Fatal and non-fatal drowning of children is a preventable major public health concern [(1), p. e008444]. In the United States, drowning is the leading cause of death among children ages 1–4, and the second leading cause of death among children ages 5–14 (2). The risk of death by drowning is higher for some disability groups when compared to those without disabilities. For example, the risk of drowning is twice as high for those with autism spectrum disorder (autism) compared to those without autism [(3), no. 4]. According to the National Autism Association “drowning is the leading cause of death among individuals with autism” [(4–6), p. 32 (7), pp. 869–874]. While it is unclear whether the risk of drowning is also greater for those with other developmental disabilities or physical disabilities, it is clear there are barriers to accessing swim instruction services designed to prevent drowning for these populations. Barriers include a lack of access to specialized training for instructors, access to specialized programming for swimmers, or environmental/contextual factors, such as training [(8), pp. 197–207 (9), pp. 419–425 (10), pp. 29–40 (11), pp. 451–455 (12), p. 1179556519872214]. Thus, there is a critical need for improved access to evidence-based drowning prevention interventions for all children, particularly for those with disabilities.

Drowning is a complex problem and drowning prevention interventions may address multiple factors including education for parents, swimming lessons, water safety education, aquatic rescue competency [(13), pp. 688–693] and barriers such as pool fencing [(14), pp. 195–204]. Swim instruction programs are an important part of the solution for drowning prevention (15). Fundamental swimming skills taught in swim instruction (LTS) programs often include the following: safe water entry and exit, floating, breath control, resurfacing after fully submerging, and swimming following submersion, swimming comfortably underwater, and becoming proficient in at least one prone and one supine stroke [(16), no. 4 (17), no. 2].

While community-based LTS programs are readily available across the U.S, through a variety of associations and organizations, children with disabilities are often underrepresented in these programs. Solish and colleagues [(18), pp. 226–236] found that 62.2% of parents of children who do not have disabilities reported participating in swimming lessons, while only 27.7% of parents of children with autism and 43.3% of parents of children with intellectual disability (ID) reported that their children participated in swimming lessons. Participation rates are also lower among ethnic minorities in low socioeconomic areas [(19), pp. 19–33 (20), no. 2]. Thus, inequities experienced by children with disabilities may be further compounded by the intersection of disability and racial/ethnic and/or socioeconomic factors.

To meet the unique needs of individuals with disabilities, adapted sports and recreation programs have been developed and implemented in various settings (e.g., schools, athletic programs, community parks and pools, etc). These programs may modify rules, equipment, facilities and/or the environment to afford people with disabilities access to meaningful and successful participation (21). Adapted aquatics programs serve individuals with disabilities using swimming, aquatic recreational activities, and water safety to promote wellness, habilitation, and rehabilitation [(22), p. 18]. A modified swimming program for individuals with disabilities requires diverse adaptations such as various teaching techniques, modified equipment, and well qualified instructors (23). Within this framework, adapted swim instruction programs have been developed, but few have been studied for their effectiveness.

