Autism Spectrum Disorders: A Transactional Developmental Perspective / Edition 1 available in Hardcover
This cross-disciplinary reference offers a thorough overview of the communication, language, social, and behavioral issues characteristic of autism spectrum disorders (ASD). Based on meticulous research of the core areas of ASD - communication, socialization, emotional regulation, and symbolic development - the authors offer practical guidelines for intervention designed for children with autism and their families.In this comprehensive book, speech-language pathologists, clinicians, early interventionists, psychologists, and educators learn how to understand and address the social and communication challenges experienced by children with autism enhance assessment and intervention methods support families in their efforts to facilitate their children's development Chapters in this volume, written by leading clinical and research authorities in ASD, will allow readers to understand the principles and philosophies behind clinical and educational practices implemented with children with autism. Readers will also encounter guidelines to use when making critical assessment and intervention decisions to create more natural, child-centered supports. All professionals will learn how to improve their educational and developmental supports for young children with autism.
About the Author
Dr. Mirenda earned her doctorate in behavioral disabilities from the University of Wisconsin–Madison. For 8 years, she was a faculty member in the Department of Special Education and Communication Disorders, University of Nebraska–Lincoln. From 1992 to 1996, she provided a variety of training, research, and support services to individuals with severe disabilities through CBI Consultants, Ltd., in Vancouver, British Columbia. She is now Professor in the Department of Educational and Counseling Psychology and Special Education at the University of British Columbia. From 1998 to 2001, she was editor of the journal Augmentative and Alternative Communication. In 2004, she was named a Fellow of the American Speech-Language-Hearing Association and was awarded the Killam Teaching Prize at the University of British Columbia. In 2008, she was named a Fellow of the International Society for Augmentative and Alternative Communication. Dr. Mirenda is the author of numerous book chapters and research publications; she lectures widely and teaches courses on augmentative and alternative communication, inclusive education, developmental disabilities, autism, and positive behavior support. Her current research focuses on describing the developmental trajectories of young children with autism and factors that predict the outcomes of early intervention.
Sally J. Rogers, Ph.D.
Professor of Psychiatry, MIND Institute
University of Californiaâ€“Davis Medical Center
Dr. Rydell has been in the field of autism and communication disorders for more than 24 years in public school, hospital, university, administration, and private practice settings. Dr. Rydell is the owner and director of Rocky Mountain Autism Center, a private center dedicated solely to working with children with autism spectrum disorders and their families. The center provides comprehensive center-, community-, and home-based assessments, programs, interventions, and training to individuals with autism, their families, and professionals. Dr. Rydell earned his doctoral and master's degrees in the field of communication disorders and special education, with a primary program emphasis in autism and early childhood education. Dr. Rydell is a Fulbright Senior Specialist grant recipient (2005) and has previously co-authored five book chapters and numerous research articles on autism and unconventional verbal behaviors. In addition, he frequently speaks at international, national, and state levels on topics related to autism.
G. Gordon Williamson, Ph.D., is an occupational therapist and special educator who directs two projects at the Pediatric Rehabilitation Department of the John F. Kennedy Medical Center in Edison, New Jersey, an interdisciplinary department that he originally founded and developed. The COPING Project, funded by the U.S. Department of Education, offers training and technical assistance to support the provision of family-centered early intervention services that enhance adaptive functioning. The Social Competence Project, previously funded by the Robert Wood Johnson Foundation, is a model demonstration program to foster the interpersonal skills of children with disabilities.
Dr. Williamson is also Associate Clinical Professor of Occupational Therapy in the Rehabilitation Medicine Department at Columbia University in New York. He is a member of the board of directors of Zero to Three/National Center for Clinical Infant Programs and the Academy of Research of the American Occupational Therapy Foundation. Previously he chaired the Parental and Child Health Advisory Committee of the New Jersey Department of Health and served as treasurer of the Division for Early Childhood of the Council for Exceptional Children.
Dr. Williamson is on the editorial board of numerous professional journals and has lectured extensively throughout the United States South America, and the Middle East. Recent publications include the Early Coping Inventory, Children with Spina Bifida: Early Intervention and Preschool Programming, and many articles related to human adaptation. His research focuses on the study of the coping resources of children and their families.
