What is echolalia

Echolalia is repeating the words or phrases of others, without necessarily understanding their meaning. Echolalia is a form of verbal imitation. Echolalia is a symptom of neurologic or psychiatric dysfunction in which the individual involuntarily and meaninglessly repeats a recently heard word, series of words, or a song. Echolalia is best known for its occurrence in individuals with autism spectrum disorder (ASD) ¹. People with autism spectrum disorder might echo their own speech, the speech of others and/or audio media from radio or television. Echolalia always involves repetition of verbalizations in some form—not vocalizations.

Echolalia is the phenomenon whereby children repeat or echo the utterances of others. Echolalia occurs in some typically developing children ², in individuals with a variety of disorders such as specific language impairment ³, intellectual disability ⁴, Tourette syndrome ⁵, aphasia ⁶, epilepsy ⁵, stroke ⁷, closed head injury ⁸, and in children with blindness ⁹.

Although previously seen by some as maladaptive behavior, an increasing body of evidence led most experts to recognize echolalia as a bridge to meaningful, self-generated speech with communicative intent.

Echolalia has often been classified into two categories based on when the echo occurs: immediate versus delayed ¹.

• Immediate echolalia is the more common type and occurs when a child repeats his interlocutor’s utterance immediately after it is produced ¹⁰.
• Delayed echolalia is when a child repeats an utterance or a segment from a television show or other media which is also known as scripting ¹¹, but with a significant time interval between the initial production of the utterance and its repetition ¹². Like immediate echolalia, delayed echolalia has been variously interpreted as meaningless and automatic ¹³ or as meaningful and functional ¹⁴.

Echolalia can also be produced with modifications to the original utterance. These mitigated echoes are still considered echolalia insofar as they are conversationally inappropriate repetitions of the previous utterance, yet they are qualitatively different from pure echolalia. Pick ¹⁵, who first documented mitigated echolalia in patients with aphasia, suggested that such modifications were indicative of the start of the patient’s recovery. Fay ¹⁶ later defined mitigated echolalia as the production of echoes that contained words that were either different from or supplemental to the original utterance; such changes can include pronominal substitutions, changes in prosody, semantic substitutions, expansions, or combinations of each of these ¹⁷. Inasmuch as they add linguistic content not included in the original utterance, mitigated echoes may be a bridge from pure echolalia to more creative and productive use of language. Children who produce mitigated echoes have more well-developed language than do children who produce pure echoes ¹⁸, and children’s echolalia tends to become more mitigated over time ³.

Echolalia key facts

• Echolalia represents a gestalt language-processing style. This means children first assign a single unit of meaning to longer segments of spoken language. What a child initially perceives as “comesitdownatthetable” may simply mean “table” to them, for example. Gradually, the child can isolate smaller and smaller parts from the original phrase and use individual words and grammatical structures to produce original sentences. Children with autism essentially learn language from the top-down, rather than bottom-up.
• Echolalia can be immediate or delayed. Immediate echolalia occurs within two conversational turns of original language input, whereas delayed echolalia occurs after more than two conversational turns take place. When a child repeats learned routines or phrases that are more complex than they can formulate on their own, that usually signifies delayed echolalia. Though delayed echoic responses may not fit current conversational context to an unfamiliar listener, they often relate personally to the child. For example, a repeated sentence or phrase can represent a significant memory, emotion or area of interest.
• Echolalia is a verbal behavior, not a vocal stereotypy. People with autism spectrum disorder might echo their own speech, the speech of others and/or audio media from radio or television. Echolalia always involves repetition of verbalizations in some form—not vocalizations.
• Echolalia supports relationship-building and social closeness. In addition to supporting language acquisition including vocabulary and syntax development, echolalia creates opportunities for people with autism to interact and engage with others through conversational turn-taking. This verbal reciprocity supports relationship-building and social-emotional closeness with others.
• Echolalia serves a variety of communicative purposes. Echolalia provides a way for people with autism to affirm, call, request, label, protest, relate information, complete verbal routines and give directives. Nonverbal indicators of engagement and comprehension, such as eye gaze, body language and gestures are often observed in combination with echolalia.
• Echolalia aids self-regulation. Most experts say echolalia improves communication even when a specific function of communication can’t be identified. Even when a child’s echoes seem out of context, for example, echolalia still supports important aspects of cognitive functioning including rehearsal, learning and self-regulation.
• Speech language therapists can support language learning through interaction. Following a child’s lead by using low-constraint language models—like comments, affirmations and reflective questions—can support natural language development in children with autism spectrum disorder who demonstrate echolalia. This sets up a facilitative interaction style, which can yield more sophisticated communication with higher levels of comprehension—for example, requesting information or commenting.

