advanced level	Level 3
Tucker and Ingvarsson (2021)	The United States	Multiple case study	To evaluate the effectiveness of a behavioral intervention to teach 3 water safety skills	3	7–8 years	Autism	HS, I	Modified behavioral skills training - 3 × 10–15 lessons/week - 8–10 weeks (4–8 hr)	Turning/grabbing, floating/yelling for help, and rolling front to back	Participants needed 13–24 sessions to master all 3 skills for a total of 5–11 hr of swim instruction	Level 4
Samsudin et al. (2022)**	Malaysia	One group pretest–posttest design	To determine whether a swimming curriculum designed for students with disabilities would improve special educator knowledge about swim instruction	17	7–19 years*	Learning disabilities	SE	Aquaexplorers Module - Varied - 6 years	Teacher knowledge on swim instruction	Teachers showed improvement in swim instruction knowledge compared to before seeing the curriculum	Level 4
Marzouki et al. (2022)	Tunisia	Pretest–posttest control group design	To investigate the effect of 2 aquatic training programs on stereotypy, locomotion, and emotion regulation in autistic children	22	6–7 years	Autism	PE	Halliwick method - 2 × 50min sessions/week - 16 sessions (13.33 hr)	Gross motor skills, stereotyped behavior, and emotional regulation	Locomotor skills improved (p < .0001) Emotion regulation not different across conditions (p > .05) but improved over time (p < .0001) Stereotypy was reduced in all groups over time (p < .0001)	Level 2
Vernerova et al. (2022)	The Czech Republic	Qualitative study	To describe the role of volunteers in a swimming organization focused on people with disabilities	11	∼21 years	CP, muscular dystrophy	I	Swimming lessons - N/A - N/A	Swimmer, parent, and volunteer perceptions	6 main themes: health and wellbeing, self-esteem, new possibilities, community, social inclusion, and respite care	Level 4
Vodakova et al. (2022)	The Czech Republic	Single case study	To evaluate the effectiveness of a 7-week aquatic program for children with autism	7	7–12 years	Autism	I	Halliwick method - 1 × 60min session/week - 9 weeks (9 hr)	Aquatic skills and gross motor skills	Overall, participants improved in swim skills and gross motor skills over 7 weeks. Two participants did not improve in breath control skills	Level 4
Bekhet et al. (2023)	The United States	Qualitative study	To evaluate the necessity, acceptability, feasibility, safety, fidelity, and effectiveness of a swimming program for autistic children	10	5.5–11 years	Autism	I	Swimming Training Program - 1 × 30min session/day - 12 days (6 hr)	Caregiver perceptions	Participants reported that the intervention was necessary, content was appropriate, instructor creativity was key, and the number of sessions was acceptable	Level 4
Carter and Koch (2023)	South Africa	Qualitative	To explore the lived experiences of parents and swimming instructors of autistic children in South Africa	11	5–16 years	Autism	I	Individual sessions - Weekly - Varied	Teachers’ experiences, parents’ experiences, and teamwork	Lack of training for teachers means heavy reliance on a teacher's personality and prior experiences. Parents reported that swimming is a meaningful occupation for their children and families	Level 4
Flippin and Clapham (2023)	The United States	Single case study	To determine if a hybrid telehealth aquatics intervention would impact a father's use of strategies and his child's speech	1	5 years	Autism	PE, SLP	Sherrill Water Fun and Success Model 1 × 40min lesson/week - 12 weeks (8 hr)	Father's use of responsive strategies and child spontaneous word use	Improved use of follow-in comments and follow-in directive by father but not responsive object play. Small impact on child's single word use	Level 4
Kemp et al. (2023)	The United States	Mixed methods study	To determine the feasibility of an aquatic occupational therapy intervention for autistic children	8	3–7 years	Autism	OT, HS	AqOTic - 1 × 45–60min session/week - 10 weeks (7.5–10 hr)	Aquatic skills and goal attainment scaling, parent perceptions	All participants improved in aquatic skills, and participants met or exceeded individual goals. Parent interviews highlighted the value of aquatic OT, benefits of participation, and new skills achieved	Level 3
Kemp et al. (2024)	The United States	RCT	To examine the impact of AquOTic on water competency skills in autistic children	37	5–9 years	Autism	OT, HS	AqOTic 1 × 60min session/week - 10 weeks (10 hr)	Water orientation and swim skills	Water orientation skills improved significantly (p < .001) as did swim skills (Cohen's d = .86, p < .001)	Level 2
Rahayu et al. (2024)**	Indonesia	Pretest–posttest with control group design	To investigate the effectiveness of augmented reality for teaching students with hearing impairments on how to swim the breaststroke	22	Unknown	Hearing impairments	PE	Augmented reality swimming - Unknown - Unknown	Swim skills	Swimmers using augmented reality were more skilled at the breaststroke than students taught using traditional swim instruction (p < .05)	Level 3
Carson et al. (2025)	The United States	One group pretest–posttest design	To evaluate the changes from days 1 to 5 of an adaptive swim program	164	3–18 years	Autism, DS, or other	I	iCanSwim - 1 × 45–60min swim lesson/day - 5 days (3.75–5 hr)	Swim skills Reasons for not progressing (if applicable)	Improved overall swim skills (p < .001) Most progressed by at least one swim level (61.6%) followed by those who maintained the same level (36.3%) or progressed more than 2 levels (1.8%). For children with autism, “fearfulness” was the most common reason for not progressing, and for those with Down syndrome, needing more practice was most common	Level 3
Cosart et al. (2025)	The United States	Qualitative	To better understand the water safety experiences of parents of children with autism	21	*3–18 years	Autism	I	Swim lessons - Varied - Varied	Parent perceptions	6 water safety themes: characteristics of autism, influences on family life, difficulty accessing water safety information, effect of autism on participation, unique needs, and instructor preparedness	Level 4

