SCUBA DIVING: THE TIDE IS IN.

An Innovative Approach to Treatment for Adolescents with Physical Disabilities

The Project TIDE (Teenagers In Deep Environments) adventure program goes outside the traditional hospital environment and uses scuba diving to enhance self-esteem, communication skills, problem solving abilities, and leisure education for teenagers with physical disabilities.

Involvement in recreation plays a significant role in fostering positive "I can" attitudes in people with disabilities. With changes in healthcare, staff are looking for new and innovative ways to continue to foster this attitude. One area gaining particular attention is in adventure programming, representing a paradigm shift from traditional treatment modalities.

Adventure Programming for Adolescents with Disabilities

Adolescence, particularly for persons with physical disabilities, is a critical stage of human development. It's a period when the need for group identification and social interaction is at its peak (Erikson, 1963). During this complex stage of development, the single defining element for self-concept is the need for a sense of personal identity (Goldhaber, 1986), which is often formed through peer interactions, and having or sustaining a disability during adolescence can have devastating consequences. Adolescents with disabilities often experience a devaluation of their identities through negative social interactions or through the absence of social interaction altogether (Cogswell, 1986). These negative experiences may result in a lower sense of self-esteem than their able-bodied peers have (Hayden, Davenport, & Cambell, 1979; Kumar, Powers, & Allen, 1976; McAndrew, 1979).

Changes in social patterns parallel alterations in recreational involvement. Of those whose disabilities occurred during their teenage years (such as those with spinal cord injuries), many were risk takers who enjoyed some degree of uncertainty in recreation activities prior to injury. Post injury, these activities are often replaced with "plug in drugs," such as TV and computer/video games, and, worse yet, many adolescents with physical disabilities cease recreation participation altogether (Dew, Lynch, Ernst, & Rosenthal, 1983).

Parents are often contributing factors to social isolation. Issues of over-protection make it difficult for parents to allow teenagers the freedom to access social and recreational opportunities that develop knowledge, skills, and self-esteem. The proliferation of sedentary recreation activity (Harrison & Kuric, 1987; Coyle & Kinney, 1990) exemplifies how adolescents with physical activities may begin to withdraw from life.

Adventure programming offers both rehabilitation professionals and individuals with disabilities an alternative to traditional treatment. In fact, tremendous growth is being documented in this area, and rehabilitation facilities are finding it a popular modality of care (Smith, 1996). Persons with disabilities are eager to participate in adventure programming, such as white-water rafting and rock climbing, for enjoyment, love of the natural environment, a feeling of accomplishment, and an opportunity to improve skills and test their own limits (Richardson, 1986). Adventure programming is particularly well suited to adolescents because of their youthful energy and propensity for risk taking (Godfrey, 1980). Studies with able-bodied adolescents have shown that those who participate in adventure programming have better self-esteem than their peers who do not (Carson & Gillis, 1994).

Why Scuba Diving?

Aquatic programs have psychosocial and physical benefits for persons with disabilities (Beaudouin & Keller, 1994), and scuba diving is an adventure activity that is rapidly gaining popularity. Scuba diving participation has the potential to improve self-esteem, oxygen uptake, muscle strength, range of motion, and aerobic endurance while allowing persons with disabilities the freedom to explore the natural world. While scuba diving, people of all ability levels have to adapt to a new environment, making it a great equalizer (Buckley, 1994). In fact, persons with disabilities often find scuba diving easier than people who are able-bodied--possibly because persons with disabilities continuously adapt to barriers on land, making the adaptations needed in an aquatic world a normal everyday experience.

Several professional dive organizations offer certification for persons with disabilities. The Professional Association of Diving Instructors (PADI) and the Handicapped Scuba Association (HSA) are two such organizations. HSA, in particular, offers multilevel certification, which enables persons of various levels of injury and ability to be certified for different dive specifications. For example, a person who is certified at level 1, the highest level, is required to dive with one buddy who, at minimum, has an open water dive certification. This person has met all standards and can take care of him/herself and another diver in distress. Level 3 certification, however, indicates the individual has the lowest level of physical functioning and must dive with two buddies, one of which must be certified as a rescue diver.

Project TIDE

Shriners Hospital's Recreation Therapy Department in Chicago regularly uses a "try scuba" experience as part of the rehabilitation process and during their annual Spinal Cord Injury Sports and Conditioning Camp. It focuses on the development of self-esteem by successfully facing and meeting physical and emotional challenges. Due to the positive feedback of these scuba experiences, Project TIDE (Teenagers In Deep Environments) was formed.

Project TIDE is a scuba adventure program for adolescents with physical disabilities organized and regulated by Underwater Safaris Scuba Center in Chicago. The program's mission is to enhance self-esteem, problem solving abilities, and communication skills that will enable them to lead more active and productive lives by overcoming adversity.

Each year an interdisciplinary team comprised of hospital staff and the scuba center select five to six participants based on preset criteria. For those who are able, this includes independence in all aspects of self-care. Persons with higher level tetraplegia can participate and use medical assistance from Shriners Hospital, which provides personal care attendants on the trip. Participants must be free of pressure ulcers, have a certain degree of comfort in the water, and be identified as benefiting from the program. Those adolescents who are accepted then undergo both classroom and experiential pool training to become certified divers. Emphasis is not placed on attaining certification, but on challenging individuals to step out of their respective "comfort zones" to experience personal growth. Metaphoring and processing the scuba experience is where the real benefits can be seen. Being able to successfully challenge and master the adventure experience often means a newfound knowledge of self.

After the classroom and pool experiences, the participants, staff, and volunteers travel to a selected destination known for its excellent diving. The Cayman Islands and Cozumel, Mexico, have ideal scuba diving conditions because of their warm, crystal-clear waters and abundant marine life. Warm water is a crucial element, as it decreases the likelihood of pokliothermia and hypothermia for persons with temperature regulation problems.

