The influence of Halliwick method on mental adaptation in aquatic environment for young individuals wit Down syndrome

Received: 14.4.2025                        DOI:

Down syndrome (DS) is a genetic disorder caused by the presence of an extra chromosome 21, affecting approximately 1 in 787 live births worldwide (Heinke et al., 2021). Characterized by a distinct set of physical and intellectual disabilities, individuals with DS often face developmental delays, cognitive impairment, and various health issues. These challenges include difficulties in adapting to new environments and activities due to sensory processing issues and cognitive limitations (Chapman & Hesketh, 2000). Consequently, engaging in physical activities, particularly in an aquatic environment, presents both challenges and opportunities for development.

The Halliwick method, developed by James McMillan in the late 1940s, is a specialized approach to teaching swimming and enhancing water-based activities for individuals with physical, intellectual, and developmental disabilities. This method is rooted in the principles of hydrotherapy and adapted physical activity, emphasizing mental adjustment, breath control, balance, and movement in water through a structured program (Lambeck & Gamper, 2011). The Halliwick method is particularly beneficial for individuals with DS, who often experience hypotonia (low muscle tone), hypermobility of joints, and cognitive challenges that can impede their physical and psychological well-being (Paul et al., 2019).

The aquatic environment offers unique therapeutic benefits for individuals with DS. The buoyancy of water reduces the impact on joints and facilitates ease of movement, which is particularly advantageous for those with muscular and skeletal limitations (Chera-Ferrario, 2012). Additionally, the resistance provided by water can help improve muscle strength and endurance (Getz et al., 2007). However, the mental adaptation to the aquatic environment is crucial for reaping these physical benefits. Mental adaptation in this context refers to the ability to adjust cognitively and emotionally to the water, including overcoming fear, enhancing concentration, and developing a sense of enjoyment and confidence in aquatic activities.

Research has demonstrated the effectiveness of the Halliwick method in improving both physical and mental skills in aquatic settings. For instance, a study on children with autism spectrum disorder, which shares some therapeutic parallels with DS, found significant improvements in mental adaptation, balance, and swimming skills following a structured Halliwick method (Vascakova et al., 2015). These findings underscore the potential of the Halliwick method to foster better mental adaptation in aquatic environments for individuals with developmental disabilities.

The primary aim of this research is to explore the influence of the Halliwick method on the mental adaptation of young individuals with DS to the aquatic environment.

By focusing on mental adaptation, this study seeks to understand how the structured and supportive framework of the Halliwick method can facilitate cognitive and emotional adjustments, thereby improving the overall aquatic experience for these individuals. This research provides insights into the effectiveness of the Halliwick method in fostering mental resilience, promoting psychological well-being, and enhancing the quality of life for young individuals with DS through aquatic therapy.

This research highlights the potential of the Halliwick aquatic exercise program as a sport-recreational activity for individuals with DS, aimed at improving their health status, psychophysical abilities, and physical activity levels. The positive outcomes suggest that such programs can be a valuable addition to the therapeutic and recreational options available for individuals with DS, contributing to their overall well-being and quality of life.

Methods

Design and Participants

This study employed a single-group design which included baseline, post-control, and final measurements. The sample consisted of 14 young individuals with DS, with an average age of 21.8 ± 8.0 years. Inclusion criteria for participation in the study were as follows: a confirmed diagnosis of DS, ability to understand and follow simple instructions, and medical clearance to participate in moderate physical activity. Exclusion criteria included any severe behavioral issues that could impede participation, contraindications to aquatic therapy, or recent surgeries or injuries that would prevent safe engagement in the exercise program.

Procedures

Before the first test (baseline measurement), the assessors underwent training and preparation to familiarize themselves with the techniques and protocols of the WOTA2 test. The mental adaptation testing in water was conducted at the "Aqua Spa Termale" swimming pool in Novi Pazar. The procedure involved two assessors: a swimming instructor who demonstrated and gave verbal instructions in the water, and a recorder stationed outside the water. These assessors were in constant communication when deciding on the final assessment of the participants' motor tasks. Optimal conditions for lighting, water temperature, air temperature, and humidity were ensured. All participants and their parents or guardians were informed about the protocol before testing began. The tests adhered to the ethical principles outlined in the Declaration of Helsinki on biomedical research involving human subjects (World Medical Association, 2013).

Intervention Program

The intervention program was conducted at the pool of the Sports Center "Novi Pazar" and the pool "Aqua Spa Termale" in Novi Pazar. The baseline measurement of all subjects was performed before the start of the program. Following this, there was a 12-week control period during which the subjects did not engage in any form of organized exercise beyond their regular physical education classes. After this period, a post-control measurement was taken, followed by a 12-week intervention program of water exercises.

