Rett Syndrome: Implications for Physical Education and Other Movement Settings
Outwardly, Sarah appears to be like any other smiling, outgoing elementary school student, no different from the other students in her second grade class. On closer observation, a difference is seen in Sarah’s hands. Her hands appear to have a mind of their own, constantly moving in a repetitive, wringing, and non-purposeful pattern. If asked, Sarah’s second grade or general physical education teacher would say Sara has difficulty engaging in performance activity with her hands, and it appears to take Sarah a great amount of focus and concentration to move her hands out of the wringing pattern. Aside from this initial observation, several other features beyond hand wringing make Sarah’s movements different from her peers.
Sarah’s movements indicate difficulty with balance and coordination. She is unable to perform locomotor skills such as hopping or jumping as part of the warm-up routine in physical education. Instead, Sarah typically remains standing still while her peers perform these activities. Unless prompted, Sarah prefers watching her peers perform rather than engaging in the activity herself. This is understandable, because even attempting to move from a sitting position on the floor to a standing position takes Sarah a great amount of concentration, work, and balance.
Like many second grade girls, Sarah has a favorite color: pink. She even has a toy dog named Rosie. However, when asked about playing with Rosie, or for that matter when conversing with her about anything, it is apparent Sarah has difficulty articulating her words. Although highly animated and smiling when she speaks, when asked to perform a task or answer a question she does not respond or answer immediately. She takes several seconds to process the task of responding, and sometimes does not respond at all.
Sarah has Rett Syndrome (RS), a neurological disorder which is the result of a gene mutation (National Institute of Neurological Disorders and Stroke, 2009). Although scientists at Baylor College of Medicine discovered the gene that causes RS in 1999, it was originally discovered by Dr. Andreas Rett in 1966 (Bruey, 2004; Rapp, 2006). RS is a rare syndrome occurring in an estimated one out of 10,000 to 23,000 female births in the United States; however, this incidence may be greater as new evidence is discovered. Due to the nature of the gene mutation, this disorder rarely occurs in males. The nature and appearance of this Syndrome has implications for teaching movement and for participation in physical education or recreation. The purpose of this article is to give an overview of RS and provide a resource for physical educators, adapted physical educators, and other leaders in recreation and sport programs. This article presents the unique needs of a child with Rett Syndrome, as well as strategies that can be used when working with children with RS in movement programs.
What is Rett Syndrome?
RS is classified as a pervasive developmental disorder (also known as autism spectrum disorder) (Bruey, 2004). Differing from autism, this rare Syndrome is characterized by normal early development in the first six to eight months of life (Rett Syndrome Research Foundation, 2006). The Diagnostic and Statistical Manuel of Mental Disorders, Fourth Edition, Text Revisions (DSM-IV-TR, 2000) uses the following five criteria for diagnosing a child with RS: (a) slowing of head growth between the ages of 5 and 48 months, (b) loss of purposeful hand movement, (c) loss of social engagement, (d) poorly coordinated gait or trunk movements, and (e) significantly impaired expressive and receptive language development with severe psychomotor retardation (American Psychiatric Association, 2000). While not classified as a degenerative disorder, there are four stages of progression in RS (Hunter, 1999; Rapp, 2006) (see Table 1). In each stage of RS, a child displays noticeable characteristics similar to autism, such as decreased interest in surroundings and decreasing ability to communicate. These characteristics can be quite apparent in social and movement settings.
Table 1
Stages of Rett Syndrome*
| Stage I – Early Onset |
|---|
6-18 months — stage lasts for 1 month to a year
|
| Stage II – Rapid Onset |
1 to 4 years — stage lasts for weeks to months
|
| Stage III – Plateau or Pseudo-stationary |
2-10 years — stage can last for a year
|
| Stage IV - Late Motor Deterioration |
10 and older — stage lasts for years or decades
|
Medical, Motor, and Social Implications of Rett Syndrome
Although RS can sometimes initially be misdiagnosed as autism, there are some very distinctive characteristics of RS, including loss of previously learned skills, hand-wringing, seizures, poor balance and coordination, and loss of muscle control, often leading to the need for a wheelchair (Bruey, 2004, Novitsky, 2008). It is important to note children with RS might display different combinations and progressions of the Syndrome. Some progress through the four stages more rapidly, and, therefore, have more limited skills than others who progress more slowly. Additionally, some might not display all characteristics described in the following discussion. Therefore, it is critical to keep this spectrum of characteristics in mind when preparing for a child with RS to participate in general physical education or another movement setting.
