Using Story-Based Interventions to Improve Episodic Memory in Autism Spectrum Disorder

Tiffany L. Hutchins, Ph.D.1 and Patricia A. Prelock, Ph.D., CCC-SLP, BCS-CL1

ABSTRACT

Episodic memory (EM) and scene construction are critical for organizing and understanding personally experienced events and for developing several aspects of social cognition including self-concept, identity, introspection, future thinking, counterfactual reasoning, theory of mind, self-regulation, ﬂexible problem-solving, and socially adaptive behavior. This article challenges the reader to think differently about EM in children with autism spectrum disorder (ASD), as we expand our understanding of autobiographical memory that requires an ability to travel back in time and re-experience an event. The role of EM in cognitive and behavioral functioning for children with and without ASD is described. The value of story-based interventions such as Social Stories and Comic Strip Conversations for supporting EM is discussed with adaptations recommended to ensure a rich personal recall of an event. By focusing on EM and scene construction, there is potential for increasing the potency of story-based interventions for achieving maximum therapeutic impact.

KEYWORDS: Social cognition, social stories, episodic memory, autobiographical memory, elaborative reminiscing Downloaded by: Charles A. Dana Medical Library. Copyrighted material.

Learning Outcomes: As a result of this activity, the reader will be able to (1) explain episodic memory (EM) and the deﬁcits in EM for children with autism spectrum disorder (ASD); (2) describe four considerations for determining a topic for an EM social story; and (3) list three reasons elaborative reminiscing is critical for supporting the personal narratives and conversations of children with ASD.

1Department of Communication Sciences and Disorders, Their Communication Partners; Guest Editor, Amy L. University of Vermont, Burlington, Vermont. Donaldson, Ph.D., CCC-SLP. Address for correspondence: Tiffany L. Hutchins, Semin Speech Lang 2018;39:125–143. Copyright Ph.D., Department of Communication Sciences and Disor- # 2018 by Thieme Medical Publishers, Inc., 333 Seventh ders, University of Vermont, 407 Pomeroy Hall, Burling- Avenue, New York, NY 10001, USA. Tel: +1(212) 584- ton, VT 05405 (e-mail: [email protected]). 4662. Enhancing Communication and Social Interaction DOI: https://doi.org/10.1055/s-0038-1628365. Skills of Children with Autism Spectrum Disorders and ISSN 0734-0478. 125 126 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

“We were at school and it was a ﬁeld day behavioral functioning in typical development and our whole class took turns throwing wet and ASD; (2) discuss the theoretical bases of spongy balls at each other. It was kind of scary at story-based interventions, which we will argue ﬁrst ’cuz I saw this blue ball coming at me fast are well suited to address EM challenges in and then it hit me right in the face! But then I ASD; and (3) propose adaptations to these realized it doesn’t hurt at all so I wanted to get interventions to make them theoretically poin- hit. I got hit four times and it felt good. It was ted and increasingly therapeutic for supporting soooo hot outside and the water was really cold.” EM. Along the way, we describe the importance of event structure and elaborative reminiscing and consider what practices might be —an episodic memory recounted by best for individuals with ASD who vary widely Kenna, a neurotypical 9-year-old in their language and intellectual abilities.

Individuals with autism spectrum disorder (ASD) can demonstrate remarkably good rote EPISODIC MEMORY memories (especially for highly specialized Early formulations characterized EM on the information that coincides with their interests), bases of how it could be distinguished from which may account for the fact that ASD is semantic memory.4 Semantic memory and EM rarely understood as a condition in which are two kinds of autobiographical (about self) memory is severely impaired. Yet, episodic memory: semantic memory is concerned with memory (EM)—a special kind of declarative the content of memories and what is “known” autobiographical memory that allows a person (e.g., your English teacher’s name in high to travel back in time and re-experience an school), whereas EM is concerned with the event—has repeatedly been shown to be impai- context of memories and what is “experienced” red in ASD. During episodic recollection, the (e.g., what you remember about your high conjurer reconstructs the cognitive landscape school graduation ceremony). More specifi- from a first-person perspective and grounds it in cally, EM refers to recollections in the context time (when) and space (where). The content of of a particular time and place, and with refe- EM includes other information as relevant rence to oneself as a participant in the episode.5 about the “who, what, why, and how” of an As such, EM builds and relies upon semantic event as well as any associated thoughts and memory, but it subsumes and goes beyond it. emotions.1,2 Now, imagine a mental life where EM is multifaceted and has several requisite this faculty is disrupted. Without the ability to components. These include the capacity for lay down a record of what the self has personally mental time travel (which is not unique to experienced, it would be difficult to relate EM and is also involved in episodic future disparate aspects of one’s experience in an thinking), the representation of self (because Downloaded by: Charles A. Dana Medical Library. Copyrighted material. adaptive way, to track one’s experiences over time travel requires a time traveler), and an time to develop a continuous self-concept, and awareness that one is engaged in time travel. to apply the lessons from past experience to This last essential aspect of EM is also known as problem-solve in the present and plan for the autonoetic (“self-knowing”) consciousness (or future. autonoesis). As Tulving explained: Despite the importance of EM, very few researchers have formally proposed interven- When we do travel back in time, our tions to support EM in children with language conscious awareness of our experience is disorders or developmental disabilities (alt- different from our ordinary “online” aware- hough some discuss using personal narratives ness of our environment. We seldom con- to support EM),3 and speculation around how fuse the feeling that we are remembering a this might best be accomplished for children on past event with the feeling that we are the autism spectrum is still in its infancy. In this looking at the world, that we are imagining article, we (1) describe EM, its correlates, and what is on the other side of a mountain, or its far-reaching implications for cognitive and that we are dreaming. These and other STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 127

