Jennifer Knott, CTRS, discusses aquatic therapy programming for autistic individuals. She highlights the potential of such programs for removing barriers to involvement and expanding individual recreation repertoire to build memories and experiences together in a community-based setting. The speaker emphasizes the lifelong nature of aquatic therapy and presents various examples of individualized treatment techniques and goals. The speaker highlights the absolute need for teaching autistic people water safety skills and details how water’s essential qualities assist therapy techniques and individual skill-building. Knott asserts that we can promote lifelong health, wellness, and leisure development for autistic individuals by harnessing the power of the water and designing inclusive accessible programs. 

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Handouts are online at: Aquatic Therapy for Individuals with Autism

In this webinar: 

1:30 – About Jenn Knott
4:08 – Recreation therapy
6:15 – Aquatic therapy
8:25 – Properties of water
10:30 – Water safety skills
13:30 – Need for physical activity across the lifespan
15:55 – Barriers to community aquatic programming
18:40 – Aquatic therapy approach
20:20 – Aquatic therapy assessments
22:00 – Skills addressed in aquatic therapy
28:30 – Sensory stimulation in the water
33:20 – Case study: Donovan
38:00 – Swim skills are transferable
40:30 – Teaching swim safety skills
43:02 – Alleviating fear and anxiety
47:45 – Q & A

Introduction

Jennifer Knott introduces herself and explains how her intense passion for aquatic therapy was born. Her journey in aquatic therapy began while she was in college and volunteered at Hattie Laram, a group home for individuals with severe to profound disabilities. There she witnessed the transformative power of water on individuals’ physical functioning, behavior, and mood (1:30). Knott notes that this experience solidified her decision to dedicate her life’s work to eliminating barriers and providing meaningful recreation programs for individuals with special needs. She started Rec2Connect to provide communities with more accessibility to these life-changing therapies across an individual’s life (3:00). 

Recreation and aquatic therapy

Recreation therapy, although not widely known, is a lifelong therapy that uses recreational approaches to address the specific needs of individuals with chronic disabilities, syndromes, or diseases (4:08). Knott explains that treatment methods are highly individualized and can include any recreation (not just aquatic). Methods retain similar goals to physical, occupational, and speech therapy techniques. Skills taught in these programs aim to be transferable across opportunities and daily life. 

The speaker defines aquatic therapy as a form of recreation therapy that uses “water and specifically designed activity by qualified personnel to aid in the restoration, extension, maintenance, and quality of function for persons with acute, transient, or chronic disabilities, syndromes, or diseases” (6:40). Aquatic therapy includes goals that address skills which can be transferred to land and can be administered by a variety of professionals (7:35). Knott details properties of water like buoyancy, resistance, and hydrostatic pressure, which provide sensory-rich environments and help with focus and centering (8:30). For example, the hydrostatic pressure of water evenly distributed across the body offers a comforting “hug” and balanced sensory inputs. 

Aquatic therapy and autism

The speaker notes that many autistic individuals are often drawn to the water but lack the necessary safety awareness and skill sets. She discusses research suggesting a need for teaching swimming skills at a young age, highlighting that autistic children are 160 times more likely to die from drowning compared to the general pediatric population (10:30). Knott therefore asserts that swimming should be taught as an imperative survival skill before any behavioral, speech, or occupational therapies. She provides examples of safety measures such as specialized bracelets and watches and locks on doors and pools to ensure the well-being of autistic individuals in the water (12:35). Knott emphasizes the need for physical activity across the lifetime as a driver for mental and physical health (13:30). The presenter notes significant barriers to community aquatic programming and their effectiveness in skill-building for individuals with autism and other disabilities (15:50). 

Many autistic individuals exhibit hyperactivity, sensory-seeking behaviors, aversion to water, motor deficits, hypertonia, and balance issues. The speaker explains that participating in aquatic therapy can address these challenges and provide opportunities for lifelong leisure and skill development (19:00). She summarizes the aquatic therapy approach as individualized (based on patient assessments), goal-driven, and focused on lifelong skills, like motor movement. Personalized sessions are based on an individual’s interests and are often conducted weekly to track progress and guide future therapy sessions (21:15).