Note: AP = adapted physical activity teacher; BMI=body mass index; CI-MAT = multisystem aquatic therapy; CP= cerebral palsy; DS = Down syndrome; E = educator; HS = healthcare student; I = swim instructor; MLP = most-to-least prompting; OT = occupational therapist; MD = medical doctor; P = physiotherapist; PE = physical education teacher; PT = physical therapist; RCT = randomized controlled trial; RT = recreational therapist; SCI = spinal cord injury; SE = special educator; SLP = speech language pathologist; YMCA = Young Men's Christian Association. N/A: indicates that due to study design, the data points are not applicable. . *In studies where participants are coaches or caregivers speaking about individuals with disabilities, ages, sample sizes, and disabilities included in the extraction chart are those of the individuals with disabilities (not caregivers or coaches). **Three corresponding authors were contacted via email for clarification regarding missing data for participants’ ages.

Table 2.

Data Charting Summary—Question 2: What Adapted Swim Instruction Strategies Have Been Described (and in What Populations)?

Strategy	Description	Condition	Characteristic	Articles	Frequency Count
Small instructor/swimmer ratio	Instructor to swimmer ratios included 1:1, 1:3, 1:5 ratios	Autism, CP, intellectual disabilities	Spastic/rigid muscles, muscle weakness (including UE, LE, and core)	(Aherne & Coughlan, 2017; Alaniz et al., 2017; Battaglia et al., 2019; Bekhet et al., 2023; Caputo et al., 2018; Carson et al., 2025; Carter & Koch, 2023; Chu & Pan, 2012; Flippin & Clapham, 2023; Fragala-Pinkham et al., 2011; Gajić et al., 2020; Hutzler et al., 1998a; Hutzler et al., 1998b; Johnson et al., 2021; Jorgić et al., 2012; Kafkas & Özen, 2015; Kemp et al., 2023, 2024; Lawson et al., 2014, 2019; Lawson & Lisk, 2019; Mackinnon, 1997; Marzouki et al., 2022; Munn et al., 2021; Özer et al., 2007; Pan, 2011; Pan, 2010; Pimenta et al., 2016; Vaščáková et al., 2015; Yanardag et al., 2013, 2015; Yılmaz et al., 2005, 2010; Zanobini & Solari, 2019)	(ƒ=35)
Strategic use of play/free time	Strategically using play or free time to motivate swimmers or practice specific skills	Autism, DS, CP, spina bifida occulta, intellectual disabilities		(Aherne & Coughlan, 2017; Caputo et al., 2018; Carson et al., 2025; Chu & Pan, 2012; Dimitrijević et al., 2012; Ennis, 2011; Flippin & Clapham, 2023; Fragala-Pinkham et al., 2011; Johnson et al., 2021; Jorgić et al., 2012; Jull & Mirenda, 2016; Kemp et al., 2023; Lawson et al., 2014; Lawson & Lisk, 2019; Levy et al., 2017; Marzouki et al., 2022; Munn et al., 2021; Özer et al., 2007; Pan, 2011; Pan, 2010; Samsudin et al., 2022; Vaščáková et al., 2015; Vodakova et al., 2022; Yanardag et al., 2013; Yılmaz et al., 2010; Zanobini & Solari, 2019)	(ƒ=26)
Skill progression through stages	Facilitating swim skills in a progressive manner following predetermined stages. Includes American Red Cross, Gabrielsen method, Halliwick Method, Silvia Method, CI-MAT, the Sherrill Model, and Transition approaches	Autism, DS, CP, intellectual disabilities		(Aherne & Coughlan, 2017; Battaglia et al., 2019; Caputo et al., 2018; Casey & Emes, 2011; Chu & Pan, 2012; Flippin & Clapham, 2023; Gajić et al., 2020; Getz et al., 2007; Güeita-Rodríguez et al., 2021; Johnson et al., 2021; Jorgić et al., 2012; Kemp et al., 2023; Lawson et al., 2014; Lawson & Lisk, 2019; Levy et al., 2017; Mackinnon, 1997; Marzouki et al., 2022; Pan, 2010; Pimenta et al., 2016; Samsudin et al., 2022; Vaščáková et al., 2015; Vodakova et al., 2022; Yilmaz et al., 2010a; Yılmaz et al., 2010; Zverev & Kurnikova, 2016)	(ƒ=25)
