Interview with Lynne Hewitt, Ph.D., CCC-SLP, Associate Professor, Bowling Green State University
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Beck:Hi Lynne. Thanks so much for your time today.Hewitt::Hi Doug. I am delighted to work with you.Beck:Lynne, I think you and I have some common educational roots. I went to the State University of New York (SUNY) at Buffalo for my undergraduate and master's degrees, although my doctorate was from
Beck:Hi Lynne. Thanks so much for your time today.
Hewitt::Hi Doug. I am delighted to work with you.
Beck:Lynne, I think you and I have some common educational roots. I went to the State University of New York (SUNY) at Buffalo for my undergraduate and master's degrees, although my doctorate was from the University of Florida, but I think you too, spent quite a bit of time in Buffalo?
Hewitt::Yes, that's right. I earned my Master's and my doctorate from SUNY Buffalo.
Beck:If I may ask, what year did you finish your doctorate and what was your dissertation topic?
Hewitt::I finished my doctorate in 1994. My doctoral mentor was Dr. Judy Duchan and my dissertation was on conversational discourse and an analytical approach to pragmatic language issues relating to autism.
Beck:That's fabulous. How did you get interested in autism?
Hewitt::Well, my undergraduate degree was in English and Linguistics, and that was not exactly a "growth area" so I moved over to communication disorders. That gave me the chance to keep up my interest in language, and as a graduate student, I had the good fortune of working with Judy, and she was interested in autism. So as I took classes and studied and learned more about it, it evolved as my topic because I was so involved with Judy's research in language. Basically it fascinated me that people could have intact phonology, morphology, syntax and more, but they still lacked a key ingredient in language ability. In fact, people with autism can have high IQs, but yet may be unsuccessful in many life contexts such as a basic job interview, because they often lack the pragmatic communicative competence.
Beck:And so given your interests, and Judy's area of expertise, it seems like you were in the right place at the right time.
Hewitt::Yes, I agree, and I feel very fortunate to have been at SUNYAB at that time, and working with Judy
Beck:Thanks Lynne. OK...let's start with a basic pragmatic definition of autism.
Hewitt::Autism is a developmental disorder having three components, all of which are apparent by the age of three. The first component is a deficit in social ability, the second is a deficit in communication, and the third is having a restricted repertoire of interests and activities.
Beck:How common is autism in the general public? I know I have read it is far more common in boys than girls, and I've seen numbers saying anywhere from 1 in 250, to 1 in 2500, that's a pretty large range!
Hewitt::Well, there is a very large range of numbers out there, and so I don't like to quote numbers any longer, because it's just very controversial, but I think it is far more commonly diagnosed today, than it was years ago. If you include the broader class of all individuals affected to some degree with autism, estimates can range as high as 60 per 10,000.
Beck:Do you think that's due to an increase in autism, or more awareness and better diagnostics, and more people making the diagnosis?
Hewitt::Great question. I think we've gotten past the point where the diagnosis is a stigma on the parents, and I think more and more, we're seeing people with lesser signs and symptoms going for assessments and receiving services. In other words, in decades past, only the more severe types of problems would receive attention and autism to get the diagnosis, but now, kids with much less obvious problems will be assessed. Plus practitioners have more experience and training, so there is more willingness to consider the diagnosis, and the criteria have changed and broadened as well. The stigma of autism itself is lessenedyears ago, even individuals with significant and clear indicators of autism might not get the diagnosis-- if you look through old charts and files you'll see the term "autistic-like" used frequently without a real diagnosis ever having been given.
Beck:And so more people are actually making the diagnosis in less severe cases, and so perhaps the diagnosis is on the rise, but perhaps the actual population has remained stable?
Hewitt::Well, it is possible that some portion of the increase is due to a genuine rise in the incidence, but it's not clear how much.
Beck: What do you think is the core reason, or the etiology of autism?
