The Meaning Behind the Message: Helping Children who use Echolalia
By Lauren Lowry Hanen SLP and Clinical Staff Writer
I’ll never forget the first child I met who used delayed echolalia. During my initial home visit, Lucy (client's name has been changed) approached me, took my hand, and said “Let’s play Ring Around the Rosie.” But when I started playing Ring Around the Rosie, Lucy seemed upset and pulled me towards a line of blocks she had set up on the floor. Confused, I turned to her mother, who explained that this was the way Lucy started social interactions. Several months prior, she had played Ring Around the Rosie with a peer for the first time. She enjoyed it so much that every time she wanted to play with someone since that day, she initiated the interaction with “Let’s Play Ring Around the Rosie,” even though she didn’t want to play that particular game at that moment. I learned a lot about echolalia from Lucy and her family. I learned that you have to become a bit of a detective because children’s messages don’t always reflect their intended meaning. I learned that you have to work with the family in order to understand the context in which the echolalia is used. And I learned to interpret the meaning behind the child’s message.
These principles are echoed in an article by Lillian Stiegler (2015), who describes echolalia in children with autism spectrum disorder (ASD) and the research base upon which our intervention principles are drawn. Below I share this information, along with Stiegler’s suggestions for intervention, as well as how they fit with the approach to echolalia in the More Than Words® Program.
What is echolalia?
Echolalia refers to the repetition of others’ utterances, one’s own utterances, or audio media (television shows, etc.) (Stiegler, 2015). However, that doesn’t tell the whole story. After all, according to that definition, we all use echolalia from time to time! In fact, echolalia can be a feature in typical language development, although prolonged use of echolalia (past the age of 2 ½) usually signals a problem with language acquisition (Roberts, 1989). Children with ASD often use echolalia beyond early childhood and more frequently than typically developing children. Echoed utterances are generally more linguistically complicated than the child could generate himself, and they are sometimes part of a learned routine.
Echolalia is usually described according to the following:
Types of echolalia
Immediate echolalia – echoed utterances that are produced within two conversational turns of the original utterance
Delayed echolalia – echoed utterances that are produced more than two conversational turns after the original utterance. Because of the time delay, these utterances may seem very unconventional as they are sometimes used in a different context than the original utterance.
Echoed utterances can be either:
Pure – an exact repetition of the original utterance
Mitigated – echoic responses that evidence modifications from the original utterance (e.g. Let’s go outside -> “Let’s go over there”)
(Stiegler, 2015; Fay, 1967; Blanc, 2014)
In the field of speech language pathology, we treat echolalia differently from other UVBs which may not have a communicative purpose.
Echolalia can serve many functions
Many formative investigations into echolalia were conducted in the 1980’s and 1990’s (e.g. Prizant & Duchan, 1981; Prizant & Rydell, 1984; Rydell & Mirenda, 1994; McEvoy, Loveland, & Landry, 1988; Voilette & Swisher, 1991). These researchers conducted detailed analyses of echolalia use with individuals at different ages and with a variety of language levels. They uncovered a number of functions served by both immediate and delayed echolalia:
Possible functions of immediate echolalia:
answering “yes” to questions
maintaining social interactions
Possible functions of delayed echolalia:
completion of verbal routines
calling (to draw attention to oneself or to initiate/maintain interaction)
(Stiegler, 2015; Prizant, 1983)
Some echolalia was identified as noninteractive yet serving functions such as rehearsal, learning, or self-regulation (Stiegler, 2015; Prizant, 1983). More recent studies from the field of interactional linguistics (e.g. Sterponi & Shankey, 2014; Stribbling, Rae, & Dickerson, 2007) have confirmed that echolalia seems to serve several functions, and that it also contributes to the development of relationships and social-emotional attachments (Stiegler, 2015). All of the above research has paved the way for an approach which looks for the underlying functions of a child’s echolalia, and considers it as part of the child’s overall gestalt style of language processing.
Gestalt processing style
It’s generally recognized that the majority of children acquire language by first learning single words, and then eventually combining these together to form short utterances. This progression reflects an analytic processing style, whereby children can analyze and break down adults’ longer utterances into smaller component parts (Stiegler, 2015). However, many children with ASD likely use a gestalt processing style, which means they capture longer units of speech at early stages of language acquisition (Stiegler, 2015). They don’t understand the internal structure or meaning of these utterances, so they use them as wholes or chunks of language (Manning & Bobkoff Katz, 1989). While this style of language processing characterizes the learning style of many children with ASD, it is also used by some typically developing children (Stiegler, 2015). Gestalt language acquisition emerges according to the following stages:
Stages of gestalt language acquisition
Stage 1: echolalia – utterances are largely echolalic and serve either a turn-taking function in conversation or a self-stimulatory function
Stage 2: mitigation – cognitive growth and social experiences fuel echolalia that serves a greater variety of functions. Children’s echoes evidence mitigation. They break down utterances and recombine shorter segments, or they use one- and two-word utterances.