Skills addressed in aquatic therapy

Knott reiterates that skills addressed in aquatic therapy sessions extend beyond swimming and aim to be transferable. These can include gait, core strength, following directions, balance, gross motor skills, sensory regulation, and much more (22:00). She presents different examples of activities that address core strengthening, like pushing objects underwater or using fins for kicking (25:00). Motor skills and strength can be addressed with weighted medicine balls, squeezing sponges, and pool games that incorporate physical actions and hand-eye coordination. The speaker describes techniques used to build capacity for using one’s arms and legs simultaneously in water compared to on land (27:00). Knott reiterates the importance of incorporating sensory activities into therapy techniques, as well as allowing sensory breaks (32:34). She outlines a case study where therapeutic goals addressed sensory needs, core-strength, and coordination, as well as swim safety skills such as grasping the pool wall, swimming to the pool wall, and holding breath underwater (33:20). The presenter notes that many individuals experience water aversion and discusses techniques for building trust and alleviating fear and anxiety surrounding water (43:00). 

Knott reiterates the impact of aquatic therapy on lifelong health and wellness such as increased physical activity, decreased likelihood of drowning, increased strength, and opportunities for social activities (44:40). She provides thanks and references before the Q & A session where she covers accessibility to aquatic therapy programs, potentially toxic chemicals in pools, autism-friendly swimming environments, and more (47:45). 

Gray Atherton, Ph.D., discusses pet ownership as it relates to autistic individuals. She gives context for the importance of this topic, details the theories underpinning her research, and outlines her recent mixed-method studies. The speaker describes differences in the directness of animal communication compared to human social cues and underscores the positive relationship between pet ownership and mental health for autistic people. Atherton describes themes in her qualitative research, noting potential barriers and breakthroughs. The presenter provides ideas and solutions for future research and application directions and introduces the research team before opening the question and answer session.

Learn more about our speaker, Gray Atherton, Ph.D. HERE

Take the knowledge quiz HERE

In this webinar

0:59 – Agenda
1:55 – Introduction and context
3:31 – Theory behind animal connections and autism
5:15 – Eye gazing serotonin feedback loops
7:02 – Visual cues in animal interactions
8:58 – Mixed methods approach and study outlines
10:39 – Study: Autistic vs. non-autistic pet ownership survey
15:11 – Equal animal attachment across groups
17:15 – Pet attachment and mental health in autism
17:34 – Study: Real-life applications for pet contact
18:40 – Themes from research
19:25 – Sensory benefits
20:31 – Companionship
21:08 – Judgment
22:56 – Social lubricant
24:37 – Barriers
26:33 – Responsibility as a breakthrough
27:43 – Challenges
29:00 – Ideas, solutions, and future directions
30:54 – Volunteerism
32:09 – Mentoring
33:25 – Ways to start
36:25 – Presentation summary
37:26 – Research team
38:06 – Q & A

Summary 

Research shows that autistic people prefer interactions with animals over humans and that 80% of autistic children have participated in pet therapy. This, the speaker asserts, gives context as to why pet contact in relation to autism is an important topic (1:55). The Biophilia Theory, as described in Atherton’s recent publication (3:31), asserts that humans innately love nature and seek connection with other forms of life (4:45). Most of human history, she continues, has been lived in a direct relationship with nature which allowed humans and domesticated animals to evolve in stride and foster a connection of love and affection (6:15). For example, studies have revealed that when humans and dogs exchange eye gazes both participants experience an increase in serotonin, creating a serotonin feedback loop. Therefore, humans have a profound physiological and biological connection with domesticated animals. (There is an emphasis on domestic animals as such feedback loops do not occur in gaze exchanges with wolves)  (5:15). 