Amy M. Wetherby, Ph.D., is Professor and former Chair of the Department of Communication Disorders at Florida State University. She received her doctorate from the University of California-San Francisco/Santa Barbara in 1982. She has had more than 20 years of clinical experience in the design and implementation of communication programs for children with autism and severe communication impairments and is an American Speech-Language-Hearing Association fellow. Dr. Wetherby's research has focused on communicative and social-cognitive aspects of language difficulties in children with autism and, more recently, on the early identification of children with communicative impairments. She has published extensively on these topics and presents regularly at national conventions. She is a co-author of the Communication and Symbolic Behavior Scales (with Barry M. Prizant [Applied Symbolix, 1993]). She is the Executive Director of the Florida State University Center for Autism and Related Disabilities and is Project Director of U.S. Department of Education Model Demonstration Grant No. H324M980173 on early identification of communication disorders in infants and toddlers and Personnel Preparation Training Grant No. H029A10066 specializing in autism.
Barry M. Prizant, Ph.D., has more than 25 years experience as a clinical scholar, researcher, and consultant to young children with autism spectrum disorders (ASD) and related communication disabilities and their families. He is an American Speech-Language-Hearing Association fellow and is a member of the Interdisciplinary Council on Developmental and Learning Disabilities. Formerly, he was Associate Professor of Psychiatry in the Brown University Program in Medicine, Professor in the School of Communication Sciences and Disorders at Emerson College, and Advanced Post-Doctoral Fellow in Early Intervention at University of North Carolina at Chapel Hill. He has developed family-centered programs for newly diagnosed toddlers with ASD and their families in hospital and university clinic environments. He has been an invited presenter at two State of the Science Conferences on ASD at the National Institutes of Health (NIH) and has contributed to the NIH Clinical Practice Guidelines for early identification and diagnosis of ASD. Dr. Prizant's current research and clinical interests include identification and family-centered treatment of infants, toddlers, and young children who have or are at risk for sociocommunicative difficulties, including ASD.
Barbara Coyne Cutler, Ed.D., got her advocacy training the hard way. Divorced and with two small children to raise, she began to search out services for her son with autism. It took her almost 10 years to realize that being a patient, no-trouble-at-all parent was not the way to get attention or services. She learned painfully through her personal experience that a parent has to become vocal, visible, knowledgeable, and relentless in order to become an effective advocate. As a parent of a now middle-age son in continuing need of services, Dr. Cutler has been through the system in the dark days when her small son seemed to have no rights at all through the early days of the educational rights movement and later into the adult service system. From a once quiet and compliant parent she has become a leading advocate for people with disabilities and their families. Aware of deficiencies in systems serving people with disabilities, Dr. Cutler worked on her own professional development, acquiring bachelors and master's degrees from Harvard (where she was also a Merrill Fellow of the Radcliffe Institute) and a doctorate in special education from Boston University.
Dr. Cutler has directed educational, supported works and community resource programs, including the Autism National Committee (http://www.autcom.org), which she serves on now; facilitated the development of a model respite care program; trained parents and professionals in positive behavior support programs; and provided individual consultation in various states to public schools dealing with the needs of students with autism and developmental disabilities.
In her more than 30 years of service, she has continued to advocate as a member of boards of service, state, and advocacy organizations including her local Commission on Disability and Regional Developmental Disabilities Council. She has presented throughout the United States, Puerto Rico, and Canada. She has published chapters in various disability-related books and newsletters.
Looking back, she realizes that because of her son's disability, her career was chosen for her. "I've made my personal and career decisions by dealing with the crises that parents of children with disabilities learn to expect as part of their daily routine. It's a life that's sometimes harrowing, sometimes rewarding—but never, never dull. I have never regretted my decisions. Without strong parent advocates, our sons and daughters could be overlooked and poorly served."
Dr. Cutler lives next door to her son, George, and his wife, Sherrie, and across the street from her son, Robert. The family is often together on weekends and is always available to support each other.
