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Luennoitsijat  |  SPEAKERS

Anne-Marie Bisgaard

Anne-Marie Bisgaard is a consultant paediatrician specialized in neurodevelopmental disorders and rare diseases. She works at Center for Rett syndrome and Center for Rare Diseases at the University Hospital of Copenhagen, Rigshospitalet. Since 2011, she has been the head of the national Danish Rett center which was then established for both children and adults with Rett syndrome.

She did her PhD within the clinical genetic area in 2007 (The phenotype of patients with submicroscopic chromosomal abnormalities and mental retardation. Description of new microdeletion syndromes). Since then, her research focus has been on neurodevelopmental disorders, which in recent years mainly has been within Rett syndrome and related disorders and Cornelia de Lange syndrome. The focus is both on the molecular causes and mechanisms for disease and on clinical issues and how to manage these.  

Her clinical work focuses on different rare diseases, especially Rett syndrome. Individuals with Rett syndrome are followed lifelong on a regular basis by a multidisciplinary team. The visits result in an individual report concerning medical, physiotherapeutic, behavioral and communicative issues. The families also have access to advice from a dietician and a social worker associated the center.

Michelle Stahlhut

 

Michelle Stahlhut, PT PhD works as a research physiotherapist at the Danish Center for Rett syndrome. Michelle Stahlhut obtained her doctoral degree within disability research at Lund University in 2018. The primary area of her research is health promotion throughout life in individuals with Rett syndrome and she especially focuses on validation of outcome measures and development and evaluation of physical activity interventions.

 

Abstract:

Up-time participation in girls and women with Rett syndrome

Rett syndrome is associated with multiple disabilities including intellectual disability leading to a high level of dependency in all aspects of daily living including participation in physical activities. The different impairments and restrictions could have negative effects on the health and quality of life in those with Rett syndrome.

In Denmark 122 individuals are diagnosed with Rett syndrome in the ages of 2 to 64 years. A total of 105 in the cohort have a MECP2 mutation. At the Danish center for Rett syndrome we focus on optimal and lifelong health-promotion and also enhancing the quality of life of those affected with Rett syndrome and their families.

During the last 5 years the research at the Danish center for Rett syndrome has concentrated on three major areas: 1) Outcome measures, 2) Description of the population with Rett syndrome and 3) Development of a health-promoting intervention that focus on ‘uptime’ – that is standing and walking activities.

1) First of all it has been important to establish a toolbox of valid and reliable outcome measures and we have been involved in the validation of several outcome measures (Functional Mobility Scale – Rett Syndrome, Two-Minute Walk Test, Rett Syndrome Gross Motor Scale, ActivPAL, Quality of life inventory – Disability). Building the repertoire of outcome measures is valuable to both researchers and practitioners for intervention studies and clinical monitoring.

2) Secondly, we have described the patterns of sedentary time and steps across ambulation levels in 48 girls/women with Rett syndrome aged 5-60 years. On average 83.3% of waking hours were spent in sedentary behaviors (n=48) and the median daily step count was 5128 (n=28). Advancing age and poorer walking skills were associated with higher levels of sedentary time.

3) Finally, we have focused on the development of an ‘Uptime participation’ intervention which was evaluated in 14 girls/women with Rett syndrome aged 5-48 years. This intervention focused on participation in enjoyable activities to promote ‘uptime’ in home, school/day center and community settings. Primary outcomes were sedentary time and daily steps. Some of the secondary outcomes were walking capacity and quality of life. Significant positive effects were seen after the intervention in sedentary time (-4.1%), daily steps (+708 steps), walking capacity (+18.9m) and quality of life (+2.8 points).

Michelle Stahlhut

 

Michelle Stahlhut, PT PhD works as a research physiotherapist at the Danish Center for Rett syndrome. Michelle Stahlhut obtained her doctoral degree within disability research at Lund University in 2018. The primary area of her research is health promotion throughout life in individuals with Rett syndrome and she especially focuses on validation of outcome measures and development and evaluation of physical activity interventions.

 

Abstract:

Up-time participation in girls and women with Rett syndrome

Rett syndrome is associated with multiple disabilities including intellectual disability leading to a high level of dependency in all aspects of daily living including participation in physical activities. The different impairments and restrictions could have negative effects on the health and quality of life in those with Rett syndrome.