Medical Concerns
Several medical issues are associated with RS, with the most prominent being seizures. Seizures can result when the brain’s electrical activity is disrupted (The Merck Manual, 2008). There are different types of seizures, including absence, simple and complex partial, myoclonic, and tonic-clonic (formally known as grand mal seizures) (The Merck Manual, 2008). In RS there is no one specific seizure seen; children with RS might have both partial and/or generalized (tonic-clonic) seizures. Seizures in RS could result from a variety of reasons, depending on the child (Hunter, 1999, NINDS, 2009). In addition to seizures, children with RS often have gastroesophageal reflux, constipation, scoliosis, abnormal breathing (like hyperventilation or apnea), insomnia, poor circulation, and poor temperature regulation (International Rett Syndrome Association, 2006). All of these potential medical issues can cause delays in the motor domain (ISRA, 2006). Teachers, coaches, and recreation specialists must be aware of any medical precautions when working with children with RS.
Physical and Motor Abilities
Children diagnosed with Rett Syndrome tend to display both poor gross and fine motor skills, such as in using utensils, tying shoes, throwing, catching, and jumping (Bruey, 2004; Novitsky, 2008). Depending on the stage of RS, muscle tone can be higher or lower ((NINDS, 2009). Children with RS tend to have significantly better gross motor skills than fine motor due to the distinctive physical characteristic of hand-wringing (Hunter, 1999). Repetitive hand movements seen in RS are non-functional and thought to be involuntary rather than self-stimulatory, which is more characteristic of classic autism (Mount, et al., 2003; NINDS, 2009). It is often difficult to redirect these children when they are displaying hand-wringing or other repetitive movements, which in turn can hinder teaching and practicing various motor skills (Houston-Wilson, 2005; Katsiyannis et al., 2001). In addition to hand-wringing, children diagnosed with RS have several other physical and motor characteristics.
A child’s motor ability with RS can be significantly impacted by motor apraxia and ataxia. Motor apraxia is inability of the body to perform a movement when prompted by the brain (Hunter, 1999). As a result, the child might have a delay in responding to a motor request. The child wants to move and perform the task, but seems to be unable to tell the body what to do. Motor ability also can be impacted by ataxia. Ataxia, literally translated from the Greek. means without order or incoordination (National Ataxia Foundation, 2007). Ataxia occurs when the part of the nervous system controlling movement and balance is impaired (NAF, 2007). In RS, ataxia can be observed in difficulty transitioning from position to position (e.g., from sitting to standing). This balance disruption can make it challenging for a child with RS to complete tasks involving balance such as hopping, bending, or standing on one foot (Hunter, 1999). The combination of motor apraxia and ataxia clearly negatively affect the child’s ability to perform many gross motor skills used in general physical education and other movement settings.
Another motor characteristic of RS is hypotonia. Hypotonia (decreased muscle tone) results in soft or squishy feeling muscles and a floppy or rag doll appearance of the body. This floppiness is the result of a neurological problem rather than lack of exercise (Hunter, 1999; NINDS 2009). Hypotonia makes it difficult for the child to move efficiently or perform activities involving strength (e.g., grasping or throwing an object).
Conversely, depending on the stage of the disability, some children with RS might display hypertonia. Hypertonia is an abnormal increase in muscle tension and reduced ability of a muscle to stretch (NINDS, 2009). Spastic movements and tight muscles can lead to contractures or limited movement in the joints. Clearly hypertonia impacts a child’s ability to participate in general physical education activities. Limited range of motion and increased muscle tension can cause the child to move slowly and stiffly (Hunter, 1999). As a result, the child might not be able to execute skills requiring a certain amount of flexibility and range of motion, such as the overhand throw or the sit and reach fitness test.