Glen Dunlap, Ph.D., Research Professor, Division of Applied Research and Educational Support (DARES), Department of Child & Family Studies, Florida Mental Health Institute, University of South Florida, Tampa, Florida 33612-3899
Dr. Dunlap is a research professor at the University of South Florida, where he works on several research, training, and demonstration projects in the areas of positive behavior support, child protection, early intervention, developmental disabilities, and family support. He has been involved with individuals with disabilities for more than 35 years and has served as a teacher, administrator, researcher, and university faculty member. Dr. Dunlap has directed numerous research and training projects and has been awarded dozens of federal and state grants to pursue this work. He has authored more than 185 articles and book chapters, coedited four books, and served on 15 editorial boards. Dr. Dunlap was a founding editor of the Journal of Positive Behavior Interventions and is the current editor of Topics in Early Childhood Special Education. He moved to Reno, Nevada, in 2005, where he continues to work on research and training projects as a member of the faculty at the University of South Florida.
Karen A. Erickson, Ph.D., David E. and Dolores J. Yoder Distinguished Professor, Director, Center for Literacy and Disability Studies, University of North Carolina at Chapel Hill, 321 S. Columbia Street, Suite 1100 Bondurant Hall, Chapel Hill, North Carolina 27599
Karen A. Erickson is Yoder Distinguished Professor and Director of the Center for Literacy and Disability Studies at the University of North Carolina at Chapel Hill. A former teacher of children with significant disabilities, Dr. Erickson's current research addresses literacy and communication assessment and intervention for students with a range of disabilities, including significant disabilities. Dr. Erickson is codeveloper of the Tar Heel Reader online library of accessible books for beginning readers as well as several other assistive, learning, and communication technologies.
Dr. Lise Fox is a professor in the Department of Child and Family Studies of the University of South Florida in Tampa, Florida and the Co-Director of Florida Center for Inclusive Communities: A University Center for Excellence in Developmental Disabilities (www.flcic.org ). Lise was the Principal Investigator of the Technical Assistance Center for Social Emotional Intervention (www.challengingbehavior.org) funded by the Office of Special Education Programs. Dr. Fox is engaged in research and training efforts related to the implementation of the Pyramid Model in early education and care classrooms, program-wide models of implementation, and positive behavior support. She received the Mary E. McEvoy Service to the Field Award from the Division for Early Childhood.
Read an Excerpt
Excerpted from chapter 1 of Autism Spectrum Disorders: A Transactional Developmental Perspective, edited by Amy M. Wetherby, Ph.D., & Barry M. Prizant, Ph.D.
Copyright © 2000 by Paul H. Brookes Publishing Co. All rights reserved.
Introduction to Autism Spectrum Disorders
The terms autism spectrum disorders (ASDs) and pervasive developmental disorders (PDDs) currently are used synonymously to refer to a wide spectrum of neurodevelopmental disorders that have three core features: impairments in social interaction, impairments in verbal and nonverbal communication, and restricted and repetitive patterns of behavior (American Psychiatric Association, 1994). Major advances have been made since the 1980s in understanding the social and communication difficulties of children with ASD or PDD. This progress has resulted in a greater emphasis on early sociocommunicative patterns in the diagnostic criteria for the generic category of PDDs, which includes the subcategory of autistic disorder (American Psychiatric Association, 1994). More specifically, the following essential features for autistic disorder compose the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition:
- Impairment in social interaction, manifested by impairment in the use of nonverbal behavior, lack of spontaneous sharing, lack of socioemotional reciprocity, and/or failure to develop peer relationships
- Impairment in communication, manifested by delay in or lack of development of spoken language and gestures, impairment in the ability to initiate or maintain conversation, repetitive and idiosyncratic use of language, and/or lack of pretend play
- Restricted repertoire of activities and interests, manifested in preoccupation with restricted patterns of interest, inflexible adherence to routines, repetitive movements, and/or preoccupation with parts of objects
Because language and communication difficulties are essential features of this syndrome, educators and practitioners need to have current understanding of these characteristics and issues pertaining both to assessment and to intervention programs for children with ASD.
Autism is now understood to be of neurogenic origin and can have a dramatic impact on the family members of individuals with ASD. New treatment strategies are frequently introduced and discussed in the media and the professional literature; however, there is great variability regarding the extent to which treatments address the core characteristics of ASDs. In fact, much disagreement remains as to the nature of the core characteristics as opposed to secondary or frequently observed associated characteristics. Furthermore, most published intervention studies fail to employ meaningful outcome measures that document changes in barriers to learning that are characteristic of ASDs or meaningful lifestyle changes for the individual or family.