In Denmark 122 individuals are diagnosed with Rett syndrome in the ages of 2 to 64 years. A total of 105 in the cohort have a MECP2 mutation. At the Danish center for Rett syndrome we focus on optimal and lifelong health-promotion and also enhancing the quality of life of those affected with Rett syndrome and their families.

During the last 5 years the research at the Danish center for Rett syndrome has concentrated on three major areas: 1) Outcome measures, 2) Description of the population with Rett syndrome and 3) Development of a health-promoting intervention that focus on ‘uptime’ – that is standing and walking activities.

1) First of all it has been important to establish a toolbox of valid and reliable outcome measures and we have been involved in the validation of several outcome measures (Functional Mobility Scale – Rett Syndrome, Two-Minute Walk Test, Rett Syndrome Gross Motor Scale, ActivPAL, Quality of life inventory – Disability). Building the repertoire of outcome measures is valuable to both researchers and practitioners for intervention studies and clinical monitoring.

2) Secondly, we have described the patterns of sedentary time and steps across ambulation levels in 48 girls/women with Rett syndrome aged 5-60 years. On average 83.3% of waking hours were spent in sedentary behaviors (n=48) and the median daily step count was 5128 (n=28). Advancing age and poorer walking skills were associated with higher levels of sedentary time.

3) Finally, we have focused on the development of an ‘Uptime participation’ intervention which was evaluated in 14 girls/women with Rett syndrome aged 5-48 years. This intervention focused on participation in enjoyable activities to promote ‘uptime’ in home, school/day center and community settings. Primary outcomes were sedentary time and daily steps. Some of the secondary outcomes were walking capacity and quality of life. Significant positive effects were seen after the intervention in sedentary time (-4.1%), daily steps (+708 steps), walking capacity (+18.9m) and quality of life (+2.8 points).

Meir Lotan

Lotan Meir M.Sc.PT Ph.D. is a physical therapists from Israel. He´s working with girls with Rett syndrome over the past 26 years. He is a part of the Israel national evaluation team and has given consultations to about 500 girls with Rett syndrome across the globe. He works as a physical therapist with 15 girls on a regular weekly basis. He has written 30 articles and 4 books on Rett syndrome, and has done many research programs on this topic.

Abstracts:

PHYSICAL THERAPY INTERVENTIONS IN RETT SYNDROME

The presentation will describe appropriate physical therapy and physical activity programs in individuals with RS such as:

  • A functional and physical fitness improvements due to a daily treadmill, training program with children with RS
  • The results of a two year follow up on an intensive program through the Conductive Education (Peto) method
  • The results of an intensive regime for scoliosis at different ages
  • Sensory insights into Rett syndrome
  • The results of a home  program
  • The results o f a remote rehabilitation program

Conclusion:

The presentation will suggest that intensive programs executed on a daily basis are capable of improving function, physical fitness, and outcome of scoliosis in children with RS. The presentation also suggests that such intensified programs can be executed by non-professional personnel, under the supervision of a qualified physical therapist.

 

WALKING IN RETT SYNDROME

The presentation will discuss different topics related to walking in Rett syndrome:

  1. Enhancing walking ability in young children with RS and CDKL5 using the UpSee device.
  2. Independent walking and loosing walking ability in RS over the years 
  3. Treadmill training for improving function and physical fitness in RS
  4. Regaining walking ability in an adult with RS after losing walking ability.
  5. Enhancing walking ability in a woman with RS using ABA method.  

Significance: The different research projects and case studies suggest that walking can be administered even in severe cases of RS, it can improve core element characteristics of RS, it can be regained in specific situation after it has been lost, and can be enhanced in individuals with RS who prefer to avoid walking.  

The presentation suggests specific tool for paraprofessionals working with this population to implement similar programs due to the importance of an active life style for those with or without disabilities.

Meir Lotan

Lotan Meir M.Sc.PT Ph.D. is a physical therapists from Israel. He´s working with girls with Rett syndrome over the past 26 years. He is a part of the Israel national evaluation team and has given consultations to about 500 girls with Rett syndrome across the globe. He works as a physical therapist with 15 girls on a regular weekly basis. He has written 30 articles and 4 books on Rett syndrome, and has done many research programs on this topic.