Atherton explains that, although autistic individuals often avoid human eye contact, eyes are one of three focal points they consider when interacting with animals (7:02). The speaker implies this trend could be because animals give much more direct social cues than humans – as there are no contradictory social signals to puzzle together (i.e., contradicting words and facial expressions), animal behavior is more straightforward to interpret (8:03). The presenter details another recent study and the mixed method approach they used to discover outcomes and themes of pet ownership among autistic individuals (8:58): 

Experiment 1: Researchers surveyed 700 adults, half of whom were autistic, on lifetime pet ownership, pet attachment, and mental health (10:39). Contrary to previous research, Atherton and her team found that autistic people are less likely to own pets as children and adults. They also found pet ownership corresponded with better life satisfaction (12:20). Atherton asks viewers not to distance this finding from its context, reminding them that the ability to own a pet likely corresponds with having a steady job and home, which innately increase life satisfaction. Pet attachment, she continues, is related to better mental health in autistic individuals (17:15). The study also found that autistic people use relationships with pets to compensate for social avoidance experienced as a result of social difficulties (16:15). Importantly, both groups exhibited equal attachment to pets, and the type of pet did not change the relationship quality (15:11). The presenter asserts that this fundamentally dismantles the assumed stereotype that autistic people lack emotional complexity and connection compared to the non-autistic population. 

Experiment 2: Researchers interviewed autistic participants about pet experiences to understand what real-life applications exist for pet contact (17:34). Atherton lists themes found in the research (18:40) and details several benefits of having pets. Sensory benefits, for example, include the touch of fur and scales, weight of an animal on one’s lap, and the bidirectional calming interaction of petting an animal (19:25). Animals also offer a type of social presence that allows individuals not to be alone, but does not apply pressure to perform or conform (20:31). Further, the speaker shares, pets can offer a solution to masking because there is no judgment as animals accept care and love in whatever form it’s given, which boosts owner confidence and self-esteem (21:08). Pets can also act as a social lubricant, opening connections between family members and the community (22:56). Barriers discovered in the study included economic standing and a personal fear or anxiety that, as an autistic person, one cannot be responsible for taking care of another being (24:37). However, she continues, the responsibility of pet ownership seems to spur a breakthrough in self-confidence and independence as it provides motivation to care for someone else and, therefore, a reason to get up, put the video game down, and ensure employment and housing (26:33). 

The presenter reviews the challenges found in these studies (27:43) and provides ideas and solutions for future directions (29:00). For example, if pet ownership is unavailable, volunteerism can allow for animal contact and simultaneously create a connection with a community and job experience (30:54). Atherton suggests ways to start preparing for pet ownership (33:25), including fostering, starting with smaller pets, getting advice from a mentor (32:09), and more. The speaker summarizes the presentation (36:25) before opening the question and answer session (38:06), where she discusses equine therapy (39:04), mental health indicators (41:20), benefits to early childhood development (46:11), hoarding (48:50), the effects of pet ownership on aggressive behavior (55:15), and more. 

Vicki Kobliner, MS RDN, CD-N, discusses steps for optimizing preconception health through good nutrition and healthy environments. She discusses the US healthcare systems and statistics and asserts that, although the numbers can be scary, taking preventive action is often simple. The speaker outlines steps for personal health risk assessment and self-advocacy with family and healthcare providers. Kobliner discusses aspects of a nutritious diet and best practices for protein and produce consumption. She considers environmental exposure to chemicals and pesticides and provides alternatives for household products and foods. The presenter highlights the need to “keep it simple” and summarizes the healthy baby road map before the Q & A. 

In this webinar: 

1:10 – Introduction and disclaimer
2:16 – Healthy Baby Roadmap and presentation goals
4:04 – US health statistics
7:00 – Study – Folate deficiencies and risk of autism
8:08 – Study – Maternal diet and fetal microbiome
8:45 – Placental microbiome
9:22 – Study – Toxins and chemical and umbilical blood
10:45 – Study – Body burden of chemical exposure
11:35 – State of women’s health care in the US
13:22 – Assessment and action steps for a healthy baby road map
16:40 – Health history and clues to look for
20:00 – Medications and supplements
21:50 – Study – Acid-suppressive drugs and childhood asthma
22:37 – Gut health during pregnancy
23:59 – MTHFR gene (Methylenetetrahydrofolate reductase)
25:35 – Genotypes for CT variant of MTHFR
26:38 – Testing
27:30 – What matters for nutrition
28:10 – Proteins, produce, and fats
32:11 – Dirty Dozen and Clean Fifteen
32:58 – Water
33:34 – Priority preconception nutrients
34:26 – Omega 3s, Vitamin D, and Choline
38:07 – Inflammatory triggers
38:41 – Study – Maternal inflammation and chronic illness risk
39:29 – Pitch the parabens, toxic bedding, and kitchen storage
42:11 – Cleaning supplies and air filters
43:40 – Reducing stress
44:37 – Steps for advocacy
45:40 – How to keep it simple
46:23 – Q & A