This volume provides a theoretical and research foundation for understanding the nature of the communication and language problems experienced by children with ASD and for guiding decision making in educational programming and, in particular, communication assessment and intervention. The first part (Chapters 2 through 8) examines the developmental context of children and their families and explores the underpinnings of ASDs and how these relate to communication and language problems. The second part (Chapters 9 through 15) examines issues pertaining to education and treatment for children with ASD. Because the topic of autism is so broad across the life span, this volume focuses on the first decade of life, spanning infancy, childhood, and elementary school age.
A DEVELOPMENTAL TRANSACTIONAL PERSPECTIVE
The theoretical and research framework underlying this book draws heavily from the transactional model of child development. That is, child development is viewed as a transactional process that involves a developmental interaction vis-à-vis the child and communicative partners (McLean, 1990; McLean & Snyder-McLean, 1978). Developmental outcomes at any point in time are seen as a result of a continuous dynamic interplay among child behavior (which is greatly influenced by neurophysiological variables), caregiver responses to the child's behavior, and environmental variables that may influence both the child and the caregiver (Sameroff, 1987; Sameroff & Chandler, 1975; Sameroff & Fiese, 1990). Over time, when a young child's social behavior can be accurately interpreted or read by a caregiver and the caregiver is able to respond in such a way as to meet the child's needs or to support social exchange, both caregiver and child develop a sense of efficacy (Dunst, Lowe, & Bartholomew, 1990; Goldberg, 1977). A cumulative effect of positive contingent responsiveness is that interactions become more predictable as expectancies and contingencies increase. This perspective emphasizes the reciprocal, bidirectional influence of the child's social environment, the responsiveness of communicative partners, and the child's own developing communicative competence.
A child's emotional and physiological regulation, which underlies the capacity to be "available" for learning and participating actively in a social context, is seen as an essential foundation within the transactional model. Development is therefore influenced by a child's ability to maintain some degree of emotional and physiological regulation and to produce increasingly readable and conventional signals, as well as by a caregiver's ability to respond effectively to the child's signals and to embed reciprocal and mutually satisfying transactions in everyday activities and routines. We believe that the nature of the social, communication, and language impairments in autism can best be understood by reflecting on the acquisition process from a transactional developmental perspective and have invited distinguished researchers and clinicians to contribute toward this end.
CURRENT ISSUES IN COMMUNICATION AND LANGUAGE OF CHILDREN WITH AUTISM
Dawson and Osterling (1997) reviewed eight early intervention programs for preschool children with autism, ranging from intensive, one-to-one discrete trial approaches to programs in inclusive environments using naturalistic procedures. They concluded that the level of success achieved across these programs was fairly similar; these programs generally were effective for about half of the children. Effectiveness was determined based on changes in measures such as IQ scores and classroom placement. They noted that few of these programs documented progress on goals addressing social and communicative aspects of development.
Their conclusions provide important implications for intervention programs and directions for future research. First, no evidence indicates that one program or approach works better than others, and, therefore, caution is warranted in drawing conclusions about intervention efficacy. Second, there is much to be learned about effective programs to enhance social and communication skills in children with autism because little empirical data are available. These findings underscore the need to better understand which specific intervention methods work best to accomplish which goals for which children. We contend that directions for future research, particularly intervention studies, should be rooted in theory and research about the nature of ASDs and of the developmental process.
OVERVIEW OF THIS VOLUME
We have invited authors who represent a range of orientations and perspectives (e.g., behavioral, neurobehavioral, developmental, family systems) to contribute to this volume. This volume will help clinicians and educators gain access to the most current theories and research to better understand children with ASD and be exposed to guidelines for developing innovative intervention approaches to enhance social, communication, and language skills in these children.
Part I of this volume examines the developmental context and explores the underpinnings of ASDs and how these relate to communication and language difficulties. Lord and Risi (Chapter 2) begin with an overview of the diagnostic features of ASDs and the differentiating characteristics of the subcategories. They discuss the importance of the diagnosis with a focus on diagnosis in young children. They compare and contrast research on diagnostic measures based on parent report and observational measures in 2- and 3-year-olds. Implications for earlier and more accurate diagnosis are provided, with an emphasis on changes in developmental characteristics during the preschool years.