Disability-related training or experienced instructors	Utilizing a disability-focused training program or experienced adapted swimming instructor to teach swim skills	ADHD, autism, DS anxiety, behavioral disorders		(Alaniz et al., 2017; Caputo et al., 2018; Carson et al., 2025; Casey & Emes, 2011; Chu & Pan, 2012; Cosart et al., 2025; Getz et al., 2007; Güeita-Rodríguez et al., 2021; Johnson et al., 2021; Kemp et al., 2023, 2024; Kuhfuss & Lucas (2010); Lawson et al., 2014, 2017; Lawson & Lisk, 2019; Mackinnon, 1997; Marzouki et al., 2022; Munn et al., 2021; Pan, 2011; Pan, 2010; Tucker & Ingvarsson, 2021; Vodakova et al., 2022; Zanobini & Solari, 2019; Zverev & Kurnikova, 2016)	(ƒ=24)
Individualized approach	Understanding the swimmer's abilities, personal factors, and needs and adapting instructions or benchmarks to meet needs of the individual child	Autism, CP, DS, TBI, muscular dystrophy, spina bifida occulta, intellectual disabilities	Spastic/rigid muscles Muscle weakness (including UE, LE, and core), paralysis	(Aherne & Coughlan, 2017; Bekhet et al., 2023; Carson et al., 2025; Carter & Koch, 2023; Dimitrijević et al., 2012; Ennis, 2011; Flippin & Clapham, 2023; Fragala-Pinkham et al., 2011; Getz et al., 2007; Johnson et al., 2021; Kafkas & Özen, 2015; Kemp et al., 2023, 2024; Kuhfuss & Lucas (2010); Lawson et al., 2014, 2017, 2019; Lawson & Lisk, 2019; Mackinnon, 1997; Munn et al., 2021; Pan, 2011; Pan, 2010; Peganoff, 1984; Vaščáková et al., 2015; Vernerova et al., 2022; Vodakova et al., 2022; Yilmaz et al., 2010a; Yılmaz et al., 2005, 2010; Zanobini & Solari, 2019; Zverev & Kurnikova, 2016)	(ƒ=24)
Preparatory activities	Including focused/purposeful warm ups, strengthening activities to prepare for movement, using a task to prepare for another objective	Autism, CP, DS, spina bifida occulta	Spastic/rigid muscles Muscle weakness (including UE, LE, and core)	(Battaglia et al., 2019; Carson et al., 2025; Casey & Emes, 2011; Chu & Pan, 2012; Dimitrijević et al., 2012; Ennis, 2011; Fragala-Pinkham et al., 2011; Johnson et al., 2021; Kafkas & Özen, 2015; Munn et al., 2021; Özer et al., 2007; Pan, 2011; Pan, 2010; Pimenta et al., 2016; Vodakova et al., 2022; Yanardag et al., 2013; Zanobini & Solari, 2019; Zverev & Kurnikova, 2016)	(ƒ=18)
Positive feedback	In the form of verbal praise, token reward systems, CTD, MLP, medal, etc.	ADHD, autism, DS, behavioral disorders, anxiety		(Bekhet et al., 2023; Casey & Emes, 2011; Chu & Pan, 2012; Jull & Mirenda, 2016; Kafkas & Özen, 2015; Kemp et al., 2024; Lawson et al., 2014; Levy et al., 2017; Munn et al., 2021; Pan, 2010; Rogers et al., 2010; Tucker & Ingvarsson, 2021; Yanardag et al., 2013, 2015; Yilmaz et al., 2010a; Yılmaz et al., 2005, 2010)	(ƒ=17)
Orientation and mental adjustment	Providing opportunities and time for students to acclimate to the water environment and adjust to its properties. Relating to other familiar tasks with water (such as washing face)	Autism, CP, intellectual disabilities		(Aherne & Coughlan, 2017; Battaglia et al., 2019; Caputo et al., 2018; Getz et al., 2007; Güeita-Rodríguez et al., 2021; Hutzler et al., 1998a; Johnson et al., 2021; Jorgić et al., 2012; Kemp et al., 2023, 2024; Lawson & Lisk, 2019; Marzouki et al., 2022; Samsudin et al., 2022; Vaščáková et al., 2015; Vodakova et al., 2022; Yanardag et al., 2013, 2015; Zanobini & Solari, 2019)	(ƒ=17)