Hewitt::As far as the cause, some neuroscientists are investigating the thought that perhaps it has to do with cerebellar anomalies, and there is a recent theory that these cause a deficit in learning. The cerebellum needs to communicate efficiently and effectively with the frontal lobe. The symptoms of autism are more related to higher level cognition, so it seems counterintuitive to put the finger on subcortical structures. But because the brain is a complex system, it is important to look at how the components interrelate. And it seems that breakdowns in communication among various regions of the brain may be playing a causal role in some of the key problems seen in autism. But what causes the original anomalies is not yet known.
Beck:I guess autism is one of the Pervasive Developmental Disorders (PDDs) such as autism, Asperger's and Rett's Disorder, and others, which are categorized as PDDs in the 1994 Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), by the American Psychiatric Association?
Hewitt::Yes, that's the standard in the USA, and the DSM-IV describes the specific diagnosis, within the chapter covering the umbrella term "PDD."
Beck:And I guess "autistic spectrum" is sometimes a preferred term for autism?
Hewitt::Yes. Many experts feel that the subcategories you mentioned above are not always clear, and kids that don't totally fit within DSM-IV characteristics still should be identified as having aspects of the syndrome. One recent development that I see as positive is that there is less fear of the term autism, as it becomes better understood. In the past, many felt that the diagnosis of autism was the worst possible, because of the fear that the child would never relate to his or her family. Because many children and adults with autism are experiencing success and happiness, this fear of the term itself has I think diminished.
Beck:With regard to SLP, what are the primary effects one typically sees with children diagnosed with autism?
Hewitt::The number one thing we see is in the area of pragmatics. Of course it varies child-to-child with their developmental level, but in a very young child, you might see a restricted range of communicative intent, or a lack of interest in communication. With an older child, you might also see a restricted range of communication, where, relative to age expectations, their ability to participate in a variety of communicative contexts is impaired, especially for the more purely social purposes. And the restricted range of interests can manifest itself in language, where only certain topics grab a child's interest.
Beck:OK, so let's suppose we have a child, diagnosed at age 2.5 years, what are the things an SLP would focus on in their actual treatment protocol?
Hewitt::Well again, each child is different, but I would expect that a good starting place might be to work on increasing their ability to take in information in social contexts, which is based on the social interaction theory of development. In other words, while some success has been achieved using decontextualized drill-based interventions, I would not start there. If the child has a particular problem with social learning, which is key to successful language development, we need to figure out how to put that missing social piece back in. So for young children there are some parent-training and family-training programs that follow these guidelines. One problem faced by SLPs is trying to get enough hours of intervention for a child with complex special needs, and that's where parent training offers a good alternative. The best programs generally meet the needs of the child by decreasing stimulation and distractions in the environment, while increasing the amount of input in the target area, and there are a variety of ways to do this. It's important to consider different sensory issues as well, making use of visual supports and decreasing excessive auditory input. The bottom line is providing a learning environment that has predictable patterns, repeated input, and yet is rich enough to foster learning that generalizes beyond the immediate situation.
Beck:And so the bottom line on your philosophical approach is that a "top-down" approach is preferred?
Hewitt::Well, the main thing is to consider the totality of what is causing the child to have difficulty acquiring the competencies that he or she needs. So, the end goal of intervention is always functional communicative competence, which is necessarily a "top down" phenomenon. So in that sense you are right. The brain develops based on your genetic predisposition and the experiences and stimuli that come along. So what happens in your personal experience will influence and impact the development of your brain. But this is a complex process. I believe that all aspects of language are influenced by higher level cognitive structures, and I certainly don't believe in a separate, encapsulated "bottom up" layer of language processing. But it is important to emphasize that the system needs rapid, overlearned responses to be able to function efficiently, so "bottom-up" processes are also present. The brain is a massively parallel system, and we have a long way to go before we understand the staggering complexity of how it works.
Beck:How do you measure "success" with autistic children?
Hewitt::That's a tough one, and there's no real universal answer. Sometimes, families might want to define success as normalizationthat is, development completely undistinguishable from typical, and anything short of that might be thought of as a failure. But to me, pragmatically, anytime you set goals and achieve them, and you move to the next level, that's a success. The gold standard is for the child to grow and thrive into adulthood, have a happy and independent life, and ultimately be able to hold down a job and have a satisfying social network .
