Introduction

It is possible that many education professionals have heard of Fragile X Syndrome but know basically nothing about the disorder. It is very possible that teachers will work with children with the disorder at some point during their career. What should these teachers know about the disorder? What are characteristics of children with the disorder? What are good practices for working with children with Fragile X Syndrome? What are poor practices for working with children with Fragile X Syndrome? Specifically for this manuscript, because of the benefits of recess that are noted, the question to be addressed is: What are appropriate modifications to activities for children with the Fragile X Syndrome in the recess setting?

Definition, Signs, and Symptoms of Fragile X Syndrome

Fragile X Syndrome is a "genetic condition that causes a range of developmental problems including learning disabilities and cognitive impairment" (National Institutes of Health: Genetics Home Page, 2016, p. 1). Usually, males are more severely affected by this disorder than females (National Institutes of Health: Genetics Home Page, 2016). A problem with a specific gene that normally makes a protein needed for brain development causes the disease. A person can only make little or none of the protein as a result of the problem with the gene. This causes the symptoms of Fragile X (Cleveland Clinic: Diseases and Conditions: Fragile X Syndrome, 2016)

Although signs and symptoms vary greatly, they often include many of the following according to the National Institutes of Health. It should be noted that, as alluded to earlier, many of the symptoms are often milder in females than in males.

* Intelligence and learning

** These problems can range from the mild, such as learning disorders or problems with mathematics, to the severe, such as an intellectual or developmental disability. ** Individuals with the syndrome also have attention disorders, hyperactivity, anxiety, and language-processing problems. A person with Fragile X may have more capabilities than his or her IQ (intelligence quotient) score suggests.

* Physical

** Most infants and younger children with Fragile X don't have any specific physical features of this syndrome. When these children start to go through puberty, however, many will begin to develop certain features that are typical of those with Fragile X.

** Physical features include a narrow face, large head, large ears, flexible joints, flat feet, and a prominent forehead.

** These physical signs become more obvious with age.

* Behavioral, social, and emotional.

** Most children with Fragile X are afraid or anxious in new situations.

** Individuals may have trouble making eye contact with other people.

** Boys, especially, may have trouble paying attention or be aggressive.

** Girls may be shy around new people. They may also have attention disorders and problems with hyperactivity.

* Speech and language.

** The children may have problems speaking clearly, may stutter, or may leave out parts of words. They may also have problems understanding other people's social cues, such as tone of voice or specific types of body language.

** Girls usually do not have severe problems with speech or language.

** Some children with Fragile X begin talking later than typically developing children. Most will talk eventually, but a few might stay nonverbal throughout their lives.

* Sensory

** Many children with Fragile X are bothered by certain sensations, such as bright light, loud noises, or the way certain clothing feels on their bodies.

** Sensory issues as a result of items such as bright light, loud noises, or the way certain clothing feels on their body, might cause them to act out or display behavior problems (National Institutes of Health: What are the symptoms of Fragile X Syndrome, 2016, p. 1).

Prevalence of Fragile X

The percentage of children with the syndrome is relatively low. However, Fragile X is the most common known cause of inherited intellectual disability (Center for Disease Control and Prevention: Fragile X Syndrome, 2016). One in 4000 boys are born with the disorder. At a rate less frequent, one in 8000 girls are born with the disorder (March of Dimes: Fragile X Syndrome, 2014). This is roughly one in every 5300 children. In Virginia elementary schools with 500 students, roughly one in eleven schools at any time will have a student with Fragile X Syndrome.

Benefits of the Recess Setting for Students with Fragile X

Recess is basically a planned, supervised activity allowing time for active, free play. It is suggested that kids participate in a minimum of 20 minutes of recess a day. Recess should not be taken away as a consequence of punishment. Simply stated, the benefits of the recess setting are high for all children. Included in these benefits are both physical and social and emotional benefits (Praxis Physical Education: Practice and Study Guide: Benefits of Recess for Elementary School Children, 2015). In terms of general physical benefits, recess has been shown to lead to an improvement of general fitness and endurance levels for children (Kids Exercise, 2009). Also, it is important to remember that increased out-of-school activity levels is evident as children usually are involved in physical activities on days in which they participate in in-school physical activities (Dale, Corbin, & Dale, 2000).

More specifically for children with Fragile X are the benefits recess can have on intelligence and learning, physical, behavioral, social, speech and language, and sensory characteristics. Following the discussion of characteristics of the disorder are basic methods to address these characteristics in the recess setting.

Intelligence and learning

Most children with Fragile X have some type of intelligence and/or learning problems. As noted, these problems can range from the mild, such as learning disorders or problems with mathematics, to the severe, such as an intellectual or developmental disability. Learning problems can stem from attention disorders, hyperactivity, anxiety, and language-processing problems. Modifications for the recess setting may include the following:

* Clearly explain and display the proper manner to use equipment--such as swings.

* Explain items in a very basic format and should be done daily. This is beneficial for all students.

* Try to provide enough activities/equipment to limit waiting time.

* Provide a peer-partner for the student with Fragile X to help display equipment and/or participate in activities. This may reduce hyperactivity, anxiety, and possibly language-processing problems.

Physical

In terms of physical characteristics, most younger children with Fragile X, as noted, don't have any specific physical features of this syndrome. When these children start to go through puberty, however, many will begin to develop certain features that are typical of those with Fragile X. These features include a narrow face, large head, large ears, flexible joints, flat feet, and a prominent forehead. As these characteristics do not usually develop until after elementary school, no modifications would probably need to be made as a result of them in the recess setting. Flat feet may be a concern for older children in elementary school. Modifications for a child with flat feet may include:

* Organize non-competitive games.