Focus on safety	Paying close attention to the safety of swimmers and understanding individual swimmer's precautions	ADHD, autism, CP, DS, seizure, behavioral disorders, anxiety, spina bifida occulta		(Alaniz et al., 2017; Bekhet et al., 2023; Carson et al., 2025; Carter & Koch, 2023; Cosart et al., 2025; Dimitrijević et al., 2012; Ennis, 2011; Kemp et al., 2023, 2024; Lawson et al., 2014, 2019; Lawson & Lisk, 2019; Munn et al., 2021; Özer et al., 2007; Pimenta et al., 2016; Tucker & Ingvarsson, 2021; Zverev & Kurnikova, 2016)	(ƒ=16)
Parent and/or swimmer collaboration	Collaborating with parents and swimmers, using their knowledge of what works best for the swimmer. Can include swimmer-directed sessions, parent involvement, using intake forms, or using the swimmer's preferred communication form	Autism, CP, developmental disability, spina bifida occulta		(Bekhet et al., 2023; Caputo et al., 2018; Carter & Koch, 2023; Cosart et al., 2025; Ennis, 2011; Flippin & Clapham, 2023; Johnson et al., 2021; Kemp et al., 2023; Kuhfuss & Lucas (2010); Lawson et al., 2014, 2017; Munn et al., 2021; Peganoff, 1984; Sato & Haegele, 2017; Zverev & Kurnikova, 2016)	(ƒ=16)
Visual demonstration	Use of visual cues including video demonstration and VAS	Autism, hard of hearing/deaf, developmental delay, SCI, general and physical disability		(Bekhet et al., 2023; Chu & Pan, 2012; Fragala-Pinkham et al., 2011; Gelinas & Reid, 2000; Güeita-Rodríguez et al., 2021; Jull & Mirenda, 2016; Kafkas & Özen, 2015; Kemp et al., 2023; Lawson et al., 2014, 2017; Munn et al., 2021; Pan, 2011; Pimenta et al., 2016; Rahayu et al., 2024; Yanardag et al., 2013)	(ƒ=14)
Physical support and positioning	Manual assistance and positioning of swimmer	Autism, DS, ADHD, anxiety, behavioral disorders, intellectual disabilities		(Aherne & Coughlan, 2017; Alaniz et al., 2017; Carter & Koch, 2023; Casey & Emes, 2011; Fragala-Pinkham et al., 2011; Lawson et al., 2014, 2017, 2019; Pimenta et al., 2016; Rogers et al., 2010; Tucker & Ingvarsson, 2021; Yanardag et al., 2013, 2015; Yilmaz et al., 2010a)	(ƒ=14)
Multidisciplinary collaboration	Collaborating with OT/PT, physician to gain knowledge of medication, safety, specific needs, and adaptations	Autism, CP		(Alaniz et al., 2017; Battaglia et al., 2019; Ennis, 2011; Fragala-Pinkham et al., 2011; Getz et al., 2007; Güeita-Rodríguez et al., 2021; Kafkas & Özen, 2015; Kemp et al., 2023, 2024; Lawson et al., 2014; Pan, 2011; Peganoff, 1984)	(ƒ=12)
Structured routine and repetition	Utilizing repetition and routine to cue swimmers and build skills. Includes using a hello or goodbye song, blocked practice, cue to begin and end lessons, repetitive practice	Autism, DS		(Carson et al., 2025; Carter & Koch, 2023; Ennis, 2011; Güeita-Rodríguez et al., 2021; Kemp et al., 2023, 2024; Lawson et al., 2019; Munn et al., 2021; Pan, 2011; Yilmaz et al., 2010b, 2010a; Yılmaz et al., 2005)	(ƒ=12)
Use of evaluation/assessment	Utilizing tools, systematic evaluation, or video footage to identify current skills of swimmers and anticipate next progression	Autism, CP, DS		(Carson et al., 2025; Casey & Emes, 2011; Flippin & Clapham, 2023; Kemp et al., 2023, 2024; Lawson et al., 2014, 2017; Lawson & Lisk, 2019; Munn et al., 2021; Özer et al., 2007; Pan, 2011)	(ƒ=11)