Background and introduction

Kobliner defines the healthy baby road map (2:16) with reference to preconception planning for chronic illness risk reduction (1:10). She explains that 38% of children in the US have one or more chronic illnesses and that more than one in five kids have a mental, emotional, developmental, or behavioral problem (4:04). The presenter outlines studies investigating folate deficiencies and risk of autism (7:00), maternal diets and infant gut microbiota (8:08), and the levels of toxins and chemicals present in umbilical cord blood after birth (9:22). Kobliner discusses body burden and explains the different effects of chemical exposure on a mother (150 – 200 pounds) and a fetus (one pound) (10:45). The presenter details how women are treated within current US medical systems (11:35) and asserts that “women need facts so they can be empowered to make the choices that align with their pregnancy goals” (13:00). This knowledge, she continues, must be acquired via personal research (13:22) and discussions with family and health care providers (16:05).

Assessing and planning for risks

Health history information, like genetics, supplements, and family and personal medical history, is vital for understanding what risks to consider (16:40). The speaker discusses critical factors and clues in medical histories (17:50) and suggests investigating the sources and intake amount of essential vitamins and nutrients in one’s diet (20:00). Kobliner discusses birth control and vitamin B (21:40) and summarizes the first study that significantly associated acid-suppressive drugs and the risk of childhood asthma (21:50). The speaker demonstrates how changes to gut microbiota during pregnancy often lead to increased lactic acid and have been linked to an elevated risk of gestational diabetes, autoimmune diseases, and preterm pregnancy (22:37). 

The MTHFR gene (Methylenetetrahydrofolate reductase) is integral to the body’s ability to process folate, which is necessary for producing DNA and modifying proteins (basis of fetal development) (23:59). Kobliner details the difference between active folate and folic acid (synthetic), noting that children may inherit folate mutations (24:45). She outlines potential genotype mapping for the MTHFR CT variants and underscores that such mutations do not indicate disease but mean that the body needs support for normal folate processing (25:35). To investigate potential risks further, the speaker advises asking one’s doctor to test levels of various vitamins and thyroid panels and conduct a comprehensive digestive stool analysis before conception (26:38). 

What matters for nutrition

Kobliner dives into aspects of a quality diet (27:30) and discusses differences in protein sourced conventionally, organically, and pasture-fed (28:10), noting that truly grass-fed animals are the most nourishing. She considers pesticides in produce and stresses their correlation with developmental disabilities (30:06). The Environmental Working Group’s annual Dirty Dozen and Clean Fifteen is a good reference for understanding which produce is safe to purchase conventionally and which is not, based on known pesticide levels (32:11). Kobliner provides sources and ideas for buying affordable pasture-fed protein and clean produce. The speaker gives examples of inflammatory and anti-inflammatory fats and highlights the need to consume the correct type (not avoiding fats) and add lacto-fermented foods to one’s diet (31:18). She also suggests using a good water filter as water generally lacks minerals and contains chlorine, fluoride, pesticides, antibiotics, and BPA which seeps from plastic bottles as well (32:58). 

The speaker lists priority preconception nutrients (33:34), underscoring Omega 3s as “hands down the most important thing to do to support preconception and periconception health” (34:26). Kobliner explains that up to 60% of the US population is vitamin D deficient as the recommended levels, between 30 and 70, are insufficient to support optimal health and should be between 50 and 75 (35:30). Choline, she continues, is under-appreciated for its effect on neurological health and is often chronically deficient in women (37:06). The presenter reminds viewers that such deficiencies are generally an easy fix as long as one is aware of one’s risks and needs. 