During the 12-week intervention period, water exercise classes were held twice a week for 60 minutes each session, amounting to a total of 24 sessions. The sessions followed the Halliwick method (ten points) adapted for people with disabilities, incorporating elements of hydrotherapy (the exercise program is detailed in Table 1). The target attendance rate was set at >80%, allowing a maximum of five absences during the experimental period. After this period, a final measurement was taken.

The program aimed to enable individuals with DS to move safely and independently in water, essentially teaching them to swim. Instructors worked with several groups, maintaining an approximate instructor-to-child ratio of 1:3. Additional props were used to tailor the tasks to the age and handicap of the participants.

Table 1. 12-week Halliwick method programme

Week	Session	Halliwick Point
I	1-2	1. Mental Adjustment
II	3-4	2. Disengagement
III	5-6	3. Transversal Rotation Control
IV	7-8
V	9-10	4. Sagittal Rotation Control
VI	11-12	5. Longitudinal Rotation Control
VII	13-14
VIII	15-16	6. Combined Rotation Control
IX	17-18	7. Upthrust
X	19-20	8. Balance in Stillness
XI	21-22	9. Turbulent Gliding
XII	23-24	10. Simple Progression and Basic Swimming Stroke

Measures

The Water Orientation Test Alyn 2 (WOTA2) was utilized to assess orientation and functioning in water. This test comprises 27 items (skills) based on the ten-point principles of the Halliwick concept, but for the purpose of this study only items 1 –

13 were specifically assessed for Mental Adjustment (MA). The metric characteristics of the WOTA2 test have been verified in research by Tirosh, Katz-Leurer and Getz (2008), demonstrating very high reliability (ICC = 0.97). The testing and scoring protocol are detailed in the WOTA2 test evaluation manual (Tirosh, 2016).

Statistical Analysis

Descriptive statistics were employed to summarize the data. Paired sample t-tests were conducted to compare baseline and post-control measurements, as well as post-control and final measurements. Cohen's effect size (ES) was also calculated to determine the magnitude of the observed effects.

Results

The results of the paired sample t-tests, both at the item level (Figure 1) and for overall Mental Adjustment (Tables 2 and 3), indicate varying degrees of improvement in Mental Adjustment (MA) to the aquatic environment across different phases of the intervention program.

Item-Level Analysis

General Mental Adjustment to the Water: The participants showed a gradual improvement in general mental adjustment from the Baseline to the Final measurement. However, the significance levels indicate that this change was not statistically significant between Baseline and Post-Control but became more pronounced from Post-Control to Final.

Blowing Bubbles through the Mouth, Nose, and with Face/Head Immersed (Items 2, 3, 4) : These items related to exhaling techniques showed modest improvements across the measurements. Although there were slight increases in performance from Baseline to Post-Control, significant improvements were observed mainly from PostControl to Final, indicating that repeated exposure and practice had a cumulative positive effect on participants' comfort.

Rhythmically Exhaling while Moving & Exhaling Alternately from Nose and Mouth (Items 5, 6) : These more complex exhaling tasks showed similar trends, with some improvement over time. However, the changes were more substantial between Post-Control and Final measurements, suggesting that as participants adapted more to the water environment, and their ability to perform these tasks improved significantly.

Entering and Getting out of the Water (Items 7, 8): The results show consistent improvement across all measurements for these fundamental tasks. The significant differences between Post-Control and Final measurements indicate that participants gained confidence and autonomy in basic water entry and exit maneuvers.

Chair (Box) Position, Progression along Pool Edge, Walking across the Pool, Jumping across the Pool, and Jumping and Ducking in & out of Water (Items 9-13) : These items, which involve more complex movements and interactions with the water, demonstrated notable improvements, especially between the Post-Control and Final measurements. The most significant changes were observed in tasks involving movement and balance (e.g., walking and jumping in water), reflecting the effectiveness of the Halliwick method in enhancing participants' physical coordination and mental adjustment.

Figure 1. Differences in items scores between baseline, post-control and final measurements. Item 1 = General Mental Adjustment to the water; Item 2 = Blowing bubbles through the mouth; Item 3 = Blowing bubbles through the nose; Item 4 = Blowing bubbles with face/head immersed; Item 5 = Rhythmically exhaling while moving; Item 6 = Exhaling alternately, from nose and _mouth; Item 7 = Entering the water; Item 8 = Getting out of the water; Item 9 - Chair (Box) Position; Item 10 = Progression along pool edge using hands; Item 11 = Walking across the pool; Item 12 = Jumping across the pool; Item 13 = Jumping and ducking in & out of water; ns = Not significant (p > 0.05); * = p < 0.05; ** = p < 0.01; *** = p < 0.001.

Overall Mental Adjustment (MA%) Analysis