One adapted program with national reach in the US is the iCan Shine, iCan Swim Camp. iCan Shine is a non-profit organization 501(c)3 “whose mission is to provide quality learning opportunities in recreational activities for individuals with disabilities” (24). iCan Swim is a 5-day adapted swim camp for children with disabilities agedthree years or older that provides instruction of basic swimming and water safety skills. The iCan Swim program curriculum is focused on developing swimming skills that fall within the categories described by the American Red Cross swim instruction program Levels 1–3 (25). All lessons include an emphasis on comfort in water and skills related to safety such as: recognizing lifeguards, entering/exiting in shallow and deep water safely, using a lifejacket, breath control as well as swimming skills such as body positioning and stroke mechanics. When appropriate, advanced swimmers are provided with additional instruction focused on more advanced swimming strokes such as breaststroke and butterfly. Program eligibility criteria include being at least 3 years of age and having a medical, neurological, developmental, or physical diagnosis that is considered a disability. Individuals that have a gastrostomy-tube that is less than two months old, a tracheostomy,or exhibit aggressive behaviours (at the discretion of program directors and instructors) are excluded for safety concerns. Participants attend one swim session daily Monday – Friday for one week. Swimmers are grouped into sessions by age, rather than skill level as accurate skill level may be unknown and to promote developmentally appropriate social groupings (i.e., not have very young children and adolescents in the same group). Each session includes two iCan Shine adapted swim instructors and three to six swimmers who are paired with at least one volunteer swim buddy, one to two additional volunteers may provide general support for the group. Swim sessions last 45-minutes for swimmers aged 3–7 years and 60-minutes for swimmers 8 years and older. The iCan Shine instructors conduct a swim assessment on Day1 to determine participants' current swimming ability and help develop individual goals for their time at camp. Swimmers' skills are reassessed on Day 5 to evaluate and document progress. The typical iCan Swim lesson sequence consists of a water safety lesson, a group game for warm-up, individual or small group skill practice, a group activity for skill reinforcement, and a group activity for wrap-up. A summary of daily training and swim instruction content is provided in the Supplementary Table S1. Since the sequence of skills presented in traditional swim instruction program may not be developmentally valid or appropriate for those with disabilities [(26), pp. 269–285], the adapted framework, as adopted by iCan Swim, allows for an individualized approach where swimmers can work on skills within any level as appropriate for developing functional swimming skills. Additionally, iCan Swim incorporates programmatic factors that have been shown to foster success in adapted swimming programs such as providing training to qualified instructors and 1:1 support for swimmers [(27), p. 1473328, (28)].

Effectiveness of the iCan Swim program has been partially examined. Rogers et al. (23), evaluated the effectiveness of this program for children on the autism spectrum. Their secondary data analysis showed that autistic children demonstrated improvements in performance over the 5-day program. The study also examined factors linked to limitations in performance outcomes such as age and time out of water. Questions remain regarding outcomes for children with other disabilities, whether the same personal factors influence outcomes for other diagnoses and the effectiveness of the 5-day program when accounting for participation (i.e., time in session).

The primary aim of this study is to expound upon the work of Rogers et al. (23) and evaluate the changes observed from Day 1 to Day 5 of iCan Shine's 5-day iCan Swim camp for individuals from various disability groups. Secondary aims explored (a) relationships between intervention response and personal factors (e.g., fearfulness and challenging behaviours) and (b) predictors for change in swim level performance.

This study presents a secondary data analysis to determine the effectiveness of a 5-day adapted swim instruction program, iCan Swim, on the development of swimming skills among children with disabilities ages 3 to 18 years. This study was reviewed by Florida International University's Institutional Review Board (IRB) and determined to be exempt (IRB Protocol Non-Human Subjects Research #: IRB-21-0465).

The purpose of this study was to evaluate the effectiveness of a 5-day adapted swim instruction program, iCan Swim, on the progression of swim skills (according to predefined skill levels) in a sample of 164 children with disabilities ages 3 to 17 years. Consistent with a previous study determining the efficacy of iCan Swim programs on children with autism [(23), p. 5557], most participants (61.6%) in the present study improved their swim skill level from Day 1 to Day 5, regardless of age, sex, or diagnosis. These results suggest that children with disabilities can acquire swim skills in a brief time limit (5 days). Having participants progress from non-swimmers to swimmers in a brief time limit demonstrates the feasibility of rapid skill acquisition when appropriate supports and instruction are provided to people with disabilities.

The peer-reviewed literature presents variability, and it seems there is little consensus on what presents a valid, effective adapted swim instruction curriculum for children with disabilities, along with best practices for program development and implementation. Forde et al. (17) reported on an inclusive program for children with and without disabilities that focused on six swimming and water safety skills during 10, 30-min sessions over a two-week period; the six skills targeted included (1) not swimming alone, calling for help and reaching and throwing when others are in distress, (2) entering the water by jumping in, (3) performance of progressive arm stroke, (4) performance of back float with no support for three seconds, (5) skill in jumping in, turning, and stoke/kick to the wall, and (6) skill to exit the water using ladder, step or side. Jorgic et al. (29) utilized the Halliwick Method along with swimming exercises and measured the effects of this swimming program on the gross motor function, mental adjustment to the aquatic environment, and the ability to move and swim in the water among 7 children with cerebral palsy; the intervention consisted of 12, 45-minute sessions over six weeks. Lawson et al. (30) investigated the effects of KU Sensory Enhanced Aquatics program, an individualized swim instruction program that used sensory preferences and task analysis to teach swimming to children with autism (n = 83); the program consisted of 8, 30-minute sessions over 8 weeks and the swim skills measured included water orientation, front stroke, backstroke, breaststroke, butterfly, diving, and use of googles. Levy et al. (31) investigated the effectiveness of a behavioral treatment package of shaping, prompting, and positive reinforcement to teach underwater submersion to children with autism (n = 3); each session lasted 30-minutes, with the length of the intervention ranging from 12 to 27 sessions among the 3 participants. Kemp et al. (27) examined the efficacy of AquOTic, an occupational-therapy-based aquatic intervention (n = 37) that includes play and child-based activities, task-specific training, positive reinforcement, sensory supports, and a modified Halliwick approach; the program consisted of ten 60-min sessions over 10 weeks. Rogers et al. (23) utilized the same iCanSwim program as the present study, but they only included children with autism in their analysis. Compared to existing programs iCan Swim is on the higher end of duration (45–60-min/session) and the lower end of the frequency of sessions (5 sessions).