Beck:Thanks Lynne. I've really enjoyed speaking with you and thanks so much for sharing your time and knowledge.
Hewitt::My pleasure Doug. Thank you, too!
Hewitt::Hi Doug. I am delighted to work with you.
Beck:Lynne, I think you and I have some common educational roots. I went to the State University of New York (SUNY) at Buffalo for my undergraduate and master's degrees, although my doctorate was from the University of Florida, but I think you too, spent quite a bit of time in Buffalo?
Hewitt::Yes, that's right. I earned my Master's and my doctorate from SUNY Buffalo.
Beck:If I may ask, what year did you finish your doctorate and what was your dissertation topic?
Hewitt::I finished my doctorate in 1994. My doctoral mentor was Dr. Judy Duchan and my dissertation was on conversational discourse and an analytical approach to pragmatic language issues relating to autism.
Beck:That's fabulous. How did you get interested in autism?
Hewitt::Well, my undergraduate degree was in English and Linguistics, and that was not exactly a "growth area" so I moved over to communication disorders. That gave me the chance to keep up my interest in language, and as a graduate student, I had the good fortune of working with Judy, and she was interested in autism. So as I took classes and studied and learned more about it, it evolved as my topic because I was so involved with Judy's research in language. Basically it fascinated me that people could have intact phonology, morphology, syntax and more, but they still lacked a key ingredient in language ability. In fact, people with autism can have high IQs, but yet may be unsuccessful in many life contexts such as a basic job interview, because they often lack the pragmatic communicative competence.
Beck:And so given your interests, and Judy's area of expertise, it seems like you were in the right place at the right time.
Hewitt::Yes, I agree, and I feel very fortunate to have been at SUNYAB at that time, and working with Judy
Beck:Thanks Lynne. OK...let's start with a basic pragmatic definition of autism.
Hewitt::Autism is a developmental disorder having three components, all of which are apparent by the age of three. The first component is a deficit in social ability, the second is a deficit in communication, and the third is having a restricted repertoire of interests and activities.
Beck:How common is autism in the general public? I know I have read it is far more common in boys than girls, and I've seen numbers saying anywhere from 1 in 250, to 1 in 2500, that's a pretty large range!
Hewitt::Well, there is a very large range of numbers out there, and so I don't like to quote numbers any longer, because it's just very controversial, but I think it is far more commonly diagnosed today, than it was years ago. If you include the broader class of all individuals affected to some degree with autism, estimates can range as high as 60 per 10,000.
Beck:Do you think that's due to an increase in autism, or more awareness and better diagnostics, and more people making the diagnosis?
Hewitt::Great question. I think we've gotten past the point where the diagnosis is a stigma on the parents, and I think more and more, we're seeing people with lesser signs and symptoms going for assessments and receiving services. In other words, in decades past, only the more severe types of problems would receive attention and autism to get the diagnosis, but now, kids with much less obvious problems will be assessed. Plus practitioners have more experience and training, so there is more willingness to consider the diagnosis, and the criteria have changed and broadened as well. The stigma of autism itself is lessenedyears ago, even individuals with significant and clear indicators of autism might not get the diagnosis-- if you look through old charts and files you'll see the term "autistic-like" used frequently without a real diagnosis ever having been given.
Beck:And so more people are actually making the diagnosis in less severe cases, and so perhaps the diagnosis is on the rise, but perhaps the actual population has remained stable?
Hewitt::Well, it is possible that some portion of the increase is due to a genuine rise in the incidence, but it's not clear how much.
Beck: What do you think is the core reason, or the etiology of autism?
Hewitt::As far as the cause, some neuroscientists are investigating the thought that perhaps it has to do with cerebellar anomalies, and there is a recent theory that these cause a deficit in learning. The cerebellum needs to communicate efficiently and effectively with the frontal lobe. The symptoms of autism are more related to higher level cognition, so it seems counterintuitive to put the finger on subcortical structures. But because the brain is a complex system, it is important to look at how the components interrelate. And it seems that breakdowns in communication among various regions of the brain may be playing a causal role in some of the key problems seen in autism. But what causes the original anomalies is not yet known.