Carpenter and Tomasello (Chapter 3) describe the social-pragmatic approach to language acquisition with a focus on the process of cultural learning. They review research on how children acquire language and examine the role of joint attention, the flow of social interaction, and social-cognitive foundational skills. They examine the process of language acquisition in children with autism from a social-pragmatic perspective and discuss how impairments in the foundational skills of joint attention, understanding others' communicative intentions, and role-reversal imitation can explain many other impairments in the language of children with autism.
Mundy and Stella (Chapter 4) examine three prominent models to account for the social communication impairments of autism, the theory of mind (ToM) model, the executive function model, and the social orientation model. They conclude that the social orientation model has the best explanatory power for the developmental progression of autism in that it accounts for the earliest-emerging features of the disorder. They hypothesize that the early social-orienting disturbance may have a negative impact on postnatal brain development and on executive function and ToM development. In discussing implications they highlight the importance of measures of joint attention.
Rogers and Bennetto (Chapter 5) examine the roles of imitation and executive function to account for the deficits in social relatedness; communication; and restricted, repetitive behaviors in autism on the basis of empirical research published since the late 1980s. In reviewing findings on imitation, motor impairments, and dyspraxia in autism, they conclude that there is support for autism-specific impairments on imitative and nonimitative motor tasks. In reviewing findings on executive function, they conclude that there is consistent evidence of impairments on global tasks of executive functions in older and higher-functioning individuals but not in preschoolers. On the basis of Stern's (1985) model of emotional development, they hypothesize that a severe and early deficit in imitation/praxis could impair the physical coordination of social exchanges but argue that the affective system holds clues about the primary impairment of autism.
Wetherby, Prizant, and Schuler (Chapter 6) review research on the nature of communication and language impairments in autism, focusing on the capacities for joint attention and symbol use. They examine research on developmental patterns that reveals how strengths and weaknesses in communication, social-affective, and symbolic abilities cluster in distinct profiles in children with autism. They explore how developmental theory can contribute to a better understanding of the communication patterns in autism and provide implications for earlier diagnosis, meaningful measures of abilities and outcomes, and decisions about intervention efficacy.
Anzalone and Williamson (Chapter 7) present an overview of theories on motor planning and sensory processing in ASDs. They also examine issues of sensory integration dysfunction relative to the variety of ways it may be manifest in children with ASD and its impact on adaptive functioning. Implications for infusing treatment principles into educational programs for children with ASD are discussed, with particular emphasis on changing the environment and incorporating a daily sensory diet to prevent sensory defensiveness and promote self-regulation.
Akshoomoff (Chapter 8) explores the neurological underpinnings of autism. She reviews neuroimaging and autopsy studies and examines two neurodevelopmental models of autism: a complex model involving multiple neural systems and the cerebellum and an attention model. She discusses how early damage to specific neurological sites can lead to the behavioral symptoms of autism and suggests the importance of addressing the speed of shifting attention and the size of the attentional "spotlight" in early intervention programs.
Part II of this volume examines issues pertaining to communication and language in the education and intervention for children with ASD. Prizant, Wetherby, and Rydell (Chapter 9) begin with a historical perspective on approaches to enhancing language and communication abilities of children with ASD. They provide a critical analysis of a continuum of approaches ranging from traditional behavioral to developmental, social-pragmatic approaches, including middle-ground "hybrid" approaches that draw from both behavioral and developmental research and educational traditions. They conclude by describing an evolving model for establishing therapeutic priorities that focuses on capacities in communication and emotional regulation and for developing the requisite transactional supports (i.e., family members, peers, environmental supports) necessary to optimally enhance children's development.
Twachtman-Cullen (Chapter 10) describes the specific sociocommunicative challenges faced by higher functioning children with ASD, including children with a diagnosis of Asperger syndrome. She explores these challenges in reference to theories on information processing and social-cognitive constructs such as ToM. Guidelines for enhancing abilities also are addressed with attention given to the complex and often subtle nature of the problems experienced by these children and the related challenges in education and communication enhancement.
Schuler and Wolfberg (Chapter 11) provide an overview of theories and research on patterns of play development in children with ASD. Particular attention is given to aspects of social play and how such impairments affect social and language development. The authors present guidelines for promoting play development within a social inclusionary context based on their extensive clinical and research experience on "integrated play groups" for children with ASD.