Children with RS usually display hypotonia in the early years. However, as the child grows older and the disorder progresses, muscle tone switches to hypertonia. Some suggest fluctuating muscle tone can affect the child’s endurance (Hunter, 1999; Rapp, 2006). As a result the child can have difficulty participating in fast paced games and activities seen in typical physical education or movement settings, such as chasing and dodging games.
Social Implications
Since children with Rett Syndrome go through a progression of four stages, the social impacts can be different at the different stages. For example, during stage two, the child tends to lose some previously learned skills (Bruey, 2004). Loss of skills, such as communication and motor skills, can have social implications for the child. Limited motor skills might prevent the child from social interaction inherent in games and activities that involve movement (Evans & Meyer, 2001). As a result, at this stage of RS it might be difficult for the child to interact with peers. Many children with RS also go through a period of social withdrawal as part of their regression period, and during this period the children could become irritable, cry frequently, and avoid eye contact (Hunter, 1999). A separate adapted physical education setting is most appropriate during this stage of RS.
Interestingly, in stage three of RS the child tends to be more sociable (Bruey, 2004). Nevertheless, since many children with RS have difficulty with verbal communication, much social interaction is accomplished through non-verbal measures such as body language and facial expressions (Evans & Meyer, 2001). For example, a child might be more responsive around peers as noted by giggling, smiling, and looking at classmates. It is important to note that throughout all stages, it will be extremely difficult for the child to spontaneously create positive friendship experiences. Rather, parents, teachers, and peers need to accommodate the child with RS by creating social experiences for them (Evans & Meyers, 2001).
Suggestions for Physical Education and Movement Settings
Once the physical educator, coach, and recreation leader are aware of the medical, motor, and social needs of children with RS, there are several teaching strategies that can be used to facilitate motor learning. The following highlights some of these strategies aimed at including a child with RS in general physical education and other movement settings. These strategies can be used as tools to facilitate learning on behalf of the child, as well as creating a safe environment for her and the rest of the class.
Medical Management
As previously stated, one of the main medical concerns with children with RS is seizures. Therefore, as a physical educator it is important to know how to react if a seizure occurs. First aid for a seizure depends on the type of seizure. More severe seizures, like tonic-clonic seizures which result in violent movements, can cause the person to fall and could result in injury. A person experiencing this type of seizure should never be restrained, nor should any attempt be made to put something in the mouth. Additionally, potentially dangerous objects should be moved from the area to prevent the child from injury. Usually after a seizure the individual is very tired and might not be fully alert; therefore, the child should be given time to recover (The Merck Manual, 2008). Most importantly, if a severe seizure occurs (like tonic-clonic), it is important to keep bystanders calm. Seizures occurring within a physical education, sport, or recreation setting may be particularly frightening to peers. Therefore, it might be necessary to explain to peers what happened to the child and that she will be all right after some rest. To understand more about seizure management, safety precautions, and first aid treatment of seizures, talk to the school nurse. Other medical complications (noted previously) also could impact engagement in the movement setting. The school nurse, in consultation with the child’s physician and parents, can help physical educators, coaches, and recreation specialists identify pertinent medical markers and create an appropriate healthcare/emergency plan for each individual child who has a seizure disorder.
Physical and Motor Accommodations
Few studies have examined effects of physical activity and motor accommodations for children with RS. However, a recent study by Lotan, Isakov, and Merrick (2004) examined effects of physical fitness training in children with RS. Results suggested a daily physical fitness program resulted in improved functional ability of these children. However, there has been virtually no information on accommodating children with RS in general physical education and recreation settings. Therefore, recommendations outlined below are based upon personal experiences as an adapted physical education specialist supporting a child with RS in a general physical education setting.