Beck:I guess autism is one of the Pervasive Developmental Disorders (PDDs) such as autism, Asperger's and Rett's Disorder, and others, which are categorized as PDDs in the 1994 Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), by the American Psychiatric Association?
Hewitt::Yes, that's the standard in the USA, and the DSM-IV describes the specific diagnosis, within the chapter covering the umbrella term "PDD."
Beck:And I guess "autistic spectrum" is sometimes a preferred term for autism?
Hewitt::Yes. Many experts feel that the subcategories you mentioned above are not always clear, and kids that don't totally fit within DSM-IV characteristics still should be identified as having aspects of the syndrome. One recent development that I see as positive is that there is less fear of the term autism, as it becomes better understood. In the past, many felt that the diagnosis of autism was the worst possible, because of the fear that the child would never relate to his or her family. Because many children and adults with autism are experiencing success and happiness, this fear of the term itself has I think diminished.
Beck:With regard to SLP, what are the primary effects one typically sees with children diagnosed with autism?
Hewitt::The number one thing we see is in the area of pragmatics. Of course it varies child-to-child with their developmental level, but in a very young child, you might see a restricted range of communicative intent, or a lack of interest in communication. With an older child, you might also see a restricted range of communication, where, relative to age expectations, their ability to participate in a variety of communicative contexts is impaired, especially for the more purely social purposes. And the restricted range of interests can manifest itself in language, where only certain topics grab a child's interest.
Beck:OK, so let's suppose we have a child, diagnosed at age 2.5 years, what are the things an SLP would focus on in their actual treatment protocol?
Hewitt::Well again, each child is different, but I would expect that a good starting place might be to work on increasing their ability to take in information in social contexts, which is based on the social interaction theory of development. In other words, while some success has been achieved using decontextualized drill-based interventions, I would not start there. If the child has a particular problem with social learning, which is key to successful language development, we need to figure out how to put that missing social piece back in. So for young children there are some parent-training and family-training programs that follow these guidelines. One problem faced by SLPs is trying to get enough hours of intervention for a child with complex special needs, and that's where parent training offers a good alternative. The best programs generally meet the needs of the child by decreasing stimulation and distractions in the environment, while increasing the amount of input in the target area, and there are a variety of ways to do this. It's important to consider different sensory issues as well, making use of visual supports and decreasing excessive auditory input. The bottom line is providing a learning environment that has predictable patterns, repeated input, and yet is rich enough to foster learning that generalizes beyond the immediate situation.
Beck:And so the bottom line on your philosophical approach is that a "top-down" approach is preferred?
Hewitt::Well, the main thing is to consider the totality of what is causing the child to have difficulty acquiring the competencies that he or she needs. So, the end goal of intervention is always functional communicative competence, which is necessarily a "top down" phenomenon. So in that sense you are right. The brain develops based on your genetic predisposition and the experiences and stimuli that come along. So what happens in your personal experience will influence and impact the development of your brain. But this is a complex process. I believe that all aspects of language are influenced by higher level cognitive structures, and I certainly don't believe in a separate, encapsulated "bottom up" layer of language processing. But it is important to emphasize that the system needs rapid, overlearned responses to be able to function efficiently, so "bottom-up" processes are also present. The brain is a massively parallel system, and we have a long way to go before we understand the staggering complexity of how it works.
Beck:How do you measure "success" with autistic children?
Hewitt::That's a tough one, and there's no real universal answer. Sometimes, families might want to define success as normalizationthat is, development completely undistinguishable from typical, and anything short of that might be thought of as a failure. But to me, pragmatically, anytime you set goals and achieve them, and you move to the next level, that's a success. The gold standard is for the child to grow and thrive into adulthood, have a happy and independent life, and ultimately be able to hold down a job and have a satisfying social network .
Beck:Thanks Lynne. I've really enjoyed speaking with you and thanks so much for sharing your time and knowledge.
Hewitt::My pleasure Doug. Thank you, too!