mental activities are conscious too, but the time as source-monitoring abilities (e.g., kno- consciousness is plainly and recognizably wing how you know something), which is, in different. The term autonoetic has been turn, considered part of the (rather sprawling) used to refer to this special kind of cons- construct of theory of mind.7,19–21 Other aspects ciousness that allows us to be aware of of theory of mind that codevelop with EM subjective time in which events happened. include, but are not limited to, introspection, Autonoetic awareness is required for [epi- imagination, counterfactual reasoning, and sodic] remembering. No autonoesis, no future thinking.9,22,23 These cognitive codeve- mental time travel.5(p.2) lopments have led many researchers to conclude that the common psychological mechanism By contrast, semantic memory requires only underlying EM is actually “scene construc- noetic (“knowing”) consciousness, which is the tion.”19,24 Scene construction refers to “the process ability to be aware of information about the of mentally generating and maintaining a com- world. With autobiographical semantic memory, plex and coherent scene or event. This is achie- I can “know” that I had a birthday party. I can also ved by the retrieval and integration of relevant know who came, what we ate, and what we did, informational components, stored in their moda- and although these contents of memory can lity-specific cortical areas, the product of which accompany my awareness of my own knowledge, has a coherent spatial context, and can then they do not require the subjective first-person later be manipulated and visualized.”19(p.299) vantage point that constructs the contextual Although the complexity of the processes under- framework that allows me to “re-experience,” pinning EM may be key to its flexibility and through autoneotic consciousness, my own pre- unique power for problem-solving (e.g., future- vious experiences such as a birthday party.6 This oriented planning, innovation), it may also contextual framework grounds happenings in a explain why EM is highly vulnerable to insult particular place and time, carries with it “the as observed in normal aging and a variety of experiential ‘flavor’ of remembering,”5(p.4) and clinical conditions including ASD.19 allows one to reflect on the perceptual origins and qualities of one’s own knowledge.7 From an evolutionary perspective, learning Episodic Memory in Autism Spectrum and memory are useful insofar as they inform Disorder future behavior. Thus, a primary purpose of Although semantic memory (i.e., the “knowing EM is to drive and support the development of system” responsible for encoding and retrieval future thinking,8 which “considerably improves of general knowledge) appears to be relatively the chances of forming optimal plans of action spared (and superior in some individuals under to guide adaptive future behavior.”9(p.2) Indeed, some circumstances),25 EM has repeatedly been future thinking is believed to be essential for shown to be impaired in ASD. For example, Downloaded by: Charles A. Dana Medical Library. Copyrighted material. flexibility of thought and action; difficulty individuals with ASD (even those with high acting with the future in mind may result in language and intellectual skills), tend to have overdependence on routinized, inflexible pat- relatively good recognition (cued) recall (a terns of behavior and the restricted and repeti- proxy of semantic memory) but impaired free tive behaviors often observed in ASD.10,11 recall (a proxy of EM) and offer less specific and EM develops in parallel with (and likely fewer accurate recollections of personally expe- casually contributes to) some of the most deve- rienced events.9,15,26,27 Williams, Lind, and lopmentally significant sociocognitive human Happe noted that, as a result.28 achievements. These include the emergence of script and schema knowledge,12,13 a stable identity and self-concept, and the development of conscious awareness itself.14–16 These are essen- We use the term relatively to highlight the relative strength of semantic memory compared with episodic memory while tial to psychological continuity and make EM a also acknowledging that deficits in autobiographical sine qua non aspect of the “self-memory sys- semantic memory (e.g., “What was the name of your teacher 17,18 tem.” EM also emerges around the same last near?”) in ASD have been documented.25 128 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

Caution must be exercised when STORY-BASED INTERVENTIONS attributing to people with autism memory By far, Social Stories (SSs) represent the most processes of the episodic kind. I may know popular story-based intervention strategies to that a particular event has happened to me in remediate the core deficits of ASD.34–37 SSs are the past, and hence report details of the carefully written, individualized stories that are event quite accurately, without actually designed to facilitate social understanding by remembering† the event. Only this latter giving individuals with autism the information kind of ‘remembering’ is thought to rely they need to be successful in social situations.36 on metacognition.28(p.162) SSs follow a specific format and are guided by principles for describing a person, event, or Because individuals with ASD report fewer concept in the context of a social situation.34 instances of episodic remembering, differences They typically follow a storybook format, are may exist in the way they make sense of composed of simple sentences and a title, and information. For example, when encoding include an introduction, a body, and a conclu- information, they may miss connections bet- sion. Key messages conveyed in text are typically ween items and fail to see how information can reinforced using visual supports (e.g., line draw- be flexibly manipulated, ultimately impacting ings, icons, photographs). A frequent goal of their ability for self-conscious awareness.14 SSs has been to share relevant information in Indeed, the EM deficits of ASD likely the context of a challenging social situation. contribute to difficulties making use of category This information often includes a description of (e.g., animals, plants) relations to enhance recall where and when a situation takes place, who is and problems accessing pertinent information involved, what is happening, and why.34 Gray to recall relevant aspects of a scene.29,30 These describes her recommended process for gathe- challenges have implications for stimulus over- ring accurate and relevant historical informa- selectivity and the ability to identify and use tion to inform the content and development of relevant contextual information to disambi- an SS.35 Crucially, the perspective of the indi- guate meaning, which is a well-documented vidual in context is integral. The information- deficit in ASD.31,32 Even when accurate prag- gathering process should focus on the “relevant matic inferences can be drawn, persons with cues, the typical sequence of events, ideas from ASD often experience difficulty justifying their those involved in the situation, and the per- correct answers, suggesting that they are poor spective” of the individual with ASD.34(p.174) source monitors who are not always aware of SSs have a sister intervention (also developed how they derive answers from contextual infor- by Gray) known as Comic Strip Conversations mation.33 Finally, problems with EM in ASD (CSCs).34,38 CSCs are designed to explain chal- are strongly associated with difficulties in future lenging social situations through writing and thinking, counterfactual reasoning, and central drawing using simple stick figures and thought Downloaded by: Charles A. Dana Medical Library. Copyrighted material. coherence,22,27 leading many to believe (as and talking bubbles. SSs and CSCs share a broad described above) that mental simulation and theoretical orientation (to recount an experience, scene construction are core EM underlying provide relevant and accurate contextual infor- difficulties.10 mation from a first-person perspective, and use this information to plan for the future). The primary difference between SSs and CSCs is that the former is an independent or joint book † As Tulving cautioned, the “common sense reflected in this reading activity, whereas the latter involves active theory is seduced by the word ‘remember’ which, in everyday child participation, which may make CSCs most usage, does not distinguish between re-experiencing the past appropriate for individuals with strong language on one hand and all other . . . consequences of acts of and intellectual abilities.39,‡ learning on the other.”5(p.19–20) Thus, as do the researchers and theoreticians who pursue the topic of EM, we too adopt the terms remember and know in a restricted, technical sense ‡ But see Hutchins and Prelock,39 who reported success using to refer to two different states of conscious awareness (i.e., SSs and CSCs to address theory of mind targets in autonoetic and noetic, respectively). minimally verbal children with ASD. STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 129