Stage 3: isolating words and recombining – early semantic-syntactic rules are acquired and echolalic utterances are broken down further. Spontaneous language increases and expresses functions previously fulfilled by echolalia.
Stage 4: generation – more spontaneous and flexible language continues as semantic, syntactic, and morphological rules are acquired. Most communicative functions are served by spontaneously generated utterances. Echolalic utterances may be observed when an individual is tired, confused, or distracted.
(Prizant, 1983; Blanc, 2013)
Our intervention approach when it comes to echolalia hinges on the idea that, in order to acquire flexible, spontaneous language, children ultimately need to move from using gestalt processing to analytic processing (Manning et al., 1989).
Intervening with children who use echolalia
Based on her review of several treatment approaches developed from the research mentioned above (e.g. SCERTS, Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006; Learning Style Profile for Children with Autism Spectrum Disorders, Rydell, 2012; Natural Language Acquisition, Blanc, 2012), Stiegler (2015) provides suggestions for intervening with children who use echolalia. These suggestions are summarized below, followed by a description of how they fit with the approach described in the More Than Words Program.
Facilitate verbal initiations with a “low-constraint” interaction style during natural settings
Stiegler’s (2015) first suggestion is to encourage children to initiate communication frequently, as opposed to focusing on responding to questions and prompts. Children with ASD should be provided with many opportunities to communicate with a variety of communication partners during natural social communication settings. This goal can be accomplished when communication partners use a “low-constraint” interaction style. This suggestion is based on research by Rydell & Mirenda (1991, 1994), which revealed that communication partners’ interaction style can influence echolalia:
a high-constraint, directive interaction style is associated with increased immediate echolalia – this style is characterized by commands, prompts and wh- questions which control the interaction and expect specific responses. As it tends to place pressure on the child with ASD, this style results in a higher percentage of echolalic responses, especially immediate echoes which don’t demonstrate comprehension.
a low-constraint, facilitative style is associated with delayed echolalia that evidences comprehension – this style is characterized by comments, affirmations and reflective questions, and it tends to elicit delayed echolalia with evidence of comprehension and functionality. Low-constraint utterances follow the child’s lead and don’t necessarily expect specific responses.
Interventionists are urged to use a facilitative interaction style with low-constraint utterances when working with individuals with ASD, as it promotes initiations and more sophisticated communication which demonstrates comprehension (Stiegler, 2015).
“Low-constraint” interactions in More Than Words From the very beginning of the More Than Words program, parents learn how to use a low-constraint, responsive style to encourage their child to initiate interactions. When parents Follow their Child’s Lead they allow their child to initiate messages often. This also helps them tune in to their child’s interests, which enables them to keep interactions going by joining in their child’s play. These sustained interactions provide even more opportunities for the child to initiate.
Throughout the program, parents continue to use this responsive style while interacting during a variety of routines with their child. Daily routines offer predictable, naturally occurring situations with many opportunities to initiate communication. Parents use the R. O. C. K. strategy to offer their child an opportunity to communicate by waiting at a specific point during the routine. Because the language used during routines is repetitive and predictable, it helps echolalic children know what to say.
Determine the child’s comprehension and underlying communicative functions
Carefully observing and analyzing children’s echolalia is critical in order to determine its meaning and function. Stiegler (2015) suggests two ways to assess a child’s intent and discern the underlying function of echoed utterances:
look for concomitant nonverbal cues – children’s gaze, gestures, and body orientation when they use echolalia can provide information about whether the child intentionally sent a message
watch for mitigation – if the child’s echoed utterance alters or adds to the original utterance, this demonstrates that the child is starting to understand and break down “chunks” of language and recombine them together.
A further suggestion is to identify the primary source of delayed echoes in order to understand their underlying function (Stielger, 2015). For example, in the example at the beginning of this article, the primary source was a game of Ring Around the Rosie with a peer.
Finally, Stiegler (2015) suggests that echolalia can be used in subtle ways within families and other social groups, and that we need to be sensitive to this as it can shed light on the idiosyncratic meaning of echoed utterances.