Echolalia and autism

The word “autism” has its origin in the Greek word “autos,” which means “self.” Autism or autism spectrum disorder is a developmental disability that can cause significant social, communication, and behavioral challenges. The term “spectrum” refers to the wide range of symptoms, skills, and levels of impairment that people with autism spectrum disorder can have.

Children with autism spectrum disorder are often self-absorbed and seem to exist in a private world in which they have limited ability to successfully communicate and interact with others. Children with autism spectrum disorder may have difficulty developing language skills and understanding what others say to them. They also often have difficulty communicating nonverbally, such as through hand gestures, eye contact, and facial expressions.

Autism spectrum disorder affects people in different ways and can range from mild to severe. People with autism spectrum disorder share some symptoms, such as difficulties with social interaction, but there are differences in when the symptoms start, how severe they are, the number of symptoms, and whether other problems are present. The symptoms and their severity can change over time.

The signs of autism spectrum disorder begin in early childhood, usually in the first 2 years of life, although a small minority of children may show hints of future problems within the first year of life.

How does autism affect communication?

The ability of children with autism spectrum disorder to communicate and use language depends on their intellectual and social development. Some children with autism spectrum disorder may not be able to communicate using speech or language, and some may have very limited speaking skills. Others may have rich vocabularies and be able to talk about specific subjects in great detail. Many have problems with the meaning and rhythm of words and sentences. They also may be unable to understand body language and the meanings of different vocal tones. Taken together, these difficulties affect the ability of children with autism spectrum disorder to interact with others, especially people their own age.

Each person with autism spectrum disorder has different communication skills. Some people can speak well. Others can’t speak at all or only very little. About 40% of children with an autism spectrum disorder do not talk at all. About 25%–30% of children with autism spectrum disorder have some words at 12 to 18 months of age and then lose them.1 Others might speak, but not until later in childhood.

Examples of communication issues related to autism spectrum disorder:

• Delayed speech and language skills
• Repeats words or phrases over and over (echolalia)
• Reverses pronouns (e.g., says “you” instead of “I”)
• Gives unrelated answers to questions
• Does not point or respond to pointing
• Uses few or no gestures (e.g., does not wave goodbye)
• Talks in a flat, robot-like, or sing-song voice
• Does not pretend in play (e.g., does not pretend to “feed” a doll)
• Does not understand jokes, sarcasm, or teasing

People with autism spectrum disorder who do speak might use language in unusual ways. They might not be able to put words into real sentences. Some people with autism spectrum disorder say only one word at a time. Others repeat the same words or phrases over and over. Some children repeat what others say, a condition called echolalia. The repeated words might be said right away or at a later time. For example, if you ask someone with autism spectrum disorder, “Do you want some juice?” he or she might repeat “Do you want some juice?” instead of answering your question. Although many children without an autism spectrum disorder go through a stage where they repeat what they hear, it normally passes by three years of age. Some people with an autism spectrum disorder can speak well but might have a hard time listening to what other people say.