Abstracts:

PHYSICAL THERAPY INTERVENTIONS IN RETT SYNDROME

The presentation will describe appropriate physical therapy and physical activity programs in individuals with RS such as:

  • A functional and physical fitness improvements due to a daily treadmill, training program with children with RS
  • The results of a two year follow up on an intensive program through the Conductive Education (Peto) method
  • The results of an intensive regime for scoliosis at different ages
  • Sensory insights into Rett syndrome
  • The results of a home  program
  • The results o f a remote rehabilitation program

Conclusion:

The presentation will suggest that intensive programs executed on a daily basis are capable of improving function, physical fitness, and outcome of scoliosis in children with RS. The presentation also suggests that such intensified programs can be executed by non-professional personnel, under the supervision of a qualified physical therapist.

 

WALKING IN RETT SYNDROME

The presentation will discuss different topics related to walking in Rett syndrome:

  1. Enhancing walking ability in young children with RS and CDKL5 using the UpSee device.
  2. Independent walking and loosing walking ability in RS over the years 
  3. Treadmill training for improving function and physical fitness in RS
  4. Regaining walking ability in an adult with RS after losing walking ability.
  5. Enhancing walking ability in a woman with RS using ABA method.  

Significance: The different research projects and case studies suggest that walking can be administered even in severe cases of RS, it can improve core element characteristics of RS, it can be regained in specific situation after it has been lost, and can be enhanced in individuals with RS who prefer to avoid walking.  

The presentation suggests specific tool for paraprofessionals working with this population to implement similar programs due to the importance of an active life style for those with or without disabilities.

James Eubanks, PhD

Dr. Eubanks is a neurobiologist at the Krembil Research Institute in Toronto, Canada – the home of the world champion Toronto Raptors. Dr. Eubanks came to Toronto in 1992, and started his own independent laboratory in 1994. The focus of his work at that time focused on defining how epigenetic factors influence the sensitivity of the brain to epilepsy and stroke. In the early 90’s, MeCP2 was one of a relatively small number of epigenetic factors that had been identified, which is why his group was examining MeCP2 before its role in Rett syndrome was revealed. With the identification in 1999 that MECP2 mutations cause Rett syndrome, his interests shifted towards delineating how MeCP2 normally regulates brain development and function, and to identifying how the absence of MeCP2 affects brain activity. By identifying deficits caused by MeCP2 dysfunction, his work has identified targets for rationale drug development programs working to develop Rett syndrome treatments. The first clinical trial based on his research has now received approval from Health Canada and will soon begin.

 

Dr. Eubanks’ group has shown that neural circuitry deficits in mouse models of Rett syndrome can be improved by reintroducing functional MeCP2 throughout the brain, and his group has shown that selectively preserving MeCP2 function in only a small number of neurons in the mouse brain is enough to significantly improve their Rett-like behaviour. His group uses a number of procedures for their investigations, which include molecular genetics, cell culture, fluorescence microscopy, EEG and electrophysiology, animal behaviour, and the use of embryonic stem cells to generate specific neurons and make new “personalized” mouse models engineered to express rare mutations that are now known to cause neurodevelopmental conditions. These models serve as the starting point for “precision medicine “investigations that will further our understanding of how the brain is affected in these rare genetic conditions.

 

Dr. Eubanks conducted his training in the United States, where he received a bachelor's degree from the University of California, Davis, and a PhD degree from the University of California, San Diego. Upon completion of his Doctoral degree, he then conducted postdoctoral training at the Salk Institute and at Duke University before coming to Toronto. He is currently a Senior Scientist and Division Head at the Krembil Research Institute in Toronto, and a Professor at the University of Toronto. He is member of the Scientific Advisory Board for the Ontario Rett Syndrome Association, the International Rett Syndrome Foundation, and the University of Toronto Epilepsy Research Program. His lab is currently funded by the Canadian Institutes of Health Research, the Ontario Brain Institute, the LouLou Foundation, and the National Institutes of Health.