Adaptive equipment	Including swim/aqua tube, flotation devices, noodle, swim fins, floating oxygen tank, float belt, “Tot dock,” hydraulic lift, transfer board, goggles, foam mats, kick boards, aqua-vests, and paddles	Autism, CP, DS, spina bifida occulta, intellectual disabilities	muscle weakness or spasticity, oxygen tank-dependent	(Aherne & Coughlan, 2017; Casey & Emes, 2011; Ennis, 2011; Fragala-Pinkham et al., 2011; Johnson et al., 2021; Kafkas & Özen, 2015; Lawson et al., 2014, 2017; Munn et al., 2021; Zanobini & Solari, 2019; Zverev & Kurnikova, 2016)	(ƒ=11)
Multisensory prompting	Using verbal, visual, and sometimes tactile cueing to increase participation in desired task/action including CTD, and MLP	ADHD, autism, anxiety, behavioral disorders		(Bekhet et al., 2023; Jull & Mirenda, 2016; Lawson & Lisk, 2019; Levy et al., 2017; Munn et al., 2021; Rogers et al., 2010; Tucker & Ingvarsson, 2021; Vodakova et al., 2022; Yanardag et al., 2013, 2015)	(ƒ=10)
Concise verbal cueing	Short (few or single word) phrases used to cue swimmers	Autism		(Carter & Koch, 2023; Flippin & Clapham, 2023; Fragala-Pinkham et al., 2011; Jull & Mirenda, 2016; Kuhfuss & Lucas (2010); Lawson et al., 2014; Levy et al., 2017; Rogers et al., 2010; Yilmaz et al., 2010a; Yılmaz et al., 2005, 2010)	(ƒ=10)
Peer collaboration	Including peers to assist in the learning process	Autism, DS		(Caputo et al., 2018; Carson et al., 2025; Casey & Emes, 2011; Chu & Pan, 2012; Cosart et al., 2025; Lawson et al., 2014, 2017; Munn et al., 2021; Zanobini & Solari, 2019)	(ƒ=9)
Secure instructor relationship	Utilizing the relationship with the instructor to gain trust and encourage participation in tasks. Using rapport-building activities	Autism, CP, muscular dystrophy, TBI		(Battaglia et al., 2019; Caputo et al., 2018; Jull & Mirenda, 2016; Kafkas & Özen, 2015; Lawson et al., 2019; Vernerova et al., 2022; Zanobini & Solari, 2019)	(ƒ=7)
Sensory approach	Considering sensory elements and using strategies such as organization, decreasing stimulus, or providing goggles with efforts to accommodate sensory needs	Autism		(Carter & Koch, 2023; Fragala-Pinkham et al., 2011; Lawson et al., 2014, 2017, 2019)	(ƒ=5)
Task breakdown	Identifying and targeting separate components of a skill	Autism, ADHD, anxiety, behavioral disorders		(Levy et al., 2017; Rogers et al., 2010; Tucker & Ingvarsson, 2021; Yanardag et al., 2013)	(ƒ=4)
Gradual increase of demands	Slowly intensifying physical demands to allow participants’ bodies to adapt	DS, CP, autism	Reduced respiratory endurance	(Alaniz et al., 2017; Casey & Emes, 2011; Peganoff, 1984; Zverev & Kurnikova, 2016)	(f = 4)
Increased time	Minimizing time limitations on swimmers, allowing swimmers to progress at their own pace	Autism, DS		(Carson et al., 2025; Marzouki et al., 2022; Munn et al., 2021; Rogers et al., 2010)	(ƒ=4)
Environmental modifications	Altering the physical or sensory environment by means of pool temperature, non-slip pool floor, pool depth, decrease stimulus (music, noises, toys), signage, marking depth, railing, steps, and more	Autism		(Chu & Pan, 2012; Lawson et al., 2014; Pan, 2011; Pimenta et al., 2016)	(ƒ=4)
Disability-specific considerations	Catheter with collection bag; adding sounds to games for blind swimmers; gradual, non-forceful movements for RA and CP; teaching strokes on back for swimmers with poor head control, lower intensity and monitor HR of those w cardiovascular disorders; modifying strokes	Autism, CP, developmental delay, physical disability, SCI		(Cosart et al., 2025; Gelinas & Reid, 2000)	(ƒ=2)