People with autism spectrum disorder might have a hard time using and understanding gestures, body language, or tone of voice. For example, people with autism spectrum disorder might not understand what it means to wave goodbye. Facial expressions, movements, and gestures may not match what they are saying. For instance, people with an autism spectrum disorder might smile while saying something sad.

People with autism spectrum disorder might say “I” when they mean “you,” or vice versa. Their voices might sound flat, robot-like, or high-pitched. People with an autism spectrum disorder might stand too close to the person they are talking to, or might stick with one topic of conversation for too long. They might talk a lot about something they really like, rather than have a back-and-forth conversation with someone. Some children with fairly good language skills speak like little adults, failing to pick up on the “kid-speak” that is common with other children.

Below are some patterns of language use and behaviors that are often found in children with autism spectrum disorder:

• Repetitive or rigid language. Often, children with autism spectrum disorder who can speak will say things that have no meaning or that do not relate to the conversations they are having with others. For example, a child may count from one to five repeatedly amid a conversation that is not related to numbers. Or a child may continuously repeat words he or she has heard—a condition called echolalia. Immediate echolalia occurs when the child repeats words someone has just said. For example, the child may respond to a question by asking the same question. In delayed echolalia, the child repeats words heard at an earlier time. The child may say “Do you want something to drink?” whenever he or she asks for a drink. Some children with autism spectrum disorder speak in a high-pitched or sing-song voice or use robot-like speech. Other children may use stock phrases to start a conversation. For example, a child may say, “My name is Tom,” even when he talks with friends or family. Still others may repeat what they hear on television programs or commercials.

• Narrow interests and exceptional abilities. Some children may be able to deliver an in-depth monologue about a topic that holds their interest, even though they may not be able to carry on a two-way conversation about the same topic. Others may have musical talents or an advanced ability to count and do math calculations. Approximately 10 percent of children with autism spectrum disorder show “savant” skills, or extremely high abilities in specific areas, such as memorization, calendar calculation, music, or math.

• Uneven language development. Many children with autism spectrum disorder develop some speech and language skills, but not to a normal level of ability, and their progress is usually uneven. For example, they may develop a strong vocabulary in a particular area of interest very quickly. Many children have good memories for information just heard or seen. Some may be able to read words before age five, but may not comprehend what they have read. They often do not respond to the speech of others and may not respond to their own names. As a result, these children are sometimes mistakenly thought to have a hearing problem.

• Poor nonverbal conversation skills. Children with autism spectrum disorder are often unable to use gestures—such as pointing to an object—to give meaning to their speech. They often avoid eye contact, which can make them seem rude, uninterested, or inattentive. Without meaningful gestures or other nonverbal skills to enhance their oral language skills, many children with autism spectrum disorder become frustrated in their attempts to make their feelings, thoughts, and needs known. They may act out their frustrations through vocal outbursts or other inappropriate behaviors.

How does communication develops in children with autism?

Children’s reasons for communicating are fairly simple – they communicate because they want something, because they want attention, or for more social reasons.

Typically developing children can usually communicate for all these reasons, and their ability to communicate in all these ways comes at about the same time. But it’s different in children with autism spectrum disorder (ASD), who develop the ability to communication in these ways over time.

• First, they use communication to control another person’s behavior, to ask for something, to protest or to satisfy physical needs.
• Next comes communication to get or maintain someone’s attention – for example, a child might ask to be comforted, say hello or even show off.
• Last, and most difficult, are the communication skills children need to direct another person’s attention to an object or an event for social reasons.

How do children with autism communicate?

Sometimes children with autism spectrum disorder (autism spectrum disorder) don’t seem to know how to use language, or how to use language in the same ways as typically developing children.

Unconventional use of language

Many children with autism spectrum disorder use words and verbal strategies to communicate and interact, but they might use language in unusual ways.

For example, echolalia is common in children with autism spectrum disorder. This is when children mimic words or phrases without meaning or in an unusual tone of voice. They might repeat someone’s words straight away, or much later on. They might also repeat words they’ve heard on TV, YouTube or videos as well as in real life.