According to Block (2007), “students with disabilities often can be safely and successfully included in general physical education….the general physical education teacher must be prepared to make modifications to how the class is organized, how information is presented, and how support personnel are utilized (p.111).” For the child with RS to be included in general physical education, the severity and current stage of RS, as well as motor ability level must be taken into account. Since motor abilities in RS change depending on the child’s stage, physical education modifications and activities will be different for each stage. For example, in stage two, accommodations might focus on using other methods of communication (e.g., visual aids, physical assistance) to instruct a child, while in stage three accommodations might focus on stretching and increasing range of motion since hypertonia and rigidity are hallmarks of this stage (Bruey, 2004).
Physical educators, coaches, and recreation specialists should be aware of both motor capabilities and motor challenges of a child with RS, keeping aware of features of the Syndrome as it progresses in the individual child. In general, activities should focus on slowing the loss of motor and mobility skills occurring in RS as the syndrome progresses. For example, stretching should be emphasized at the beginning and end of activities due to risk of decreased range of motion caused by increase in muscle rigidity (Auxter, Pyfer, & Huettig, 2001). Ambulatory individuals should be challenged with activities involving balance, such as walking on uneven surfaces or using balance boards. Improving the child’s general balance, range of motion, and motor skills will help the child acquire new skills which can be used in general physical education, sport, and recreation settings (Auxter, et al., 2001).
An overall challenge is repetitive hand wringing, as this can interfere with performing most motor tasks (Houston-Wilson, 2005; Katsiyannis, et al., 2001). Implementing activities involving weight-bearing on hands, such as moving from sitting to standing, can encourage the child to use hands in more functional ways and aid in motor tasks requiring hand use (Kubas, 1992). Additionally, making equipment accommodations, such as using softer and lighter balls, can allow the child to practice skills using hands without added concentration needed to hold a heavy object. Finally, use equipment that is easy to grasp and hold such as hula hoops, jump ropes, and yarn balls to further encourage hand use (Katsiyannis, et al., 2001).
The tables, modified from Block (2007) explain different teaching techniques, accommodations, and modifications to activities in the physical education setting when working with children with RS.
Social Concerns and Motivation
Movement experiences can facilitate development of social skills for all children (Pangrazi, 2004). As previously discussed, social interactions are challenging for children with Rett Syndrome at all stages, with certain stages more amenable to social interactions than others. Social skills need to be taught and facilitated through various experiences. Since children with RS have difficulty spontaneously creating friendships or peer interactions, physical educators, coaches, and recreation specialists must promote these experiences (Evans & Meyers, 2001). Implementing cooperative games, partner, and group activities can compel these children to interact with peers. For example, something as simple as encouraging peers to give the child with RS a high five not only encourages purposeful hand movement, but also positive interactions with peers. Creating such experiences and opportunities for these children may aid in developing peer interaction.
Opportunities for social interaction can motivate a child to engage in physical activity. While it is recommended to keep children with RS active due to progression of stages, it can be challenging to engage these children in physical activity due to refusal or reluctance to engage with the task (Elefant & Lotan, 2002). Motivation is key when attempting to involve a person with RS in a physical activity or motor skill setting. For example, something as simple as taking a short break can be motivating for continuing an activity. Depending on the stage of RS, inclusion within a peer setting also can be motivating due to increased visual activity, as well as social engagement from peers. Music also has been found to be an effective motivation tool (Elefant & Lotan, 2002). Motivating qualities of music serve to increase social engagement and communication; adding music to physical activity makes it less likely a child with RS will reject physical activity (Elefant & Lotan, 2002).
A Note about Inclusion with Peers
Benefits of inclusion, to any degree and in any setting, are that the child with RS benefits socially and has opportunities to generalize motor skills with peers. In the school setting, encouragement for inclusion can be seen in standard five of the National Standards for Physical Education in that social responsibility within a physical setting is a goal for students (National Association for Sport and Physical Education, 2010). In addition, the Individuals with Disabilities Education Act (IDEA 2004) sets forth the following mandate for educating all children, “To the maximum extent appropriate, children with disabilities…are educated with children without disabilities, and that special classes, separate schooling, or other removal of children with disabilities from regular education environments occur only when the nature or severity of the disability is such that education in regular classes with the use the supplementary aids and services cannot be achieved satisfactorily” (U.S. Department of Education, 2004).