Note. ∼ = average; ADHD = attention deficit hyperactivity disorder; CI-MAT = multisystem aquatic therapy; CP = cerebral palsy; CTD= continuous time delay; DS = Down syndrome; f = frequency of articles that supported use of the strategy; LE: Lower extremity; MLP= most-to-least prompting; RA = rheumatoid arthritis; SCI = spinal cord injury; TBI = traumatic brain injury; UE: Upper extremity; VAS = visual activity schedule.

Discussion

This scoping review aimed to survey the literature on adapted swim instruction, identifying populations served and strategies utilized while also highlighting gaps in current scholarship. We identified 55 articles meeting inclusion criteria across 18 countries, underscoring the global interest in adapted swim instruction worldwide. The diagnoses studied most were autism, followed by cerebral palsy. A list of 26 strategies employed by studies was identified.

Strategies

To guide the application of these strategies in clinical practice, we draw upon the Person-Environment-Occupation Model (PEO), a foundational framework in occupational therapy practice that emphasizes the dynamic interaction among individual characteristics, contextual factors, and performance outcomes (Law et al., 1996). Within this framework, the Person refers to the individual swimmer with a disability who brings their unique emotional responses to the aquatic setting, prior experiences with swimming instruction, and disability-related factors that impact swimming participation. The adapted swim instruction strategies that were identified primarily targeted the Environment by optimizing the person–environment fit for each swimmer, such as incorporating structured opportunities for play, maintaining a low instructor to swimmer ratio, ensuring positive learning environment (e.g., positive feedback), and using instructors trained to support diverse learners, among other strategies found. By enhancing the alignment between the swimmer and the instructional environment, adapted swim instruction aims to improve occupational performance, operationalized here as the acquisition and execution of swim skills. While several strategies were reported across nearly half of all 55 studies (e.g., smaller instructor to swimmer ratios, n = 35; play-based approaches, n = 26; teaching skills through progressions, n = 25; and utilizing instructors with disability-focused training, n = 24; and individualized approaches, n = 24), it is noteworthy that no strategy was reported across all 55 studies. The heterogeneity of strategies likely reflects the client-centered nature of adapted swimming instruction, as well as the emerging state of this area of research and the current lack of empirical evidence needed to establish best practices or gold standards.

Adaptations were mentioned in each study, indicating their importance in the approach to swimming instruction for swimmers with disabilities. Presently, aquatic professionals who are interested in aquatics are expected to gain competency in and develop accommodations and modifications on their own time when asked to teach swimmers with disabilities. However, many of these strategies require extra training and education to fully master. Traditionally, swimming instructors can be as young as 16 years old and may not have the training needed to support swimmers with disabilities. Parents often report that their children do not learn to swim in typical swimming instruction lessons (Cosart et al., 2025; Lawson et al., 2019) indicating the need for greater access to instructors who have the skills necessary to provide adapted swim instruction. Questions also remain regarding standardized assessments, outcome measures, and what duration and frequency of specific approaches are optimal for different populations.