Greenspan and Wieder (Chapter 12) discuss their functional approach, in which a child's developmental profile is examined to capture the unique features of processing strengths and weaknesses, which orients the clinician toward the proper intervention plan. An emphasis is placed on understanding core emotional functional capacities as they relate to and support many aspects of a child's development. They then describe the underpinnings of their Developmental, Individualized, Relationship-Based Intervention (DIR) model to enhancing social and emotional development of children with ASD, with practical suggestions and examples for implementing the "floor time" approach.
Fox, Dunlap, and Buschbacher (Chapter 13) offer a way to understand the challenging behavior of children with autism and recognize the critical role of the family context. They describe positive behavioral support, which is a process for understanding the purposes of challenging behavior and developing a plan of support that promotes the development of new skills while reducing the need for and occurrence of the behavior. This approach is rooted in research and theory on the communicative purpose of challenging behavior, which is reviewed in this chapter. They offer a lucid description of the functional assessment process, including gathering information, formulating hypotheses about the function of the behavior, and developing a behavioral support plan.
Mirenda and Erickson (Chapter 14) provide a comprehensive review of the current research literature pertaining to augmentative and alternative communication (AAC) and literacy issues for children with ASD. Implementation of AAC and literacy strategies is discussed in relation to the often-observed visual processing strengths as well as sociocommunicative impairments of children with ASD. Guidelines for decision making in selecting communication systems and fostering literacy skills are presented.
Domingue, Cutler, and McTarnaghan (Chapter 15) consider the process of coping and adapting among families of children with ASD, giving particular emphasis to the experience of families from the family's perspective. The first two authors share their unique insights from the perspective of being both professionals and parents. Suggestions for incorporating family-centered practices of support, assessment, and intervention are presented, with specific justification why working within a family-centered model is essential for children with ASD and their families.
The common bond shared by all of the authors is the understanding that children with ASD and their families are uniquely individual and that there is no single explanation that accounts for the developmental profiles and challenges of all of the children. Thus, there is no single intervention approach or treatment modality that can address the varied needs of all children and their families.
Clinicians, educators, and parents will find a wealth of information in this volume that will enhance their understanding of children with ASD. This information can then be applied to supporting the development of specific children using individualized approaches, which are so essential to addressing the unique needs of each child. Our hope is that this volume also provides direction for researchers as well as practitioners to further explore specific topics and offers decision-making guidelines and innovative strategies that can be used in developing comprehensive approaches for children with ASD. The clinician/educator as "scientist" will need to explore and document the effectiveness of specific intervention procedures with particular children.
Table of Contents
Editorial Advisory Board
- Introduction to Autism Spectrum Disorders
Amy M. Wetherby and Barry M. Prizant
- Diagnosis of Autism Spectrum Disorders in Young Children
Catherine Lord and Susan Risi
- Joint Attention, Cultural Learning, and Language Acquisition: Implications for Children with Autism
Malinda Carpenter and Michael Tomasello
- Joint Attention, Social Orienting, and Communication in Autism
Peter Mundy and Jennifer Stella
- Intersubjectivity in Autism: The Roles of Imitation and Executive Function
Sally J. Rogers and Loisa Bennetto
- Understanding the Nature of Communication and Language Impairments
Amy M. Wetherby, Barry M. Prizant, and Adriana L. Schuler
- Sensory Processing and Motor Performance in Autism Spectrum Disorders
Marie E. Anzalone and G. Gordon Williamson
- Neurological Underpinnings of Autism
- Communication Intervention Issues for Young Children with Autism Spectrum Disorders
Barry M. Prizant, Amy M. Wetherby, and Patrick J. Rydell
- More Able Children with Autism Spectrum Disorders: Sociocommunicative Challenges and Guidelines for Enhancing Abilities
- Promoting Peer Play and Socialization: The Art of Scaffolding
Adriana L. Schuler and Pamela J. Wolfberg
- A Developmental Approach to Difficulties in Relating and Communicating in Autistic Spectrum Disorders and Related Syndromes
Stanley I. Greenspan and Serena Wieder
- Understanding and Intervening with Children's Challenging Behavior: A Comprehensive Approach
Lise Fox, Glen Dunlap, and Pamelazita Buschbacher
- Augmentative Communication and Literacy
Pat Mirenda and Karen A. Erickson
- The Experience of Autism in the Lives of Families
Barbara Domingue, Barbara Cutler, and Janet McTarnaghan