Age had a weak but positive relationship with changes in swim skill acquisition overall. Further analysis revealed that this correlation was primarily driven by the DS group. Within the DS group, as age increased each year, swim skill acquisition increased by 9.5%. Age was not correlated with changes in swim acquisition for children with autism; these results did not replicate other research findings that suggested age-related differences in children with autism [(23), p. 5557]. It is important to consider that the present study purposefully screened out factors such as time out of water and behavioral issues as exclusion criteria, which may account for why age was not related to swim skill acquisition in the autism group in this study.

iCan Swim is typically led by two skilled swim instructors with training in adapted aquatics. Swimming is a complex motor skill and teaching swimming and water safety to children with disabilities requires training, expertise, and a strong knowledge base of disability and diagnosis specific instructional strategies. While most aquatic professionals and staff are well trained in water safety and swim instruction instruction, many report a lack of training on disability and the appropriate modifications or accommodations needed to teach swimming and water safety to children with disabilities (10). Traditional swim instruction programs are effective for children without disabilities. However, they may not be developmentally valid for those with physical or developmental disabilities (26). Thus, it is reasonable to suspect that training in adapted swim instruction vs. basic swim instruction training may have impacts on the speed of swim skill acquisition for children with disabilities. Future work with superiority trials comparing programs that differ in instructor training and other programming factors are needed to better understand which methods are superior. Overall, increased availability of inclusive or adapted swimming programs are warranted to promote the acquisition of safety and swimming skills for children with disabilities.

Strengths of this study include the large sample size and the inclusion of swimmers with disabilities other than autism, of which most research has been focused recently. Having an expanded sample exposed to the same program allows for a preliminary look at potential differences in progress among groups. For those that did not progress to a higher swim skill level, swim instructors noted reasons for not progressing when a clear reason was available. For children with autism, the main reason reported was fearfulness, while for children with DS, the main reason reported was the need for more instruction time. These results suggest that children with autism and children with DS have unique needs that may require different instruction strategies, adaptations, and programmatic considerations. Thus, we recommend additional research to identify best-practices for meeting diagnostic-specific needs (e.g., DS or autism) or characteristic-specific needs (e.g., anxiety, rate of learning, behavioral difficulties, etc.). Researchers and providers of adapted swim instruction programs should carefully evaluate individual swimmer characteristics and program factors to determine best practices for program delivery. A systematic review of evidence-based practices is warranted to better understand the optimal approach, frequency, duration, and participant-treatment matching for adapted swim instruction.

The iCan Swim 5-day adapted swim instruction program was effective for most participants. It is, however, important to note that this program was led by skilled instructors with adapted aquatics training. Predictive factors such as fearfulness, needing more time and age should be further studied to better understand these factors and how to develop strategies for overcoming them. In our study, age was a significant predictor of swim skill acquisition within the DS group only. Primary reasons for not progressing to a higher swim skill level were: (1) fearfulness (most often among participants with autism) and (2) more practice needed (most often among participants with DS). Additional factors should be further explored in future research to better understand optimal participant-treatment matching for frequency/duration of lessons. Continuous efforts in the development and evaluation of evidence-based best practices as to when and how to deliver adapted swim instruction to children with disabilities are needed.