Professions

Occupational therapists, therapy assistants, and other rehabilitation professionals (e.g., recreational therapists, physical therapists, and speech and language pathologists) are highly skilled at using adaptive techniques and strategies to meet the unique learning needs of children with disabilities as described in the current adapted swim instruction research. Rehabilitation providers are well-equipped to assess individuals, match them to the environment, and instruction techniques needed to teach swimming skills to individuals with a variety of disabilities. However, rehabilitation professionals may not have formal training in swimming instruction and water safety education. Most adapted swimming lessons in the current literature were provided by swim instructors compared with rehabilitation providers such as occupational or physical therapists, meaning that rehabilitation providers are notably underrepresented in the research despite their qualifications.

Populations

While studies were conducted in a variety of countries worldwide, most studies originated in the United States, a Westernized country with significant economic and sociocultural resources. However, more information is needed where drowning rates are highest such as low-income countries with limited support structures or access to appropriate safeguards (Xie et al., 2025). In countries such as these, disability services and inclusion remain a challenge, and interventions to address learning to swim could be met with greater stigmatization (Global Disability Summit, 2025). Additionally, research has primarily focused on school-age children and individuals with autism or cerebral palsy with relatively fewer studies addressing other disabilities, or other age groups. Most studies were non-RCTs with smaller sample sizes, meaning that RCTs with larger sample sizes are sorely needed. It is vital that future research on adapted swim instruction represent the challenges faced by disabled swimmers in these contexts.

Limitations

This scoping review was limited to original research that was peer-reviewed and written in English regarding interventions focused on beginning swimming skills. The omission of gray literature limits this review to work that has been peer-reviewed and may have missed emerging strategies described in clinical magazines, blogs, conference proceedings, and other gray literature outlets of dissemination. This study was also limited to articles published in English. While the authors did contact authors from included studies with missing information for variables of interest (e.g., participant ages), this study did not seek stakeholder confirmation of the scoping review findings, and the conclusions are limited to the authors’ understanding and interpretation of the included studies.

Gaps in Current Research and Suggestions for Future Directions

Many included studies are classified as levels 3 and 4 and are considered lower levels of evidence. Studies also had wide ranges of ages and disabilities needing vastly different types and amounts of adaptations, making it difficult to generalize results across populations. This indicates a need for more RCTs, especially trials tailored to single disability groups with similar instructional needs, to strengthen the evidence base for adapted swim instruction. Future research should focus on narrowing age and/or developmental ranges to strengthen experimental control and provide improved rigor.

Data extracted from the articles regarding adapted swim instruction strategies included both strategies that were utilized in interventions being tested and strategies that were mentioned. For example, one article looked at the effectiveness of using a multisensory aquatic treatment program (Caputo et al., 2018). However, throughout the article, they also referenced other strategies that were included in untested aspects of the treatment program (e.g., swimmer to instructor/therapist ratios and play-based approaches). Therefore, the adapted swim instruction strategies summarized in this article should be interpreted with caution, as therapeutic tools reported or discussed by multiple studies rather than tools empirically tested by all of the studies.

Implications for Occupational Therapy Practice

Occupational therapists and occupational therapy assistants are distinctly qualified to contribute to drowning-prevention initiatives through the provision of therapeutic swim instruction. Guided by the Person–Environment–Occupation (PEO) model and grounded in core occupational therapy processes—including activity analysis, grading and adapting tasks, and supporting engagement in meaningful occupations—practitioners bring a uniquely holistic and client-centered approach to teaching this essential life-saving skill. By addressing individual factors, environmental demands, and occupational performance needs, occupational therapy practitioners can enhance safe and effective participation in aquatic environments for individuals with disabilities, thereby advancing health, wellbeing, and occupational participation.

Conclusions

While many studies on adapted swim instruction have been conducted worldwide, the field is still an emerging area of research and practice. There is a need for research in adapted swim instruction focused on creating RCTs with larger sample sizes that either target a specific disability population or include stratified samples for each disability represented. More research is needed on the effectiveness of individual strategies for successful swim instruction, as current evidence favors anecdotal and low level evidence as opposed to rigorous or experimental data. Adapted swim lessons for disabled individuals include strategies that require training, such as using adaptive equipment, physical support and positioning, and evaluations and assessments. Occupational therapists and other rehabilitation professionals have expertise in these strategies as well as habilitation skills necessary for swimming. By compiling adapted swim instruction strategies most often used in research studies, we hope we will provide valuable tools for rehabilitation professionals seeking to tailor the swimming environment to individual swimmers. Our aim is to increase the utility of our findings for those seeking to integrate modified swim instruction into their practice.