Theoretical Bases vant to the development of EM. SSs and CSCs The National Standards Project, Phase 2 and are written from a first-person perspective The National Professional Development Cen- through thoughtful consideration of how a ter on ASD have each independently concluded social situation has been experienced and inter- that there is sufficient quality, quantity, and preted by that person.35 As such, story-based consistency in the evidence base to conclude interventions are personal narratives about the that story-based interventions are an establis- past and for the future, and at the center of the hed evidence-based practice.40,41 The success of narrative is the individual with ASD. This story-based interventions is presumed to lie in notion gains importance in light of the finding their ability to improve the child’s understan- that many individuals with ASD may not ding of events and expectations and “theory of appreciate the value of having first-person mind” more generally,34,35 but the precise privileged access to their own inner states and mechanisms and key ingredients remain a topic experiences.47 Indeed, when recalling experien- of speculation. ced events, individuals with ASD are more Early on, Gray invoked weak central cohe- likely than peers without ASD to report taking rence as a factor in the social cognition diffi- a third-person (observer) view than they are a culties of persons with ASD that may be first-person perspective.9 remediated through the use of story-based interventions.34 Weak central coherence is a cognitive style, believed to be present in ASD, SOCIAL STORY ADAPTATIONS TO in which the processing of parts takes prece- SUPPORT EPISODIC MEMORY IN dence over the processing of wholes,42,43 which AUTISM SPECTRUM DISORDER raises awareness of yet other areas of functio- As described previously, SSs are an established ning that would likely be negatively impacted intervention for remediating the hallmark chal- when weak central coherence predominates. lenges characteristic of ASD, and they are These include impaired event, script, and theoretically potent for supporting EM as schema knowledge, context immunity, and well. Because SSs demand relatively little in difficulty relating social knowledge to real-life terms of active participation (the audience must situations.32,44,45 attend to the story), they may be well suited for In a related vein, story-based interventions individuals with ASD who exhibit language may be effective because they support executive and intellectual challenges.36,37 However, their functioning. For example, SSs explicitly iden- potential benefit is not limited to this group. tify the relevant content of a targeted situation, Although there is now a large number of studies thereby suppressing stimulus overselectivity and documenting their effectiveness for children irrelevant aspects of a social scene.46 Noting the with language and intellectual impairments, slower pace of learning for some individuals SSs were originally intended for and are also Downloaded by: Charles A. Dana Medical Library. Copyrighted material. with ASD, several researchers and practitioners known to be effective for individuals with also recommend that story-based interventions higher cognitive and linguistic abilities.37 As be taught using repetition. This may further such, the proposed SS adaptations that follow support executive function because with suffici- should be considered for individuals from across ent repetition, the content of stories will be the autism spectrum. increasingly predictable. This should help sup- Important considerations when selecting a port comprehension,37 reduce the need to hold topic for an EM story include event structure, information online in working memory, and typicality and recency, and distinctiveness. facilitate self-monitoring.46 Finally, and despite not being previously identified as an active ingredient, we believe Event Structure that story-based interventions may be effective With regard to event structure, personal narrati- because they recount historical events, relate ves typically recount an episode (e.g., going to the past experience to future planning, and adopt a grocery store) that is, itself, composed of several first-person perspective, all of which are rele- subevents (e.g., walking through the aisles, 130 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