There are also a number of safety precautions inherent in Project TIDE. For instance, Radloff and Helmreich (1969) found that divers who experience high levels of anxiety are the least successful divers; therefore, participants and staff strictly adhere to a "challenge by choice" philosophy. This means the participants control their level of involvement. Other safety features include a minimal one-to-one, student-to-instructor ratio. Participants are assigned to a professional dive instructor who remains with them in the water at all times. Adolescents with a higher level of injury or less physical functioning receive a higher ratio of two dive masters to one student.

Adherence to dive tables (the guidelines for dive depth and time under water) is another safety feature. However, when these tables were originally formulated, only male able-bodied subjects were used. Therefore, female divers and divers with disabilities are at a theoretically higher risk for decompression sickness. For people with disabilities, decompression sickness is considered more likely to hit sites of prior injury, such as those with spinal cord injuries (Lin, 1987). Another possible risk to consider is that unused tissues may release gasses at a different rate than that of regularly used tissues (Lin, 1987). Therefore, female divers and divers with disabilities should underdive the traditional dive table.

Evaluation and the Future

Outtake interviews are conducted with each participant. Evaluations have been overwhelmingly positive with one participant stating, "If I can do this, I can do anything!" Participants believed that they had not only achieved their goal of learning how to scuba dive, but also had learned other important lessons, such as increased ability to communicate their needs, increased self-advocacy, and a feeling of overall success. These became self-evident as the trip progressed. The participants were transformed from tentative individuals to self-assured young people. For most of the participants, these characteristics have carried over into other areas of their lives. It seems that Project TIDE is meeting its goal.

Changing the Way We Think

A paradigm shift must occur in the way treatment is being delivered in today's healthcare environment. Adventure programming is one way professionals can meet the changing needs of patients and their families. It is a proactive approach to therapy that uses an interdisciplinary team of professionals. By participating in a goal-oriented, structured outdoor adventure program, patients can increase self-esteem, problem solving abilities, and social opportunities. The outcomes of these programs are valuable lessons that will increase each participant's likelihood of success in life.

References

Beaudouin, N. M. & Keller, M. J. (1994). Aquatic solutions: A continuum of service for individuals with disabilities in the community. Therapeutic Recreation Journal, 28, 192-202.

Buckley, J. J. (1994, June 27). Set free undersea. Sports Illustrated, 2-3.

Coyle, C. P. & Kinney, W. B. (1990). Leisure characteristics of adults with physical disabilities. Therapeutic Recreation Journal, 24, 64-73.

Carson, D. & Gillis, H. L. (1984, May). A meta-analysis of outdoor adventure programming with adolescents. Journal of Experiential Education, 40-47.

Cogswell, B. E. (1984). Self-socialization: Readjustment of paraplegics in the community. In R. P. Marinell and A. E. Orto (Eds). The Psychosocial and Social Impact of a Disability, 156-164. New York, NY: Springer Publishing Company.

Dew, M. A., Lynch, K., Ernst, J., & Rosenthal, R. (1983). Reaction and adjustment of spinal cord injury: A descriptive study. Journal of Applied Rehabilitation Counseling, 14, 32-39.

Godfrey, R. (1980). Outward bound: Schools of the possible. Garden City, NY: Anchor Press/Doubleday.

Goldhaber, D. (1986). Lifespan and human development. New York, NY: Harcourt Brace Javanovich.

Erikson, E. (1963). Childhood and society. New York, NY: Norton.

Harrison, C., & Kuric, J. (1987). Community reintegration of spinal cord injury persons: Problems and perceptions. Abstracts Digest of the Annual Scientific Meeting of the American Spinal Injury Association, 13, 263-267.

Hayden, P. N., Davenport, S. H. L., & Cambell, M. M. (1979). Adolescents with myelodysplasis: Impact of physical disability on emotional maturation. Journal of Pediatrics, 64, 53-59.

Kumar, S., Powars, D., & Allen, J. (1976). Anxieties, self-concept, personal, and social adjustment in children with sickle cell anemia. Journal of Pediatrics, 88, 245-247.

Lin, L. Y. (1987). Scuba divers with disabilities challenge medical protocols and ethics. The Physical and Sports Medicine Journal, 15, 224-235.

McAndrew, I. (1979). Adolescents and young people with spins bifida. Developmental Medicine Child Neurology, 21, 619-629.

Smith, R. W. (1996, May). Trends in therapeutic recreation. Parks and Recreation, 66-71.

Radloff, R. & Helmereich, R. (1969). Stress: Under the sea. Psychology Today, 3, 28-29, 59-60.

Richardson, D. (1986, November). Outdoor adventure wilderness programs for the physically disabled. Parks and Recreation, 43-45.

The exotic experience of scuba diving can give a person the feeling of being transported into another world. For adolescents with physical disabilities, this experience goes one step further, becoming not only a fun form of recreation, but an incredible confidence booster as well. Many question the safety of diving with disabilities, but Kristen A. Johnson, MS, CTRS, and Sera J. Klass, MSW, LSW, demonstrate how effective and fulfilling this form of adventure programming can be, with proper instruction and precaution.

Johnson is the senior recreation therapist at Shriners Hospital for Children in Chicago, Illinois. A cofounder of Project TIDE, a scuba adventure program for teens with disabilities, she has published journal articles and book chapters on animal-assisted therapy, the benefits of sports and recreation for children with orthopedic impairments, and adventure therapy.

Klaas is the spinal cord injury program coordinator and assistant director of Social Services at Shriners Hospital. In addition to being a co-founder of Project TIDE, she is a licensed foster parent, an educational surrogate, and a licensed school social worker.