A student with RS, depending on the stage of progression (refer to Table 1) and age, might be able to attend general physical education classes with appropriate accommodations and/or support. The widening gap between progression of RS and expectations in the gymnasium should be the guide to determining the level of a student’s inclusion, rather than a specific grade level. For example, a student could be in the third grade and at stage two of RS, and still participate in modified physical education class activities with support of an adapted physical educator.
While IDEA sets forth regulations for students with disabilities within the school setting, the Americans with Disabilities Act (ADA) presents regulations for people with disabilities within the community. ADA was created to prevent persons with disabilities from being discriminated against based solely upon one’s disability from participating in all aspects of life, like employment, and community access (U.S. Department of Justice, 2008). For example, it would be a violation of ADA to exclude a child with RS from participating in a local community soccer team based solely on disability (Block, 2007). Therefore, if a child with RS was to participate on a local soccer team, the team must make reasonable accommodations to include that child (U.S. Department of Justice, 2008). Again, the child’s progression of RS determines appropriate participation in any community-based sport or recreation program. If the stage precludes involvement in community sport and recreation, specialized programs such as Special Olympics or therapeutic recreation programs would be options for these children.
Conclusion
Physical educators, coaches, and recreation specialists are confronted with challenges every day. However, we often find ways to overcome these challenges to create positive learning experiences for students, including students with disabilities. While inclusion of children with RS into physical education, sport, and recreation settings can be challenging, creating positive learning experiences for these children can help them become more successful overall. The following are general guidelines for accommodating children with RS in physical activity programs:
- Develop a highly structured class setting, including a direct style of teaching, moving from simple to more complex activities, using one-step directions, having a predictable routine, and using task variations. First and foremost be concerned with meeting the child’s unique learning and behavioral needs in a setting that allows the child to spend the most time practicing and learning targeted motor and fitness goals.
- Design modifications ahead of time for typically taught games and activities such as making distances shorter, using larger and lighter balls, and using peers to facilitate success.
- Participate in seizure training to better identify seizures, as well as how to use appropriate safety techniques and precautions. Engage in on-going consultation with medical professionals and parents regarding seizures and any other medical precautions.
- Create opportunities for social interactions to facilitate social learning, which can be challenging at times for children with RS.
- Determine what motivators are best for working with the individual child with RS.
Table 2
Curricular Adaptations for Children with RS
| Limitations: | Things to Consider: | Modifications: |
|---|---|---|
| Limited Strength | Shorten distance to move or project an object, use lighter equipment (e.g., balls, bats), use shorter striking implement, allow child to sit or lie down while playing, use deflated balls or suspended balls, or change requirements (a few jumps, then run). | Children with RS can be prone to having hypotonia (lack of muscle tone) and, therefore, may require shorter distances in games involving running. Hand-wringing may cause children to have difficulty performing tasks with their hands. Using lighter and bigger balls to practice skills, such as throwing or rolling, allows the child to practice using her hands without the added concentration of holding a small, heavy object requiring more hand control. |
| Limited Speed | Shorten distance (or make it longer for others), change locomotor pattern (running v. walking), or make safe areas in tag games. | Children with RS tend to move slower than peers due to motor apraxia. Modify distances the child has to run in a game, or allow the child to perform a simple locomotor skill such as walking or running (instead of hopping or jumping), so the child can finish the game or be in a more equal playing field as peers. |
| Limited Endurance | Shorten distance, reduce playing field, allow safe areas in tag games, decrease activity time for the student, allow more rest periods for the student, or allow the student to sit while playing, | Due to the child’s potential to have hypotonia or hypertonia, the child with RS may have some endurance issues. Making modifications such as shortening the distance the child has to run or walk in a game or allowing the child to rest between trials accommodates for weakened endurance. |
| Limited Balance | Provide a chair/bar for support, teach balance techniques, increase width of beams to be walked, use carpeted rather than slick surfaces, teach students how to fall, place student near wall for support, or allow student to hold a peer’s hand. | Since children with RS can be ataxic, they display limited balance. Making modifications such as providing the child with a partner or an object for support or increasing the width of certain pieces of equipment (like a balance beam) allows the child to have success in activities involving balance. |