putting food in the cart, standing in line, paying, to the ability to “unbind” pieces of information leaving).48 What constitutes a higher- or lower- so as to deploy event representations for level component in the hierarchical event struc- flexible problem solving. Although we need ture will depend on the purpose of the narrative to know much more about the binding prob- (e.g., what I did last summer, how was my trip to lem in ASD, our nascent notions about inter- the newly opened water park, what happened ventions to support EM in ASD may be when I rode the three-story waterslide). Event informed by a considerable fund of research structure should contain both high-order (topic) on typical developmental processes. For exam- and low-order event elaborations. EM stories ple, researchers showed that event representa- that will be most interesting and memorable will tions are influenced by variant and invariant also likely contain a “high point.” Personal stories experiences.13 Elements of variant experiences have purpose: “they are trying to make a point are predictable event alternatives (buying car- about a person’s experience.”3(p.265) This is rots versus buying broccoli at the grocery accomplished in analyses of classic narrative store). The presence of these elements in structure by identifying a sequence of events, a our past experiences is important because it climax or high point, and the resolution to that allows new information to be organized into high point. EM topic selection on the basis of its an event structure that, presumably, helps the potential to illustrate a clear high point is criti- child understand predictable event alternati- cally important. Although many children with ves. Based on memory studies of TD children, ASD have basic knowledge of a conventional there is evidence that very young children narrative format, they consistently lack high grasp the role of variance and invariance in points in their narrative productions.49 Yet, it recurring experiences to form general event is the high point that often makes a story representations and can distinguish these (e.g., meaningful and that signals the purpose for the going to the grocery store ¼ we go there to telling of the story. buy things) from single variants (e.g., someti- mes we buy milk, other times we buy orange juice) after a limited number of exposures Event Typicality and Recency (approximately four or five). There is also EM topic selection should take into account evidence that, after general scripts and their how typical an event is because this has impor- variants are more or less established, atypical tance in light of the relational binding problem or deviant episodes are recalled after a longer that may operate in ASD. During episodic time delay compared with routine events that encoding, various kinds of information are first adhere to an established general script. With selected and then associated in memory. New- all of this in mind, one tentative suggestion combe and colleagues provide this example and based on the ASD and TD literature is to description: selectatopicfromarecent(withinaday)and Downloaded by: Charles A. Dana Medical Library. Copyrighted material. familiar routine event (going to the grocery Flickering shadows created by the store) in which high-level script-invariant wind in the trees may co-occur with bird activities occurred (e.g., we went to the store, song, with the presence of certain flowers, bought groceries, paid, left). Elaboration of appended both visually and by their scent, the event would then be introduced to identify with a particular air temperature, and so on. details (we bought carrots) that will vary across But which of these correlations are important events over time (we bought broccoli). Recol- and which are coincidental? Sorting this issue lecting could subsequently be scaffolded to out is fundamental to causal analysis, the include unexpected or (so-called) deviant formation of categories, and the acquisition events (e.g., “Remember, we saw a little girl of knowledge about the world.50(p.74) jumpingropeinthetoyaisleofthegrocery store”), which could be marked to highlight Relational binding is likely disrupted in their atypicality (e.g., “This doesn’t usually ASD at all process levels, from sorting, orga- happen” or “This isn’t something you would nizing, and binding of information in memory expect to see in the grocery store”). STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 131

Event Distinctiveness child is first introduced to a “conversation Another promising approach to support episodic symbols dictionary” that provides symbols for recall in individuals with ASD is to identify a basic concepts (e.g., listening, talking, thin- distinctive event. An event may be distinctive in king). A location symbol is drawn in the upper either conceptual (e.g., an elephant painting left-hand corner of the work area to identify the with a paint brush) or perceptual terms (e.g., setting in which the discussed event occurs. seeing the northern lights or smelling a forest During conversation, the sequence of topic- fire). Furthermore, the more distinctive the relevant events is identified and drawn using event, the more likely it is to be episodically boxes that are enumerated in the order they (as opposed to semantically) encoded in memory occurred. At each step in the sequence, the adult and, therefore, recalled in richer detail.15,51 For guides the child’s writing and drawing by gathe- this reason, we recommend that, when possible, ring information through questions designed to story-based intervention begin with examples of “complete the picture.”38(p.8) Questions usually distinctive (and positive) events. Unlike routine take the form: “Who was there?”; “What hap- or more typical events as described previously, pened first?”; “What happened next?”; “What distinctive events may be recent or in the distant did you or others say?”; and “What did you or past and still be recalled with detail. others think?”34 Because CSCs demand more active participation, they may be better suited for individuals with ASD who have strong Summary of Social Story Adaptations language and intellectual abilities. As such, to Support Episodic Memory the proposed adaptations that follow should A summary of the key components of SSs are be considered for individuals with ASD who enumerated in Table 1.37 In the center column, represent the higher end of performance. Con- the conventional recommendations for develo- siderations when selecting a topic for an EM ping and implementing SS intervention are conversation include the importance of elabo- presented. In the right-hand column, our rative reminiscing, how it may be supported recommendations for adapting SSs to support during interactions with individuals with ASD, EM are offered. The value of a SS designed and the use of additional visual supports as around an EM is the power it has to prepare a discussed below. An example of an EM CSC child for future thinking or planning behavior. that was completed with a typically developing For example, asking a child, if he goes to the 9-year-old girl is also provided in Fig. 1. grocery store next week, will he likely see a girl jumping rope? Or, if he goes to the store and really wants to buy something, what will he do Elaborative Reminiscing to remember and plan for the purchase? There is a rich and impressive body of research documenting the links from maternal reminis- Downloaded by: Charles A. Dana Medical Library. Copyrighted material. cing style to neurotypical children’s socioemo- COMIC STRIP CONVERSATION tional, cognitive, and language and literacy ADAPTATIONS TO SUPPORT outcomes. One important dimension that dis- EPISODIC MEMORY IN AUTISM tinguishes caregivers on the basis of how they SPECTRUM DISORDER engage children in talk about past events con- Although far fewer studies have been conducted cerns their degree of elaboration. Compared on CSCs compared with SSs, CSCs have with caregivers who are characterized as low in recently begun to accumulate evidence for elaborative reminiscing, caregivers who are high affecting positive change in a child’s theory of on this dimension reminisce with their children mind abilities and social behavior.39,52,53 in more detailed, evaluative, and coherent ways. During a CSC, the child engages (to the extent More specifically, they ask many opened- possible) in conversation while talking and ended questions, invite children to participate drawing so as to coconstruct dialogue with an in conversation, and integrate children’s recol- adult interlocutor. A set of conventions has lections into a collaboratively constructed been offered for constructing CSCs.34,38 The narrative.54 132 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