Looking at underlying functions of echolalia in More Than Words
Parents begin thinking about the intent behind their child’s messages right away when they start Observing, Waiting, and Listening carefully to their child. This helps them notice any nonverbal cues that might indicate the child’s intent. It also helps them notice the context in which their child’s messages are sent, which provides clues about the meaning and function of echoed messages.
Parents also learn to Interpret their child’s messages at the beginning of the program. For parents of children who use echolalia, this means looking at the context and figuring out the child’s point of view so that they can determine what their child is really trying to say. Once they know the function of the echoed utterance, they are ready to provide a model their child can learn from.
Parents learn about the difference between interactive and non-interactive echolalia to further their understanding of the underlying functions of echolalia. For example, when a child recites lines from a favourite TV show while playing alone, this is considered non-interactive as the delayed echolalia in this situation is not directed to someone.
Use joint action routines to map language onto existing concepts
Using age-appropriate joint action routines with different people, objects, and actions provides a context for mapping new language onto concepts the child already understands (Stiegler, 2015). As the child becomes increasingly familiar with a routine, he learns a variety of vocabulary associated with the concepts demonstrated during the routine.
Using routines to build comprehension in More Than Words Creating predictable, enjoyable joint action routines is one of the core tasks for parents during the More Than Words Program. Whether it’s a people game, toy play, or a daily routine like getting dressed, parents are continually encouraged to use the R.O.C.K. strategy to add structure and repetition during these routines so that their child can achieve either a comprehension or social communication goal.
In terms of mapping new language, the “4 S’s” strategy (Say less, Stress, go Slow, Show & Repeat often) helps parents simplify their language to help their child understand. By building children’s comprehension, they are better able to use self-generated language instead of echolalia.
Model useful "gestalts" for the child to borrow
Stielger (2015) warns against teaching inflexible “survival” utterances that can’t be easily mitigated, such as “May I have a turn please?” or “May I use the restroom please?”. Instead, she suggests modeling shorter “gestalts” (language chunks) that are engaging, playful, and express the child’s point of view. These gestalts should be forms that a child will find useful and be able to quickly mitigate and re-combine with other language. They should also be age-appropriate and reflect something a child might say (not what an adult would say). Since targeted gestalts are selected based on careful analysis of each child’s individual language contexts and repertoire, they vary from child to child. For example, if a child’s favourite game is chase and he asks for the game by saying “chase,” his parents might be targeting “Let’s play chase.” However, this wouldn’t be a target for another child who doesn’t enjoy chase and prefers to draw, whose parents might be targeting “I need (colour)” to ask for specific colours of crayons. These modeled gestalts will be used as “building blocks to create original, self-generated, multi-purpose utterances” (Stielger, 2015, p. 760).
Modeling language for children who use echolalia in More Than Words A key strategy for parents of children who use echolalia is the Interpret strategy. When parents Interpret, they learn to “Say it as he would if he could.” By OWLing and tuning in to whatever the child is doing and trying to say, parents are able to act as their child’s interpreter and turn echoes into more appropriate language. This often requires some detective work, especially when a child uses delayed echolalia.
My favorite part of Stiegler’s (2015) article is her reference to “the Hanen Centre’s gently written guide for parents of children with ASD, More Than Words®” which she describes as capturing the approach to echolalia taken in the field of speech language pathology over the past several decades: says, “Do you want a glass of milk?” a parent could Interpret by saying “I want a glass of milk.” Parents are also encouraged to use practical, useful language like carrier phrases (e.g. “I see…” “Let’s…”, “I want…”, etc.) when they Interpret, as these phrases can be used in a variety of situations and combined with a variety of words.
My favourite part of Stiegler’s (2015) article is her reference to “the Hanen Centre’s gently written guide for parents of children with ASD, More Than Words®” which she describes as capturing the approach to echolalia taken in the field of speech language pathology over the past several decades:
“Echolalia is a good sign. It shows your child’s communication is developing. Soon he may begin to use these repeated words and phrases to communicate something to you…The words your child learns from echolalia open the door to meaningful communication” (Sussman, 2012, p. 21).
Our goal is to work with a child’s gestalt style of language learning by providing useful language models during everyday interactions. By helping parents follow their child’s lead and interpret their child’s echolalia, they will be well-equipped to help their child build a repertoire of self-generated, flexible language.
To help parents understand why children with ASD use echolalia, feel free to share our latest article “Three Things You Should Know About Echolalia”.