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Case Studies on Autism
Stopping echolalia and psychotic talk
Many developmentally disabled children are mute (do not verbalize) when you start to work with them; that is, their language or verbal output is non-existent, or is restricted to occasional vowels or consonants that appear in a random or meaningless fashion. Some children may evidence a great deal of speech, even though the speech appears to have no immediate meaning or significance for social communication. A child's speech may be echolalic when he repeats, either partially or completely, sentences that he hears other people say. The echolalia may be immediate, as when he echoes within seconds what an adult just said, or delayed in the sense that the child echoes words or sentences that he heard the preceding hour, or morning, or even weeks ago.

Other children have relatively elaborate speech, which does not appear to be echolalic. Instead the speech may be unusual word combinations ("word salads") that do not make any sense, such as "partridge hammock cake down eyelash," or the speech may be meaningful but it occurs out of context. An example of the latter is the case of a child who spends a great deal of his day describing elavators, clocks, or dates and calendars to anyone he meets and independent of what is actually happening at the time. Such inappropriate statements have been called psychotic talk.

Psychotic and echolalic talk directly interfere with the child's ability to generate appropriate speech. This is seen very clearly when you try to teach a child a simple question and in so doing block his opportunity to generate the right response. There will be many other reasons why you will want to help a child overcome echolalic or psychotic talk; for instance, the presence of such speech can delay cognitive development by interfering with learning process. Echolalic and psychotic talk, and procedures to overcome them, are described in more detail below.

Echolalic talk is not restricted to autistic children or to psychotic children, although it is often considered an indication of those conditions. Echolalia occurs in normal language development; it peaks around 30 months of age, then decreases. Echolalic speech can also be observed in children who have experienced recent traumatic brain injury.

The presence of echolalic speech in a child who is beginning therapy gives the child a better prognosis for learning language than if he were mute. Even though the child may not know the meaning of the words and word combinations he is echoing, he knows how to talk. If the child didn't have echolalic speech, then a great deal of time would have to be spent in teaching him to form sounds and words and word combinations. So, for no other reason than that time is saved, the echolalic child is far ahead of his mute peers. Children who are mute, but who later become good at speaking with language training, do so after they have passed through a stage of developing echolalic responding. The previously mute children who do not enter an echolalic stage rarely become good at using language, at least not vocal language. Therefore, it is to the child's advantage to learn to echo, even if he doesn't do so before you begin working with him. The child clearly has to go beyond echolalic (or psychotic) talk in order to function more adequately on an interpersonal level, to problem solve, and otherwise to improve in his cognitive functioning.

Why children echo is hard to say. It is unlikely that they echo because they are rewarded or re-inforced for doing so by people who listen to them. In other words, echolalia is probably not operant behavior based on socially controlled extrinsic reinforcement, but instead it may be operant behavior based on intrinsic reinforcement, like self-stimulatory behavior. The child's reinforcement may consist of his matching what he hears himself say to what he has heard other people say. In other words, the reinforcer is to match, and in that sense the child gives himself his own reinforcement. Notice how closely and how beautifully some children track the nuances of other people's speech; in fact, some children have several voices, imitating their mother's intonations, their father's, and perhaps also their teacher's. Echolalia can be viewed as storing or otherwise preserving in the brain the auditory input from one's surrounding environment. In that sense echolalic speech would be analogous to a visual afterimage. So, it may be useful to retain certain aspects of it, as an "internal" rehearsal. Procedures for helping the child move past overt echolalic responding are described below.

Overcoming Echolalia
An echolalia student is likely to echo statements that he does not understand. For example, if you say, "Point to your head," and if the child knows how to follow that command, then he will not echo that command. On the other hand, if you were to say, "Point to your cranium," then it is likely that the child would echo the statement and not follow the command. This means that you should observe some decrease in echolalic responding as the child acquires meaningful language. In any case, you may observe considerable echolalia even if the child is learning a great deal of language because he will remain ignorant of correct answers to most questions.