Children with autism spectrum disorder also sometimes:

• use made-up words, which are called neologisms
• say the same word over and over
• confuse pronouns and refer to themselves as ‘you’, and the person they’re talking to as ‘I’.

These are often attempts to get some communication happening, but they don’t always work because you can’t understand what the child is trying to say.

For example, children with echolalia might learn to talk by repeating phrases they associate with situations or emotional states, learning the meanings of these phrases by finding out how they work. A child might say ‘Do you want a lolly?’ when she actually wants one herself. This is because when she’s heard that question before, she’s got a lolly.

Over time, many children with autism spectrum disorder can build on these beginnings and learn to use language in ways that more people can understand.

Nonverbal communication

These ways of communicating might include:

• physically manipulating a person or object – for example, taking a person’s hand and pushing it towards something the child wants
• pointing, showing and shifting gaze – for example, a child looks at or points to something he wants and then shifts his gaze to another person, letting that person know he wants the object
• using objects – for example, the child hands an object to another person to communicate.

Undesirable behavior

Many children with autism spectrum disorder behave in difficult ways, and this behavior is often related to communication.

For example, self-harming behavior, tantrums and aggression towards others might be a child’s way of trying to tell you that she needs something, isn’t happy or is really confused or frightened.

How are the speech and language problems of autism treated?

If a doctor suspects a child has autism spectrum disorder or another developmental disability, he or she usually will refer the child to a variety of specialists, including a speech-language pathologist. This is a health professional trained to treat individuals with voice, speech, and language disorders. The speech-language pathologist will perform a comprehensive evaluation of the child’s ability to communicate, and will design an appropriate treatment program. In addition, the speech-language pathologist might make a referral for a hearing test to make sure the child’s hearing is normal.

Teaching children with autism spectrum disorder to improve their communication skills is essential for helping them reach their full potential. There are many different approaches, but the best treatment program begins early, during the preschool years, and is tailored to the child’s age and interests. It should address both the child’s behavior and communication skills and offer regular reinforcement of positive actions. Most children with autism spectrum disorder respond well to highly structured, specialized programs. Parents or primary caregivers, as well as other family members, should be involved in the treatment program so that it becomes part of the child’s daily life.

For some younger children with autism spectrum disorder, improving speech and language skills is a realistic goal of treatment. Parents and caregivers can increase a child’s chance of reaching this goal by paying attention to his or her language development early on. Just as toddlers learn to crawl before they walk, children first develop pre-language skills before they begin to use words. These skills include using eye contact, gestures, body movements, imitation, and babbling and other vocalizations to help them communicate. Children who lack these skills may be evaluated and treated by a speech-language pathologist to prevent further developmental delays.

For slightly older children with autism spectrum disorder, communication training teaches basic speech and language skills, such as single words and phrases. Advanced training emphasizes the way language can serve a purpose, such as learning to hold a conversation with another person, which includes staying on topic and taking turns speaking.

Some children with autism spectrum disorder may never develop oral speech and language skills. For these children, the goal may be learning to communicate using gestures, such as sign language. For others, the goal may be to communicate by means of a symbol system in which pictures are used to convey thoughts. Symbol systems can range from picture boards or cards to sophisticated electronic devices that generate speech through the use of buttons to represent common items or actions.

Echolalia treatment

You can expect communication from your child with autism spectrum disorder, even if it’s not the same as the way other children communicate.

For children with autism spectrum disorder, communication develops step by step, so it’s important to work step by step with your child.

For example, if crying in the kitchen is the only way your child asks for food, it might be too hard for him if you’re trying to teach him to say ‘food’ or ‘hungry’. Instead, you could try working on skills that are just one step on from where he is right now – for example, reaching towards or pointing to the food that he wants. Once he starts reaching or pointing, you can work on getting eye contact.