| Limited Coordination and Accuracy | Use stationary balls for kicking/striking, decrease the distance for throwing, kicking or shooting, make larger targets and goals, use larger balls for kicking and striking, increase surface of the striking implements, use a backstop, or use softer, slower balls for striking and catching to optimize safety. | Due to motor apraxia, as well as ataxia, the child displays limited coordination. To accommodate for this limitation, using larger balls or targets for activities involving accuracy allows the child to be successful. To optimize safety in a physical education setting, using softer and lighter balls for striking, throwing, and catching allows the child to participate in the activity with minimal safety risk. |
| Limited Functional Hand Use (repetitive hand wringing) | Use soft and lightweight implements and equipment for the hands providing traction, such as rubberized material for gripping, like the handle on a baseball bat. Develop activities in which the child with RS would do weight-bearing on hands. | Due to the repetitive hand wringing characteristic of RS, it is difficult for these children to grasp objects, like a baseball bat or ball. Using lightweight and soft pieces of equipment allows the child to practice skills that use hands without added concentration of holding a heavy object requiring more hand control. Implements providing traction can aid in the child’s grip without causing the child to use more hand strength. Activities involving weight-bearing on hands, such as moving from sitting to standing, would also encourage the child with RS to use hands in a functional way. An occupational therapist (who has expertise in hand function) will be able to offer sensory and motor strategies relative to skills involving the hands as the curriculum changes (Kubas, 1992). |
Table 3
Instructional Modifications for Children with RS
| Instructional Component | Things to Consider | Modifications |
|---|---|---|
| Teaching Style | Command, Problem Solving, Discovery | Since RS is under the umbrella of pervasive developmental disorders, RS can display traits similar to autism (Bruey, 2004). Therefore, an exploratory style of teaching does not work for these children. The child does not know how to interact with peers independently or the equipment (Evans & Meyers, 2001). A teacher-directed or command style of teaching provides the child with RS direction and structure needed to complete an activity within the physical education setting. |
| Level of Methodology | Verbal Cues, Demonstrations, Physical Assist | Children with RS tend to display difficulties with communication and processing information (Hunter, 1999). Therefore, providing the child with verbal cues, visual demonstrations, and physical assistance to perform an activity provides support and information needed to perform an activity successfully. Physical assistance may also be needed to aid the child in being safe in a fast paced physical education setting, since children with RS tend to move slowly (Hunter, 1999). |
| Order of Learning | What order to present instruction | Children with RS have difficulties processing information requiring them to gather information through various mediums (e.g., cues, physical assistance, and demonstrations). As a result, beginning with the simplest form of an activity or skill helps the child process the task and have success before moving on to a more complex skill. Allowing wait time for response accommodates for slower response time. |
| Provide Structure | Set organization of instruction each day | Children with RS seem to perform better when they are emotionally secure (Hunter, 1999). Participation in a structured routine allows for this security, because the child knows what to expect. As result, a high level of classroom structure and organization (such as consistent routine and visual schedules) aids the child in being more comfortable in the physical education setting and being successful in an activity. |
| Level of Difficulty | Complexity of Instructions/Organization | As stated in Order of Learning, a child with RS tends to process information when it is simplified. Starting with a simple task and then moving to more complex tasks works well for these children. Additionally, simple and concise one-step instructions enable the child to process the directions and provide a response more easily. |
| Levels of Motivation | Make setting and activities more motivating | Children with RS can become frustrated and/or become disinterested with an activity that is challenging for them, like motor activities (Hunter, 1999). Therefore, finding out what motivates the child (music, food, or social rewards) enables the child to stay more focused on the task. |
Selected References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. Text Revisions). Author.
Auxter, D., Pyfer, J., Zittel, L., Roth, K., & Huettig, C. (2009). Principles and methods of adapted physical education and recreation. (11th ed.). New York: McGraw-Hill.
Block, M. E. (2007). A teacher’s guide to including students with disabilities in general physical education (3rd ed.). Baltimore, MD: Paul H. Brookes.