Lifestyle and body burdens

Maternal inflammation has been linked to autism, asthma, obesity, tics/OCD, gestational and childhood diabetes (38:41). Kobliner notes that common inflammatory triggers include sugar, processed foods, and stress (38:07). To reduce bodily stress and burden, it is vital to account for toxins present in one’s environment and lifestyle (38:52). The speaker advises viewers to “pitch the parabens” as they can disrupt hormones and interfere with fertility and reproductive health and increase cancer risk (39:29). She lists bedding and furniture labels that indicate they are free of toxins associated with neurobehavior, reproductive health, and cancer (40:29). The speaker suggests using steel or glass containers, parchment paper, and silicone bags for kitchen storage, instead of plastics (and soft plastics) which are known endocrine disruptors with links to cancer, diabetes, and fertility issues (41:30). Household cleaning supplies are high in chemicals and toxins, but most can be replaced with a mix of vinegar, lemon juice, baking soda, and water (42:11). Kobliner suggests indoor plants and filters for cleaner air (42:55) and highlights reducing stress as a necessity that should be done however and whenever one can (43:40). 

Advocacy and moving forward

Kobliner lays out four steps to successful self-advocacy in conversations with family and healthcare providers (44:37): 

1. Do your research
2. Ask a lot of questions
3. Use a decision tree
   1. H: Healthiest option for me and my baby
   2. B: Best choice and possible alternatives
   3. R: Risk involved in my choice
4. Show evidence

The speaker gives examples for each step and reminds viewers to keep it simple. She suggests starting with the “low-hanging fruit” (easiest thing to accomplish) and asserts that progress will grow from there, one day at a time. Kobliner reviews the health baby road map before opening the Q & A. 

Jennifer Frankovich MD MS, clinical professor at Stanford University/Lucile Packard Children’s Hospital, discusses the co-occurrence of systemic inflammatory and autoimmune diseases – including the overlap between pediatric acute-onset neuropsychiatric syndrome (PANS) and autism. She outlines the presentation of classic rheumatologic diseases noting the prevalence of mental health symptoms and provides clinical criteria for PANS. Frankovich discusses PANS as a relapsing/remitting condition and explores the clinical management options, citing recent studies on steroid use. She concludes by reemphasizing the association of psychiatric symptoms with autoimmune and rheumatologic diseases and states the importance of post-flare rehabilitation before opening the floor to questions.

Take the knowledge quiz for this presentation HERE

In this presentation

3:20 – Inflammatory diseases with comorbid psychiatric symptoms
20:20 – PANS clinical criteria
34:54 – PANS model
22:15 – Prevalence of PANS comorbid traits
23:48 – Non-specific inflammatory signs
29:00 – Clinical Management of PANS
33:30 – Study: Impact of steroid treatments on PANS episode duration
37:15 – Study: Monocyte subsets associated with PANS clinical states
44:16 – Q & A session

Summary

Classic rheumatologic conditions such as Lupus (4:30), Behçet’s syndrome (5:43), Sjögren’s syndrome (9:30), Scleroderma (9:53), Spondyloarthritis (10:31), Inflammatory bowel disease (11:30), Psoriasis/Psoriatic Arthritis (12:03), CNS Vasculitis (13:05), and Sydenham Chorea (SC) (13:20) are associated with psychiatric symptoms such as OCD, anxiety, depression and/or other behavior changes. PANS (20:20) also presents with acute onset of OCD or eating disorders. These psychological comorbidities – specifically OCD – overlap with common symptoms of autism spectrum disorder making inflammatory diseases difficult to diagnose in children on the spectrum. Psychiatric symptoms in individuals with autism can distract from rheumatologic symptoms due to subtle/masked physical manifestations and/or communication difficulties. The onset of certain diseases – especially PANS – can also exacerbate psychological symptoms of ASD and often lead to autoimmune disease diagnosis (2:35).

There is a historic association of pediatric streptococcal throat infections with mental disorders – particularly OCD and tic disorders (18:00). This is especially true in cases of SC and PANS/PANDAS where patients generally present with symptoms 1 – 8 months after exposure to a Group A Streptococcal infection (13:20). Studies have also shown increased volume of basal ganglia during the first episode(s) of CS and PANS (18:42) demonstrating onset of encephalitis. PANS cases present with an acute onset of OCD or eating restrictions and at least 2 of seven comorbid symptoms (20:20). Patients display a very abrupt deterioration in performance, behavior, and mental stability – parents have described it as a personality shift overnight.