 

Rett syndrome is a severe neurodevelopmental disorder that affects a few boys but mostly affects girls. Spontaneous mutations of the MECP2 gene are the largest cause of Rett syndrome, but how deficiencies in MeCP2 function facilitate Rett syndrome pathogenesis remains largely unknown. Our work shows that increased levels of oxidative stress within cells may play a role, as administering an anti-oxidant / mitochondrial vitamin cocktail solution to MeCP2-deficient neurons improved their functional properties, and administering the same cocktail to MeCP2-deficient mice improved some of their Rett-like behavioural deficits. These results led us to question how chronically increased oxidative stress might affect biochemical signaling systems in MeCP2-deficient systems. Our cells have surveillance receptors that normally only become activated in times of need, and usually for only a short period of time. We questioned whether one of the key surveillance receptor systems present in neurons might become chronically overactive in the MeCP2-deficient brain. Our results suggest this is the case, as the expression of the surveillance receptor was dramatically increased in the MeCP2-deficient mouse brain. Importantly, restoring the expression of this receptor back to normal levels using genetic procedures significantly improved MeCP2-deficient mice. The “treated” mice regained near normal mobility, showed improved anxiety-like behaviour, and had greatly reduced numbers of epileptic discharges. These results therefore identify a new system involved in Rett syndrome pathogenesis, and suggest that it may be targetable for therapeutic development.

Gillian Townend

Biography:
Gill Townend, M.Phil., B.Med.Sci.(Speech)(Hons), CertMRCSLT, is a researcher at the Rett Expertise
Centre Netherlands – GKC, Maastricht University Medical Centre (MUMC+). She also works for Rett UK’s
communication and education project.
She is a speech and language therapist with longstanding clinical and research experience, initially

specialising in Augmentative and Alternative Communication (AAC) and more recently in Rett syndrome.

Her current research interests include: development of clinical guidelines for the management of
communication in individuals with Rett syndrome; eye tracking in individuals with Rett syndrome and
the functional use of eye gaze for communication; developing alternative assessments for measuring
receptive language and cognition in Rett syndrome; early (pre-diagnosis) communication development
in individuals with typical and atypical Rett syndrome; and the establishment of clinical and research-
based networks and collaborations within and outside of Europe. In her clinical work she also runs
support groups and ‘out and about’ communication groups for individuals with Rett syndrome and their
families.

She was responsible for organising the ‘communication track’ of the 3 rd European Rett Syndrome
Conference Maastricht in 2013, is co-founder of two national networks for Speech and Language
Therapists working with individuals with Rett syndrome – in the Netherlands and the UK, is the
European representative on the North American Rett Clinics Network, and is co-ordinator of the
international project to develop communication guidelines for Rett syndrome.

Researcher, Rett Expertise Centre Netherlands – GKC
g.townend@maastrichtuniversity.nl

Title of presentation:
Oculomotor function in individuals with Rett syndrome

Authors:
Gillian S. Townend a , Raymond van de Berg a,b,c , Laurèl H.M. de Breet d , Monique Hiemstra d,1 , Laura Wagter d ,
Eric Smeets a , Josine Widdershoven b , Herman Kingma b,c , Leopold M. G. Curfs a

Affiliations:
a Rett Expertise Centre Netherlands – GKC, Maastricht University Medical Center, Maastricht, The
Netherlands.
b Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery,
Maastricht University Medical Center, Maastricht, The Netherlands.
c Faculty of Physics, Tomsk State University, Tomsk, Russia.
d Faculty of Medicine, Maastricht University, Maastricht, The Netherlands.

Background: Individuals with Rett syndrome (RTT) rely on eye pointing/eye gaze as a primary means of
communication. Underlying an ability to communicate successfully with the eyes is a complex matrix of
requirements, with an intact oculomotor system being one element. To date, the underlying neural and
motor pathways associated with eye gaze are relatively under-researched in RTT.

Material and Methods: The eye movements of 18 girls and young women with RTT were assessed by
electronystagmography (ENG). This tested horizontal saccade and smooth pursuit (SP) eye movements,
optokinetic nystagmus (OKN) and vestibulo-ocular reflex (VOR). Results were compared to normative
data collected from 16 typically-developing (TD) children and teenagers.

Results: Overall, the RTT cohort demonstrated a range of eye movements on a par with the TD group; all
those who yielded a measurable result showed SP and saccadic eye movements, OKN and VOR. Two
areas of potential difference were (i) Saccades latency where the RTT cohort exhibited a longer latency,
and (ii) VOR where the RTT group demonstrated a slower fast phase velocity. There were, however,
greater difficulties in executing the ENG testing with the RTT cohort which made quantitative analysis
tricky. For example, reduced motivation and attention to test materials and low quality electrode
signals.