You can help your child develop these skills by praising her when she looks at you and by labeling items.

Here are some ways you can encourage communication with your child:

• Use short sentences – for example, ‘Shirt on. Hat on’.
• Use less mature language – for example, ‘Playdough is yucky in your mouth’.
• Exaggerate your tone of voice – for example, ‘Ouch, that water is VERY hot’.
• Encourage and prompt your child to fill the gap when it’s her turn in a conversation – for example, ‘Look at that dog. What colour is the dog?’
• Ask questions that need a reply from your child – for example, ‘Do you want a sausage?’. If you know your child’s answer is yes, you can teach your child to nod his head in reply by modelling this for him.
• Make enough time for your child to respond to questions.

Eye contact

Eye contact is a key part of nonverbal communication. It helps other parts of communication, like being able to notice another person’s facial expression and take emotion into account in your communication.

Here are some ideas to encourage eye contact from your child:

• Hold an object your child wants in front of your eyes so your child looks at your eyes as she looks towards the object.
• Hold onto an object your child wants for a few extra seconds before letting your child take it. This encourages your child to look towards your face when he doesn’t get the object immediately.

Behavior and Communication Approaches

According to reports by the American Academy of Pediatrics and the National Research Council, behavior and communication approaches that help children with autism spectrum disorder are those that provide structure, direction, and organization for the child in addition to family participation.

Applied Behavior Analysis

A notable treatment approach for people with an autism spectrum disorder is called applied behavior analysis (ABA). Applied behavior analysis has become widely accepted among health care professionals and used in many schools and treatment clinics. Applied behavior analysis encourages positive behaviors and discourages negative behaviors in order to improve a variety of skills. The child’s progress is tracked and measured.

There are different types of applied behavior analysis. Following are some examples:

• Discrete Trial Training: Discrete Trial Training is a style of teaching that uses a series of trials to teach each step of a desired behavior or response. Lessons are broken down into their simplest parts and positive reinforcement is used to reward correct answers and behaviors. Incorrect answers are ignored.
• Early Intensive Behavioral Intervention: This is a type of applied behavior analysis for very young children with an autism spectrum disorder, usually younger than five, and often younger than three.
• Pivotal Response Training: Pivotal Response Training aims to increase a child’s motivation to learn, monitor his own behavior, and initiate communication with others. Positive changes in these behaviors should have widespread effects on other behaviors.
• Verbal Behavior Intervention: Verbal Behavior Intervention is a type of applied behavior analysis that focuses on teaching verbal skills.

Other therapies that can be part of a complete treatment program for a child with an autism spectrum disorder include:

• Developmental, Individual Differences, Relationship-Based Approach (also called “Floortime”): “Floortime” focuses on emotional and relational development (feelings, relationships with caregivers). It also focuses on how the child deals with sights, sounds, and smells.
• Treatment and Education of Autistic and related Communication-handicapped CHildren (TEACCH): TEAACH uses visual cues to teach skills. For example, picture cards can help teach a child how to get dressed by breaking information down into small steps.
• Occupational Therapy: Occupational therapy teaches skills that help the person live as independently as possible. Skills might include dressing, eating, bathing, and relating to people.
• Sensory Integration Therapy: Sensory integration therapy helps the person deal with sensory information, like sights, sounds, and smells. Sensory integration therapy could help a child who is bothered by certain sounds or does not like to be touched.
• Speech Therapy: Speech therapy helps to improve the person’s communication skills. Some people are able to learn verbal communication skills. For others, using gestures or picture boards is more realistic.
• The Picture Exchange Communication System (PECS): Picture Exchange Communication System uses picture symbols to teach communication skills. The person is taught to use picture symbols to ask and answer questions and have a conversation.

Visit the Autism Speaks (https://www.autismspeaks.org/treatments) or Autism Society (http://www.autism-society.org/living-with-autism/treatment-options/) website to read more about these therapies.

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