Clinical management of PANS (29:00) varies based on each patient. Treatments are generally approached in three stages:

1.   Find and treat active infections (i.e. strep, sinusitis, etc.)
2.   Treat post-infectious inflammation and autoimmunity (if present)
3.   Note that inflammation can cause tissue injury making post-flare rehabilitation highly important (40:00)
4.   Treat psychiatric symptoms

Post-infectious inflammation is often treated with steroids (NSAIDS, IVIG, etc.). 5 day oral steroid bursts have proven helpful if administered at the beginning of an episode and IVIG trials are taking shape currently (32:00). PANS is understood as a relapsing/remitting disease (21:35) and most patients will return to baseline within a few months after the initial episode. Later, likely following some sort of infection, they will have a relapse episode lasting around 3 months. If flares are caught quickly and treated properly, over time episode length can shrink. However, without treatment, after 4 or 5 flares the symptoms become more chronic (33:30). Episodes generally decrease with age but it is suspected that patients maintain the predisposition to episodes throughout their lifetime and a number of patients develop autoimmune diseases over time (27:30).

Frankovich concludes (38:42) by emphasizing the strong association of post-infectious inflammatory disorders and autoimmune diseases with psychiatric symptoms. She notes that psychiatric symptoms can precede full presentation of inflammatory conditions and urges clinicians and parents to use PANS evaluation guidelines when a child with ASD suddenly develops new psychiatric traits. During the Q&A Frankovich comments on differences between regressive autism and PANS, treatment options, limitations to diagnosis and clinician assistance, international programs and more.

For treatment recommendations and steroid regimens see appendix B of the treatment guidelines found at med.stanford.edu/PANS (publications tab).

Scientist and psychiatrist Lawrence Fung, MD, Ph.D., discusses what neurodiversity is and how increased awareness and support benefits not only neurodiverse individuals but the global population as a whole. He outlines the Strengths-Based Model of Neurodiversity and presents the newly implemented Stanford initiatives for neurodiverse student and employment support.

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In this webinar:

25:04 – Focusing on individual strengths

26:11 – Implementing individualized, long-term strategies

5:42 – Holistic intelligence assessments

27:25 – Identifying meaningful development goals

Summary:

“Neurodiversity is a concept that regards individuals with differences in brain function and behavioral traits as part of normal variation in the human population.” (2:40). Conditions including autism, dyslexia, and AD/HD, are discussed.

Neurodivergent individuals make up the largest minority group in the United States but have yet to receive proper support in most social and professional settings. To address this issue, Fung asserts that employers and educators must adopt approaches based on the strengths of neurodiverse individuals instead of their “disabilities.” 

The Strengths-Based Model of Neurodiversity (21:55) employs four main components (24:18): 

1. Positive Psychology (25:04) Focused on individual strength, satisfaction, and growth
2. Positive Psychiatry (26:11) Implementing long-term solutions based on strengths, well-being, and growth
3. Gardner’s Theory of Multiple Intelligences (MI) (5:42) Tests for musical-rhythmic intelligence, inter/intrapersonal intelligence, etc. and serves as a more inclusive and holistic test for intelligence than IQ.
4. Chickering’s Seven Vectors of Development (27:25) Development goals based on self-awareness and interdependence

These strengths-based elements allow for the growth and development of neurodivergent traits, which, when given proper support, may provide a “competitive advantage.” (13:19). In fact, (according to the presenter) many neurodivergent individuals have changed the course of history, like Alan Turing (13:22), Temple Grandin, Charles Darwin, and Andy Warhol, to name a few.

Stanford University has implemented support initiatives based on the Strengths-Based Model. They aim to support neurodiverse students during their higher education and their transition to employment and independent living. Their Neurodiversity Student Support Program (NSSP) (33:53) has seen great success already, with a jump from 5 to 17 student participants in one year, despite the pandemic. Beyond this, the Neurodiversity at Work Program (NaWP) (36:35) helps neurodiverse students with job placement and partners with corporations and hospitals to train employers on neurodiverse-friendly environments and onboarding processes. 

The overall objective of the Strengths-Based Model and the Stanford programs is to maximize the potential of neurodiversity “not only for neurodiverse individuals but for all of us because neurodiverse individuals can bring so much to the table.” (31:46)