Table 1 Summary of Social Story (SS) Key Components, Conventional SS Recommendations, and Episodic Memory (EM) Story Recommendations Key Components Conventional SS EM Story Recommendations Recommendations 1. Determining a topic • Identify a situation in which the • Identify situations for which the individual is already experiencing individual is likely to have some success. accurate recollections. • Look for situations that result in • Look for personally experienced problem behavior. events that have a high point, that • Anticipate unfamiliar situations incorporate both variant and that require new knowledge or a invariant elements, and that are change in routine. either typical (and recent) or atypical or distinctive (recent or distal). We recommend that the first EM story be about a positive distinctive event. • Consider how this episodic memory could be useful or informative for future planning, thinking, behavior. 2. Gathering individualized • Learn about the individual’s • Learn about the individual’s information interests, strengths, and interests, strengths, and challenges and factors that may challenges and factors that may motivate current behaviors. motivate reminiscing. • Observe the targeted situation • If possible, observe a targeted from a third- and first-person situation (that can later be used in perspective. an EM story) and consider that • Conduct interviews with those experience from the child’s who have direct contact with the subjective perspective. individual (e.g., parents, teachers, • If observation of the event is not or other professionals) to possible, conduct interviews with establish a team effort and gain important others to gain accurate accurate and detailed information. and detailed information. • If appropriate, consider first doing a Comic Strip Conversation to elicit Downloaded by: Charles A. Dana Medical Library. Copyrighted material. information from the child about his or her subjective past experiences. 3. Development of the Social Story • Use objective statements and •Usesubjective statements and accurate and flexible language accurate and flexible language that that is meaningful to the is meaningful to the individual. individual. • Develop appropriate content and • Develop appropriate content and format through consideration of format through consideration of the individual’s age, reading level, the individual’s age, reading level, and comprehension level. and comprehension level. • Consider the use of visual • Consider the use of visual supports (i.e., photographs and supports (e.g., photographs, videos including those provided by Mayer-Johnson symbols) that the family and the use of social convey accurate information, are story apps like Pictello) that are, STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 133

Table 1 (Continued) Key Components Conventional SS EM Story Recommendations Recommendations developmentally appropriate, and themselves, literally accurate are expected to promote interest. depictions of the event. 4. Critical review and sharing of • Share a rough draft of the story • Share a rough draft of the story the Social Story with parents and others who have with parents and others who have direct contact with the individual direct contact with the individual to catch inaccuracies to guide to catch inaccuracies to guide revision. revision. • Distribute the final draft along • Distribute the final draft along with an implementation plan that with an implementation plan that outlines review schedules to outlines review schedules to foster shared responsibility and foster shared responsibility and the involvement of a team. the involvement of a team. 5. Introduction, comprehension • Introduce the SS in a relaxed and • Introduce the SS in a relaxed and checks, and adaptations as comfortable environment. comfortable environment. necessary • A simple statement such as • Our recommended introduction is: “Here is a story that I wrote for “Here is a story that I wrote for you” is often sufficient, but the you. It is about [insert general time complexity and content of the frame and high point, e.g., last introduction will vary with week when you popped a wheel circumstance. on your bike]. Stories like this are • Monitor comprehension of key just for remembering. messages. Remembering is important for • If misinterpretation or confusion understanding ourselves and our of story content becomes experiences.” Of course, the apparent, the story is revised to complexity and content of the enhance clarity. introduction will vary with circumstance. • Monitor comprehension of key messages. • If misinterpretation or confusion of story content becomes apparent, the story is revised to enhance Downloaded by: Charles A. Dana Medical Library. Copyrighted material. clarity. 6. Generalization training, • If improvements are • Once a story is comprehended, it maintenance, fading, and demonstrated in the target can be adapted or expanded. For identification of new targets behavior, the story can be example, a story series about expanded to include variations of playing on the playground can be the skill. adapted to highlight invariant • SSs are faded out following (what happened, like sliding down achievement of the targeted skill a slide) and variant (who was but can be revisited as needed. present) elements. • Identify new skills to be targeted. • SSs are faded out following comprehension of the story but can be revisited as needed. • Identify new memories to be targeted. 134 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

Figure 1 Example of an episodic memory Comic Strip Conversation.