Conclusions: “Eye-pointing can be seen as the integrated outcome of a combination of visual, social,
cognitive and motor skills” (Sargent et al, 2013). The starting point for assessing this matrix of
requirements is whether an individual can maintain and shift fixation of gaze. This study addresses that
question and suggests that individuals with RTT have an intact oculomotor system, although potential
differences in saccades latency should be explored further. Modifications should be made to traditional
ENG assessment to combat problems in testing and add strength to the results.

Walter E. Kaufmann, MD


Dr. Walter E Kaufmann is the Chief Medical Officer of Anavex Life Sciences Corp. He
has over 20 years of experience in clinical studies with focus on developing novel
therapies for genetic disorders associated with intellectual disability. Prior to Anavex, Dr.
Kaufmann was the Director of the Center for Translational Research at the Greenwood
Genetic Center, where he also held the Ravenel Boykin Curry Chair in Genetic
Therapeutics. He holds adjunct appointments at Emory University School of Medicine,
where he is an Adjunct Professor of Human Genetics, and at the University of California
Davis School of Medicine, where he is a Visiting Scholar in the Department of
Neurology. Dr. Kaufmann is also an Investigator affiliated with the Massachusetts
Institute of Technology’s Simons Center for the Social Brain. Before these academic
appointments, Dr. Kaufmann was a Professor of Neurology at Harvard Medical School
and a Professor of Pathology, Neurology, Pediatrics, Psychiatry, and Radiology at the
Johns Hopkins University School of Medicine.

Dr. Kaufmann’s major research focus has been Rett syndrome, a field where he has
published extensively on neurobiology and clinical aspects with a focus of behavioral
problems. He served as founder and leader of RettSearch, the international consortium
of Rett syndrome clinical researchers. As such, he co-authored the current diagnostic
guidelines for the disorder. He also edited the first clinical textbook on Rett syndrome,
published in late 2017. Dr. Kaufmann has also served as Co-Principal Investigator of the
NIH-funded Natural History Study of Rett syndrome (RDCRN program). He has also led
efforts at developing biomarkers and outcome measures for Rett syndrome and fragile X
syndrome. Dr. Kaufmann has played different roles, including site investigator, Principal
Investigator, and DSMB member/chair, in almost 20 drug trials for neurodevelopmental
disorders. In this context, he has been involved in virtually all neurobiologically-based
drug trials for Rett syndrome. His research has been funded by the NIH, DOD, CDC (he
is member of the Steering Committee for the CDC natural history study of fragile X
syndrome funded by CDC), and by research foundations including Rettsyndrome.org.

Dr. Kaufmann has published more than 220 journal articles, most of them original
publications. He has also served on several editorial boards and as reviewer for over
100 scientific journals. Dr. Kaufmann was also member of the Neurodevelopmental
Disorders Work Group of the Diagnostic and Statistical Manual of Mental Disorders-Fifth
Edition (DSM-5), which developed the current diagnostic guidelines for intellectual
disability and autism spectrum disorder.

Jan-Marino Ramirez

Jan-Marino (Nino) Ramirez, PhD is a Professor of Neurological Surgery and Director of the Center for Integrative Brain Research at the Seattle Children’s Research Institute.

Dr. Ramirez studies neural mechanisms involved in the generation of respiratory rhythms, neocortical activity, and epilepsy. He has conducted research investigating the neuronal mechanisms underlying erratic breathing and dysautonomia in Rett syndrome in animal models and children. In collaboration with Drs. D. Weese-Mayer and M.S. Carroll he uses quantitative methods to perform a breath-to-breath analysis and the coordination with the heart.

He also studied familial dysautonomia, congenital hypoventilation syndrome, pediatric epilepsy, and he explores the mechanisms leading to sleep apnea and SIDS. Dr. Ramirez’s work has been funded by multiple National Institutes of Health (NIH) grants since 1996.

Liisa Metsähonkala

Present position: Pediatric neurologist and deputy chief in Epilepsy Unit for Children and Adolescents, Pediatric Neurology clinic, start date 2.1.2005.

James M. Youakim

 

Investigation of Trofinetide as a Treatment of Rett Syndrome

Trofinetide is a synthetic analogue of glycine-proline-glutamate (GPE), the n-terminal tripeptide of the
insulin-like growth factor 1 (IGF-1) (Guan et al. 2015). There is evidence from preclinical studies that GPE may benefit patients with Rett syndrome (RTT) (Tropea et al. 2019; Williams et al. 2014).