Author Biographies

Katherine L. Long, M.S., M.S.O.T., OTR/L is Ph.D. Candidate in Developmental Science, Department of Psychology, and Graduate Research Assistant, Department of Occupational Therapy, Florida International University, Miami, FL.

Kristina Kobza, O.T.D., OTR/L is Occupational Therapist, Department of Occupational Therapy, Seattle Children's Hospital, Seattle, WA.

Tania Santiago Perez, Ph.D., CTRS is Associate Teaching Professor, Department of Counseling, Recreation, and School Psychology, Florida International University, Miami, FL.

Erika Kemp, O.T.D., BCP, FAOTA, OTR/L is Program Director and Clinical Associate Professor, Department of Occupational Therapy, The Ohio State University, Columbus, OH.

Tana B. Carson, Ph.D., OTR/L is Assistant Professor, Department of Occupational Therapy, Florida International University, Miami, FL.

Appendix 1. Expanded List of Databases and Search Terms

Database	Search Terms
PubMed	(“adapted” or “adaptive”) AND (“disability” or “disabled” or “autism” OR “asd” or “down syndrome” or “cerebral palsy” OR “asperger” or “spinal cord injury” or “intellectual disability” or “muscular dystrophy” OR “brain injury” OR “impairments” OR “persons with disabilities"[MeSH Terms]) AND (“swim” or “swimming” or “swimmers” or “water safety” or “non-swimmers” OR “Swimming"[Mesh]) AND (“construction” or “lesson” or “training” or “program” or “skill” or “education” or “classes”)
Embase	(‘adaptive’ OR ‘adapted’ OR ‘modified’ OR ‘tailored’) AND (‘disability'/exp OR ‘disabled person'/exp OR ‘developmental disorder'/exp OR ‘intellectual disability'/exp OR ‘autism spectrum disorder'/exp OR ‘physical disability'/exp OR ‘disability':ti,ab) AND (‘swimming'/exp OR ‘aquatic exercise'/exp OR ‘learn to swim’ OR ‘swimming lesson’ OR ‘aquatics':ti,ab OR ‘swimming':ti,ab) AND (‘instruction':ti,ab OR ‘lesson':ti,ab OR ‘training':ti,ab OR ‘program':ti,ab) NOT (‘smoking cessation'/exp OR ‘drug rehabilitation'/exp OR ‘mental health program’ OR ‘diet'/exp OR ‘weight reduction'/exp) AND [embase]/lim AND [humans]/lim AND ‘article'/it AND [english]/lim
CINAHL	MH “Swimming” AND (MH “Persons with Disabilities” OR MH “Children with Disabilities” OR MH “Persons with Intellectual Disabilities” OR MH “Intellectual Disability”) AND MH “Programmed Instruction” OR MH “Swimming/ED”
Sportdiscus	(DE “SWIMMING instruction” OR DE “SWIMMING”) AND (DE “DISABILITIES” OR DE “PEOPLE with disabilities” OR DE “PEOPLE with intellectual disabilities” OR DE “DEVELOPMENTAL disabilities” OR DE “DOWN syndrome” OR DE “CEREBRAL palsy” OR DE “PEOPLE with cerebral palsy” OR DE “AUTISTIC athletes”) AND (“adaptive” OR “adapted”)
Web of Science	(((((((((((((ALL=(adapted)) OR ALL=(adaptive)) OR ALL=(modified)OR ALL=(tailored) AND ALL=(disability)) OR ALL=(disabled)) OR ALL=(down syndrome)) OR ALL=(autism)) OR ALL=(ASD)) OR ALL=(cerebral palsy)) OR ALL=(persons with disabilities)) AND ALL=(swimming)) OR ALL=(water safety)) OR ALL =(learn to swim)) AND ALL=(instruction))
ERIC	(“adaptive” OR “adapted” OR “modified”) AND (“swimming” OR “aquatics” OR “swimming instruction” OR “water safety” OR “learn to swim” OR “beginner swimmer” OR “non-swimmer”) AND (“disabilities” OR “disabled” OR “autistic” OR “ASD” OR “Down syndrome” OR “cerebral palsy” OR “people with disabilities” OR “intellectual disability” OR “developmental disability”) AND (“swimming instruction” OR “instruction” OR “education” OR “classes” OR “training”)