Why Elaborative Reminiscing Is Critical be coached to provide more autonomy support Caregivers who are more elaborative when by taking the child’s perspective and encouraging reminiscing with their children about personally the child to pursue personal interests, thereby experienced events have children who better helping the child maintain intrinsic motivation understand the thoughts and feelings of them- and engagement. Indeed, high degrees of auto- selves and others and who demonstrate better nomy support leads to children feeling more self-regulation and self-concept formation. competent and motivated to engage, which in Children who experience more elaborative remi- turn facilitates a more active learning process and niscing also produce more complete and cohe- deeper level of information processing.57 rent personal narratives and have more detailed, accurate, and sophisticated autobiographical memories.54,55 Moreover, the links from care- Elaborative Reminiscing and Autism givers’ reminiscing style to child developmental Spectrum Disorder Downloaded by: Charles A. Dana Medical Library. Copyrighted material. outcome, although undoubtedly complex and There is wide agreement that caregiver elabora- transactional in nature, are causal and primarily tive reminiscing is a causal factor for a range of flow from caregiver reminiscing style to child child developmental outcomes. Moreover, it is outcome.55,56 The effects on child development well documented that even when child charac- also appear to be specific to reminiscing style (as teristics (e.g., language level, temperament, opposed to other aspects of parent-child dis- attachment status) and sociocultural variation course such as talkativeness or degree of elabora- are accounted for, caregiver reminiscing style tion during storybook reading). Research on uniquely predicts children’s autobiographic elaborative reminiscing gains utility in light of memories.55 Although we know individuals the finding that parents (including those with with ASD demonstrate episodic autobiographi- ASD) can be taught to become more elaborative cal memory deficits, what has rarely been consi- in their reminiscing style to support their child- dered is how caregivers may (or may not) adapt ren’s memory, the quality of children’s personal their linguistic input during interactions with narratives, and motivation to reminisce in a fairly their children with ASD to support such deve- short period of time.57,58 Crucially, they can also lopment. This is important because “children STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 135 with disabilities likely benefit from their lang- Additional Visual Supports uage environment as much as, or even more than, Clinicians may also want to consider additional typically developing children.”59(p.506) What visual supports that will be sensitive to the sparse literature is available on the topic suggests individual’s learning style or may enhance moti- that parents adopt a more directive and less vation. One potential resource is a Remember elaborative reminiscing style when interacting Symbols Dictionary (Appendix A), which dis- with their children with ASD.60 Although such plays the senses as cues to recreating an event, and adjustments may help the child verbalize more Remember Webs (Appendix B), which start with accurate recollections (a laudable goal for child- pictures or images and use the senses symbols to ren with ASD who are known to be less detailed enhance knowledge about what a child did. and accurate in reports of past experience), they Several apps are also available that could be may not be optimal for supporting the develop- used to support EM. We agree with Westby ment of memory in a truly episodic way. Gold- and Culatta, who originally suggested the use of man and DeNigris suggested that parents of Pictello to support reminiscing in children with children with ASD may have a “greater emphasis disabilities. Pictello uses pictures in a storybook on external, objective and factual elements of the format to help recount an experience. Westby and experience” and may adopt a conversational style Cullatta noted that “one can take photos or videos that “more closely resembles an interview than a of an experience and then write the story that goes natural dialogue.”60(pp.1469–1470) with the pictures. The photos provide support for Although memory is a reconstructive children with language impairments to reminisce. process (and representations of past events Having photos or videos of the experiences helps are neither complete nor wholly veridical),19 achieve accuracy of the reminiscing.”3(p.267) We autobiographical memory errors do occur would also add that Pictello is cost-effective and more often in individuals with ASD compared extremely user-friendly. This makes it a popular with individuals without ASD.25 Because “go-to” not only for clinicians and caregivers but more accurate objective (e.g., who was there) for the children with social learning challenges and subjective (e.g., how someone felt) memo- whomaybemotivatedtoengagein—andeven ries are expected to lead to more accurate scene construct reminiscing episodes to share with construction for future events, it is important others—through the use of this technology. to correct a child’s inaccurate memory (particularly for higher-order events, such as inter- preting or analyzing the emotions of an event Summary of Comic Strip Conversation the child experienced). Yet, the manner in Adaptations to Support Episodic which this is done is crucially important in Memory light of the previous finding that caregivers of A summary of the key components of CSCs are children with ASD may focus on accuracy at enumerated in Table 2. In the center column, the Downloaded by: Charles A. Dana Medical Library. Copyrighted material. the expense of an elaborative style whose goal conventional recommendations for developing and is to construct a shared experience.60 For the implementing CSC intervention are presented. In time being, we recommend that adult inter- the right-hand column, our recommendations for locutors issue gentle content corrections while adapting CSCs to support EM are offered. adding information to the ongoing dialogue (e.g., child: “Sam was at the beach”; adult: “Sam wasn’t at the beach. Remember, he ADDITIONAL SUPPORTS AND couldn’t come because he had a soccer game. CONSIDERATIONS FOR PRACTICE Jill and Sean were there and they played a USING SOCIAL STORIES AND game. Do you remember that game?”). In fact, COMIC STRIP CONVERSATIONS parents and professionals who engage children in elaborative reminiscing should be encoura- How Specific Do We Need to Be about ged by the finding that this style of commu- When? nication, in itself, leads to increases in memory When it comes to the temporal placement of accuracy over time.55 the recalled event, macrotime (the timeline 136 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

Table 2 Summary of Comic Strip Conversation (CSC) Key Components, Conventional CSC Recommendations, and Episodic Memory (EM) CSC Recommendations Key Components Conventional CSC EM CSC Recommendations Recommendations 1. Introduction of CSCs as an • The first CSC acquaints the • The first CSC acquaints the activity individual with the activity of individual with the activity of “drawing while talking.” The adult drawing while talking. Although matter-of-factly introduces the the complexity and content of the activity: “We are going to draw introduction will vary with while we talk today.” The circumstance, our recommended individual is asked what she or he introduction is: “Today we are would like to talk about or an easy going to share stories. First, I’ll just topic of interest is selected for tell you about something that the individual. happened to me. Then we will talk • The Conversation Symbols about something that happened to Dictionary is introduced to acquaint you. When we talk about you, we the individual with how to draw will draw and talk. Drawing while concepts such as thinking, talking, we talk is important because it can listening, interrupting, and loud and help us slow down, think, and quiet words. remember things better.” • The Personal Symbols Dictionary • The Remembering Symbols begins to be developed if Dictionary (Appendix A) is necessary; it is an ever-expanding introduced to acquaint the individual collection of symbols frequently with how to draw concepts related used (e.g., for specific people, to first-person perspective recall places, concepts that are part of (i.e., what did I see, hear, smell, the individual’s experience). think, and feel (emotion and touch). • The Conversation Symbols Dictionary and The Personal Symbols Dictionary (described on the left) are introduced if necessary. 2. Determining a topic • Look for situations that result in • Identify situations for which the problem behavior. individual is likely to have some • Anticipate unfamiliar situations accurate recollections. that require new knowledge or a • Look for personally experienced Downloaded by: Charles A. Dana Medical Library. Copyrighted material. change in routine. events that have a high point, that • Topics may represent a incorporate both variant and challenging situation from the past invariant elements, and that are or an anticipated future event. either typical (and recent) or • If discussing a future event, atypical or distinctive (recent or language is carefully chosen to distal). We recommend that the discourage literal interpretation and first CSC be about a positive and inflexible interpretation (e.g., distinctive event. “There will be many people at the • Consider how this episodic party” is preferable to “There will memory could be useful or be 20 people at the party) and informative for future planning, qualified (e.g., “There may be thinking, behavior. balloons and streamers” is • If discussing a future event, preferable to “There will be language is carefully chosen to balloons and streamers”). discourage literal interpretation STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 137