One procedure for stopping echolalic speech to unfamiliar statements (commands, requests) has been provided by Schreibman and Carr (1978). Echolalic children were taught to answer "I don't know," as a general non-echolalic response to questions or statements they did not comprehend. The procedure can be outlined as follows:

Step 1:
Have the child sit in a chair facing you, perhaps opposite you at a small table. As usual, have the child sit quietly, without self-stimulating, and visually attending to you. Select four or five questions to which the child does not know the answers: for example, "Why do birds sing?", "Where is London?", "How many brothers and sisters do you have?", or "Why do sailboats move?" There are many similar "How", "Why", "Who", and "Where" type questions that you might find more appropriate for your particular child. You should also select some questions to which you know your child already knows the answers, "What's your name?", "How old are you?", "Who is that?" (while pointing to his mother). Now present the first question, for example, "Why do birds sing?", very quickly, and at a low decibel level (in a whisper). Then immediately state the answer, "I don't know," very loudly. Try experimenting with the volume of your voice until the child echoes the correct answer and not the question. Reinforce him heavily for a correct response.

Step 2:
In very gradual steps, begin to raise the decibel level (loudness) of your question while gradually lowering the decibel level of the answer. if the child begins to echo the question during this process, give him a sharp "No" and backtrack a little by decreasing the loudness of the question.

You do not want him to echo the question; in fact, you prevent this by rewarding him for being quiet, for withholding his response in the presence of the question. This very promising technique of presenting the cues for the wrong answer at a very low intensity teaches the child to tolerate or not to respond to the presence of the wrong cue.

Step 3:
Eventually, ask the question, "Why do birds sing?" in a normal voice, and withhold the answer. The child has mastered the task when he withholds echolalia and gives the correct andwer, "I don't know, " without prompt and to criterion.

Step 4:
Once you have trained the response "I don't know" to questions such as "Why do birds sing?", then introduce a question to which he already knows the answer, for example, "What's your name?" (The child says his name, and is reinforced.) If he fails to respond, or responds incorrectly, prompt the correct answer, then reinforce to reestablish correct responding. The importance of introducing questions to which he already knows the answer and intermixing them with questions to which he does not know the answer is to retain the discrimination between what he knows and does not know. It should help him avoid learning to say "I don't know" to all questions.

Step 5:
Present another question, such as "Where is London?, and train the correct answer, "I don't know," to that question, continuing to intermix questions to which he knows the answer.

If you continue this procedure using questions that start with "how," "why," "when," and "where" intermixed with questions to which the child does know the answer, you will find that after a while the child will spontaneously answer, "I don't know" to a question to which he does not know the answer even when you present this question for the first time (that is, without prior training). You may say now that he knows what the "rule" is. In any case, through this procedure you can help a child terminate his echolalic responding in a variety of situations.

Psychotic Talk
In general, it is probably safe to assume that psychotic talk si self-reinforcing and will not disappear or decrease markedly if you place it on extinction or use time-out. Many children will persist in expressing psychotic talk, even though they can also talk appropriately, apparently because psychotic talk is so reinforcing to them. There should be some replacement of psychotic speech by appropriate language, since appropriate language gives the child access to many of the self-stimulatory reinforces previously available to him only through psychotic speech. That is, appropriate speech may come to substitute for the (self-stimulatory) properties of psychotic speech. In most instances, however, psychotic speech will stay at a high level, and in those instances we must actively intervene to eliminate the psychotic talk.

Overcoming Psychotic Talk
The treatment rationale behind programs to stop inappropriate and psychotic talk is that the presence of a great deal of psychotic talk socially isolates a child. It makes him stand out like a sore thumb with his friends at school or in the community. You want to help him suppress psychotic talk just as you help him suppress other kinds of self-stimulatory behaviors.

Start by giving the child a sharp "No!" (or other kind of disapproval) immediately after his psychotic production. You may want to say, "No, no silly talk," in an attempt to help him discriminate why he is beind admonished. (However, there is no guarantee that he will make the discrimination.) A better way might be to teach a child to talk "silly" (that is, psychotic) on cue. Teach him to talk "silly" or to echo when you say "Talk silly and echo," and reinforce him for talking psychotically or echoing at that time. Then switch and say, "Don't talk silly and don't echo," and reinforce him for withholding his response at that time. The main justification for going through such a procedure is to teach the child to discriminate between appropriate and inappropriate speech. Although we as adults clearly know the discrimination, it is obvious that psychotic and retarded persons do not.

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