* Cut down on activities that bring pain (heavy running and jumping) and avoid prolonged walking and standing to give arches a rest (Foot Health Facts, 2016)

Behavioral (social, and emotional)

Most children with Fragile X have behavioral concerns. These children are often afraid or anxious in new situations. They may have trouble making eye contact with other people and may have attention disorders and problems with hyperactivity. Instructional methods, noted by Lucas and Long (2010) related to recess for children with emotional disturbances, can also be used to address these characteristics and ensure participation in recess. These may include the following, plus additional methods:

* Explain the activity to the student personally emphasizing the "fun" in an activity.

* Organize all games that require teams.

* Do not allow students to "pick" teams in group activities.

* Establish clear rules.

* Reduce the number of players on a team.

* Possibly assign a peer that can answer questions for the student.

* Encourage no score keeping (p.28)

* Provide encouragement to all students (Strategies for Teaching Students with Behavioral Disorders, 2007).

* Hold the same behavioral expectations for all students (Winnick, 1995).

Speech and language

In terms of speech language, as noted, most children with Fragile X may have problems speaking clearly, may stutter, or may leave out parts of words. They may also have problems understanding other people's social cues, such as tone of voice or specific types of body language. Also, children with Fragile X often begin talking later than typically developing children or stay nonverbal throughout their lives. Instructional methods, noted by Lucas and Watson (2013), related to recess to address these speech language characteristics and ensure participation in recess may include the following:

* Provide time for delayed responses and verbal rehearsals (Seaman, Depauw, Morton, Omoto, 2007).

* Encourage and allow students to point, gesture, or use explanations and similar words to increase the listener's understanding of expressive language (Seaman, Depauw, Morton, Omoto, 2007).

* Use small, stable groups (Winnick, 1995).

* Use familiar words and supplement with verbal cues (use a variety of words to describe the same movements if needed) (Seaman, Depauw, Morton, Omoto, 2007).

* Provide directions that are simple and concrete (Seaman, Depauw, Morton, Omoto, 2007).

* Provide a comfortable environment.

Sensory

Many children with Fragile X are bothered by certain sensations, such as bright light, loud noises, or the way certain clothing feels on their bodies. Such issues may cause some children with Fragile X to act out or display behavior problems. Instructional methods related to recess to address these characteristics may include the following:

* Provide an environment with lighting that is neither too dark nor too light.

* Provide an environment that is not too loud. This may be difficult to address in the recess setting but may be more possible if the student is not in a large group.

* Provide a comfortable temperature.

Conclusion

Many children with Fragile X Syndrome are in schools today. The benefits to these children, including children with disabilities, are noteworthy. It is very possible that any teacher will have the opportunity to work with a student who has Fragile X. This paper has addressed characteristics of children with the disorder and effective practices for working with children with Fragile X Syndrome, specifically in the recess setting.

References

Center for Disease Control and Prevention: Fragile X Syndrome (2016). Retrieved June 23, 2016 from http://www.cdc.gov/ ncbddd/fxs/data.html

Cleveland Clinic: Diseases and Conditions: Fragile X Syndrome (2016): Retrieved June 13, 2016 from http:// my.clevelandclinic.org/health/diseases_conditions/hic_Fragile_X_Syndrome

Dale, D., Corbin, C. B., & Dale, K. S. (2000). Restricting opportunities to be active during school time: Do children compensate by increasing physical activity levels after school? Research Quarterly for Exercise and Sport, 71(3), 240-248.

Foot Health Facts (2016). Activity Modifications. Retrieved June 13, 2016 from http://www.foothealthfacts.org/footankleinfo/ flatfoot.htm

Kids and Exercise: (2009). The many benefits of exercise. Retrieved June 12, 2016 from http://kidshealth.org/parent/ fitness/general/exercise.html

Lucas, M.D & Long, B. (2010). Students with emotional disturbances participating in recess. The Virginia Association of Health, Physical Education, Recreation, and Dance Journal, 31 (2), p. 28-30.

Lucas, M.D. & Watson, C. (2013). Students with speech impairments participating in recess. Journal of the American Academy of Special Education Professionals, S(1), 128-131.

March of Dimes: Fragile X Syndrome. (2014). Retrieved June 12, 2016 from http://www.marchofdimes.org/complications/ fragile-x-syndrome.aspx

National Institutes of Health: Genetics Home Page. (2016). Retrieved June 12, 2016 from https://ghr.nlm.nih.gov/ condition/fragile-x-syndrome#genes

National Institutes of Health: What are the symptoms of Fragile X Syndrome. (2016). Retrieved June 12, 2016 from https:// ghr.nlm.nih.gov/condition/fragile-x-syndrome

Praxis Physical Education: Practice and study guide: Benefits of recess for elementary school children. (2015) Retrieved June 12, 2016 from http://study.com/academy/lesson/benefits-ofrecess-for-elementary-school-children.html

Seaman, J., (2007). Making connections: From theory to practice in adapted physical education. Scottsdale, AX: Holcomb Hathaway

Strategies for teaching students with behavioral disorders. (2007). General Strategies. Retrieved June 23, 2016 from http:// www.as.wvu.edu/~scidis/behavior.html#sect1

Winnick, J. P. (1995). Adapted physical education and sport. Champaign, IL: Human Kinetics

Matthew D. Lucas, Ed.D., C.A.P.E., Associate Professor, Department of Health, Athletic Training, Recreation, and Kinesiology, Longwood University