Table 2 (Continued) Key Components Conventional CSC EM CSC Recommendations Recommendations and inflexible interpretation and highlight counterfactuality (e.g., “There will be many people at the party” is preferable to “There will be 20 people at the party) and qualified (e.g., “There could be balloons and streamers” is preferable to “There will be balloons and streamers”). 3. Drawing or talking about a given • Begin by drawing a location • Begin by drawing a time stamp in situation symbol in the upper left corner to the upper right corner to indicate indicate the location of the event. when the event happened. • Comic strip boxes (a series of • Then draw a location symbol in enumerated boxes that frame the upper left corner to indicate each event and define the the location of the event. sequence of events) are drawn to • Identify the topic and develop a keep the sequence of events title that reflects the high point of clear. the event. Write the title of the • The adult gathers information to conversation at the center top. complete the picture using a • If the event represents a series of wh- questions (e.g., sequence of subevents (as “Who else is here?”; “What are opposed to a snapshot), draw and you or others doing?”; “What enumerate comic strip boxes happened?”; “What did you or (described on the left) to clarify others say?”; “What did you think the event sequence. when you said that?”; “What did • The adult gathers information to others think when they said that complete the picture using a or did that?”). series of wh- questions (e.g., • When the individual experiences “Who else is here?”; “What are difficulty answering a question, you or others doing?”; “What did she or he is guided to the logical you see?”; “What did you feel?”; answer. If this is unsuccessful, “What did you or others say?”; Downloaded by: Charles A. Dana Medical Library. Copyrighted material. the adult’s best guess is offered “What did you think when you (e.g., “Maybe your teacher was said that?”). thinking, ‘I like Andrew’”) and • The adult adopts an elaborative control of the conversation is but patient reminiscing style (e.g., returned to the individual as soon encourage elaboration with simple as possible. responses that add information to the narrative, follow the child’s lead while avoiding questions that derail the conversation in favor of a child’s special interest, give the child plenty of time to respond). 4. Summarizing the conversation • Key points are reviewed in their • Key points are reviewed in their appropriate sequence. The appropriate sequence. The individual is encouraged to individual is encouraged to

(Continued) 138 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

Table 2 (Continued) Key Components Conventional CSC EM CSC Recommendations Recommendations summarize the conversation summarize the conversation independently but the parent or independently but the parent or professional assists as necessary. professional assists as necessary. Because the purpose of all communication is information sharing, the individual is encouraged to identify this goal, which is typically accomplished through a simple restatement of the topic (e.g., “So that is one thing I did over the summer”). 5. New directions identiﬁed • The individual is asked to identify • Because the reminiscing goals are new solutions to a problem and if likely to involve “practical she or he is unable, solutions are remembering,”55(p.1571) the suggested by the adult. The pros individual is asked to reﬂect on and cons of each candidate what happened in the story that solution are discussed/weighed. might direct future thinking or Solutions that are no longer viable behavior (e.g., “Next summer, I’d are eliminated (crossed out) and like to go to the beach instead of the remaining solutions are the racetrack” or “I want to go to ranked (1, 2, 3 . . .) according to the beach again and not swallow when they will be tried the next seawater”). time this situation occurs.

against which the events of our lives play out; What If the Comic Strip Conversations e.g., days, weeks, or years ago) does not appear Intervention Is Too Easy or Too Hard? to be nearly as important as microtime (the If the CSC interventions to support EM seem moment by moment order in which an event insufficiently challenging, parents and profes- sequence unfolds; e.g., what happened sionals may increase demands by eliciting a first, second, third).19 Microtime has been greater number of details (these may be multi- described as an intrinsic property of episodic modal as relevant, e.g., “What did you hear?” or memory “that when recalled ensures it is played “What did you smell?”), increasing the com- Downloaded by: Charles A. Dana Medical Library. Copyrighted material. back in the same . . . temporal sequence in which plexity of the narrative (e.g., asking for or it was recorded.”19(p.300) By contrast, recall for providing information about additional sub- memories from specific time periods (macro- events using an elaborative reminiscing style), time) is a poor retrieval code for episodic or requiring more reflection on the mental memory. For these reasons, we encourage an states (thoughts, feelings) of self and others. emphasis on microtime (which is also founda- More often, however, we suspect that tional for the construction of well-organized intervention may be overly challenging (parti- event representations),61 while recognizing the cularly in the beginning) but there are several importance of a general time stamp. For the strategies that can be employed to support story-based interventions reviewed here, gene- children’s performance and scaffold them to ral temporal markers such as yesterday, last higher levels of episodic recall. One strategy is week, and last year are sufficient but more to shift to a distinctive event. As described general references to time (a little while ago, previously, conceptually or perceptually distinc- a long time ago) are acceptable and may be tive events are more likely to be episodically preferable in many circumstances. encoded and recalled with richer detail. STORY-BASED INTERVENTIONS/HUTCHINS AND PRELOCK 139