A recent Phase 2 clinical study evaluated treatment with trofinetide compared with placebo in 82 girls
with Rett syndrome aged 5 to 15 years (Glaze et al. 2019). At the highest dose (200 mg/kg twice daily
[BID]), trofinetide achieved statistically significant improvement compared with placebo on 3 of 5
syndrome-specific efficacy measures: (1) the Rett Syndrome Behaviour Questionnaire (RSBQ), a
caregiver assessment (P=0.042), (2) the Clinical Global Impression Scale-Improvement (CGI-I), a clinician assessment of the improvement of Rett syndrome (p=0.029), and (3) the RTT-Clinician Domain Specific Concerns-Visual Analog Scale (RTT-DSC), a clinician assessment (p=0.025). Results of the study also showed trofinetide was well-tolerated at all dose levels (50 mg/kg BID, 100 mg/kg BID, and 200 mg/kg BID).

A 12-week, Phase 3, double-blind, randomized, placebo-controlled study will begin this year to evaluate efficacy and safety of trofinetide and placebo in a 1:1 ratio in 184 females 5 to 20 years old with RTT. The study will use the RSBQ and the CGI-I syndrome specific efficacy measures as co-primary efficacy endpoints. The double-blind study will be followed by a 9-month, open-label extension study in which all participants, including those on placebo in the Phase 3 study, will be eligible to receive trofinetide. In the open-label extension study, all participants will be followed to evaluate long term tolerability and safety of trofinetide in girls and women with Rett Syndrome.

Author Summary:
James M. Youakim, M.D., is Vice President, Translational Research and External Innovation, at ACADIA
Pharmaceuticals Inc. He attended medical school and completed training in psychiatry at Baylor College of Medicine in Houston and has been working in the pharmaceutical industry on the development of central nervous system medications since 2006.

Helena Wandin

 

Helena Wandin is a Speech language therapist at the Swedish National Center for Rett syndrome and related disorders and a PhD student at Uppsala University. Her main interest is communication. She is part of the project group that develops guidelines for management of communication in Rett syndrome.

 

Title: International Guidelines for Management of Communication in Rett
Syndrome

Authors: Wandin, Helena (Sweden)1,2; Townend, Gillian (Netherlands)3; Curfs, Leopold Mg (Netherlands)3; Bartolotta, Theresa E (United States of America)4; Urbanowicz, Anna (Australia)5

Affiliatons: 1 - Swedish National Center for Rett Syndrome and Related Disorders,
Frösön; 2 - Department of Public Health and Caring Sciences, Uppsala University,
Uppsala; 3 - Rett Expertise Centre Netherlands – GKC, Maastricht University
Medical Center, Maastricht; 4 - School of Education, Monmouth University, NJ; 5 –
Social and Global Studies Centre, School of Global, Urban and Social Studies, RMIT
University, Queensland

Families of individuals with Rett syndrome report their struggles to access appropriate, knowledgeable, timely and ongoing support tailored to the individual’s specific communication needs. The aim of this project was therefore to develop rigorous international clinical guidelines for the assessment, intervention and long-term management of communication in individuals with Rett syndrome.

An expert panel consisting of 36 experienced professionals and caregivers reviewed draft guidelines through a two-stage modified Delphi study. These draft guidelines were based on the results of a literature review and international online surveys for communication professionals and caregivers. The experts reported their agreement with the statements in the draft guidelines using a Likert scale and added additional comments in response to questions about the statements. The final set of
guidelines that were developed through consensus consists of statements that reached a threshold of >70% agreement. The guidelines are based on more than 300 articles, drawn from literature relating to Rett syndrome as well as augmentative and alternative communication and clinical practice documents.

More than 400 caregivers and 120 communication professionals from over 30 countries completed the online surveys. The expert panel reviewed a comprehensive list of statements in the Delphi process
many of which reached the preset level of consensus.

The final international guidelines and a handbook for management of communication in individuals with
Rett syndrome will be described and exemplified in this presentation.

Anna Amato & Anne Berger

We are a practice for speech therapy and Augmentative Alternative
Communication (AAC). Anna Amato is the practice owner, a qualified
rehabilitation pedagogue, academic speech therapist, integrative learning
therapist and lecturer at the Catholic University of Applied Sciences
Berlin. She is working with ACC for 20 years. Anne Berger is a qualified
rehabilitation pedagogue and works in the practice of Ms. Amato.