Bruey, C. T. (2004). Demystifying autism spectrum disorders: A guide to diagnosis for parents and professionals. Bethesda, MD: Woodbine House.
Elefant, C., & Lotan, M. (2002). Rett Syndrome: dual intervention—music and physical therapy. Nordic Journal of Music Therapy, 13(2). Retrieved January 10, 2010, from http://www.njmt.no/abstract132elefant.html
Evans, I. M. & Meyer, L. H. (2001). Having friends and Rett Syndrome: How social relationships create meaningful contexts for limited skills [Electronic version]. Disibility and Rehabilitation, 23(3-4),167-176.
Hanks, S. (1990). Motor disabilities in the Rett’s Syndrome and physical therapy strategies. Brain and Development, 12, 157-161.
Houston-Wilson, C. (2005). Pervasive developmental disorders. In J.P. Winnick (Ed.), Adapted physical education and sport (4th ed.) (pp.175-185). Champaign, IL: Human Kinetics.
Hunter, K. (1999). The Rett Syndrome handbook. United States of America: International Rett Syndrome Association.
International Rett Syndrome Association (2006). Rett Syndrome. Retrieved December 6, 2007, from http://www.rettsyndrome.org/
Katsiyannis, A., Ellenburg, J. S., Action, O. M., & Torrey, G. (2001). Addressing the needs of students with Rett Syndrome. TEACHING Exceptional Children, 33(5), 74-78.
Kubas, E. S. (1992). Use of splints to develop hand skills in a woman with Rett Syndrome. American Journal of Occupational Therapy, 46(4), 364-368.
Lotan, M., Isakov, E., & Merrick, J. (2004). Improving functional skills and physical fitness in children with Rett Syndrome. Journal of Intellectual Disability Research, 48(8), 730-735.
Miken Family Medical Foundation. (producer & director). (1991). Seizure Disorders and the School I: Elementary [videocassette]. Epilepsy Foundation of America.
Mount, R. H., Charman, T., Hastings, R. P., Reilly, S., & Cass, H. (2003). Features of autism in Rett Syndrome and severe mental retardation. Journal of Autism and Developmental Disorders, 33, 435-442.
National Association for Sport and Physical Education. (2010). Moving into the future: National standards for physical education. Retrieved January 10, 2010, from http://www.aahperd.org/naspe/standards/nationalStandards/PEstandards.cfm
National Ataxia Foundation. (2007). Diagnosis of ataxia. Retrieved December 7, 2007, from http://www.ataxia.org/learn/ataxia-diagnosis.aspx#what-is-ataxia
National Institute of Neurological Disorders and Stroke (2009, November 19). Rett Syndrome fact sheet. Retrieved December 6, 2009, from http://www.ninds.nih.gov/disorders/rett/detail_rett.htm
Novitsky, S. (2008). What is Rett Syndrome? Exceptional Parent, 38(8), 31-32.
Pangrazi, R. P. (2004). Dynamic physical education for elementary school children (14th ed.) San Francisco: Pearson Education, Inc.
Rapp, C.E. (2006). Rett Syndrome: A brief update and special features in adults. Exceptional Parent, 36(5), 78-82.
The Merck Manual. (2008, March). Seizure disorders. Retrieved January 10, 2010, from http://www.merck.com/mmhe/sec06/ch085/ch085a.html
U. S. Department of Education. (2004). Individuals with disabilities education act: least restrictive environment. (Federal Register sec. 300.114) Retrieved from http://idea.ed.gov/explore/view/p/,root,statute,I,B,612,a,5,
U. S. Department of Justice. (2008). Americans with disabilities act. Retrieved from http://www.ada.gov/
Biographical Sketch
Valerie Thompson is an Adapted Physical Education Specialist for the Central Massachusetts Special Education Collaborative in Worcester, MA. She received her Masters degree in adapted physical education at the University of Virginia. Martin Block is a Professor in the Curry School of Education at the University of Virginia. He also directs the Masters Program in Adapted Physical Education at the University of Virginia.