Another general strategy is to decrease overall ding procedure. These can be shown to the amount of talk while still asking those mea- individual along with a Remember Web ningful and informative wh- questions that (see Appendix B) that can be completed in characterize an elaborative reminiscing style. collaboration with the child. Even individuals with ASD with high language and intellectual abilities can benefit from inc- reased processing time and more opportunities Additional General Memory Supports for writing time to support episodic recall.62 In Several well-documented general recommen- addition, adult interlocutors can shift from dations are considered good prescriptions to open-ended questioning (“What did you support any kind of declarative memory. These hear?”) to close-ended questioning (“Did you include: hear something loud?”) and from questions that require free recall, which is difficult in ASD but getting regular aerobic exercise also the hallmark of true episodic remembering, engaging in recall activities when relaxed: to a recognition recall (e.g., “Did you hear a stress and anxiety negatively impact recall bell?”). These recommendations are in line with writing things down: this makes journaling the Task Support Hypothesis,26,30 which states another great way to support EM in a way that individuals with ASD will tend to perform that helps the child take responsibility for at more typical levels on any memory task where the intervention support is provided during recall. Of course, the returning to the scene (aka transfer-appro- eventual goal will be to gradually scaffold to priate processing): if you are asking the child better free recall performance. to recall an event that happened on the Another strategy to support episodic recall playground, recall will be improved if you is to conduct controlled episodic encoding and actually go to the playground! retrieval sessions. This may be a particularly apt strategy when the child demonstrates poor free recall, poor recall for details, poor recall accuracy, What about Remembering Negative, or source amnesia. Indeed, this may indicate that Difficult, or Traumatic Experiences? the child is relying on semantic memory as It is important to point out that SSs and CSCs opposed to truly episodic recall. During a con- have typically focused on recounting challen- trolled episodic encoding procedure, the indivi- ging situations, and so speech-language patho- dual is engaged in a series of tasks (e.g., making a logists and related professionals will be familiar figure out of clay, lifting barbells for one minute, with the conventional range of difficult topics throwing a foam ball into a hoop, smelling or (e.g., a disagreement a child had at school, a tasting fragrant foods) and then immediately transitional event that is causes anxiety for the Downloaded by: Charles A. Dana Medical Library. Copyrighted material. asked21,51,63 to report on his or her experien- child, an aggressive or challenging behavior) cesd. These kinds of encoding procedu- that are pursued using these interventions. res will likely encourage episodic remembering Furthermore, compared with talk about posi- because they are sensory in nature and thus tive events, talk about negative events presents require a first-person perspective. Note that special opportunities for child learning. Not individuals with ASD often assume an observer surprisingly, adults tend to be naturally more perspective, but this is not possible when asked elaborative when they reminisce about difficult to recall the taste of a speckled Jelly Belly, for subjects, presumably because the adult’s goal is example, that can only be known to and expe- to encourage the child to understand the event rienced by the self. Episodic retrieval may also in a coherent way.55 Nevertheless, service pro- be facilitated through the use of visual supports, viders need to be aware of the potential perils including photographs or videos from the enco- that may accompany a reminiscing activity. Indeed, clinicians may unintentionally engage d For detailed information about how to structure prompts an individual in the recall of a traumatic event and evaluate children’s responses, readers are referred to (personal communication with Carol Westby, McIsaac & Eich51 and Piolino et al.63 2017), in which case they must respond with 140 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 39, NUMBER 2 2018

disclosure and referral to other agencies and collaborative (albeit supervised and structured) professionals as required by ethical standards reminiscing activity will develop into a more for practice. As a final word on this topic, we natural and spontaneous ability to encode agree with Gray,35 who recommended that a memories as self-experienced and to make majority of story-based intervention sessions good use of this information. focus on a positive topic or social situation. These “affirmative stories” and conversations are incredibly important to maintain meaning- DISCLOSURES ful exchanges and to ensure child motivation to Drs. Hutchins and Prelock have no relevant engage in these interventions.35 Indeed, you financial or nonfinancial relationships to (the reader) would probably conclude that disclose. reminiscing with others is no fun if all you ever reminisced about were things that were difficult or unpleasant; the individual with ASD REFERENCES is no different. 1. Clayton NS, Dickinson A. Episodic-like memory during cache recovery by scrub jays. Nature 1998; CONCLUSIONS AND FUTURE 395(6699):272–274 DIRECTIONS 2. Nyberg L, McIntosh AR, Cabeza R, Habib R, Houle S, Tulving E. General and specific brain The purpose of this article was to contribute to regions involved in encoding and retrieval of events: the sparse literature concerned with helping what, where, and when. Proc Natl Acad Sci U S A individuals with ASD to form memories in a 1996;93(20):11280–11285 truly episodic way. Like many before us, we 3. Westby C, Culatta B. Telling tales: personal event imagine that EM and scene construction are narratives and life stories. Lang Speech Hear Serv critical for organizing and understanding per- Sch 2016;47(04):260–282 sonally experienced events and for the develop- 4. Tulving E. Episodic and semantic memory. In: Tulving E, Donaldson W, eds. Organisation of ment of self-concept, identity, introspection, Memory. Cleveland, OH: Academic Press; 1972: future thinking, counterfactual reasoning, 381–403 theory of mind, self-regulation, flexible prob- 5. Tulving E. Episodic memory: from mind to brain. lem-solving, and socially adaptive behavior. Annu Rev Psychol 2002;53:1–25 What has, to this point, been lacking is an 6. Gardiner JM. Episodic memory and autonoetic articulation of how parents and professionals consciousness: a first-person approach. Philos Trans might capitalize on the success of story-based R Soc Lond B Biol Sci 2001;356(1413):1351–1361 7. Perner J, Ruffman T. Episodic memory and auto- interventions to support EM. Indeed, story- noetic consciousness: developmental evidence and a based interventions are theoretically and prac-

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Appendix A Remember Symbols Dictionary. Downloaded by: Charles A. Dana Medical Library. Copyrighted material.

Appendix B Remember Web.