Imitations and Echoes in Autistic andDysphasic Children

Dennis P. Cantwell, M.D. and Lorian Baker, Ph.D.

Abstract. This paper investigates suggestions that the amount and type of echolalic languageused hy autistic' children may provide both diagnostic" and prognostic information. Thesubjects of this study are 12 autistic and 12 dysphasic boys of matched ages (between 6; 6and II; 6 years), matched nonverbal IQs. and matched degrees of receptive language im­painnent with language ranging from use of only two word utterances to use of complexsentences. From this group. the 6 children having the most language are selected andcompared with the 6 children having the least language. The amount and types of echoesused hy these boys were somewhat different in the high and low language groups.

Repetitive or imitative or "echolalic'' language is a characteristicfeature of childhood autism. Kanner's early (1946) description ofautistic language reports a parroting of words which the child doesnot appear to understand, a repetition of stored phrases, a failureto construct original sentences, and a reversal of the pronouns"you" and "I" (which Kanner interprets as a result of the imitation).Wolff and Chess (1965) found much repetition, both immediateand delayed, in the language of 14 schizophrenic children theystudied. Rutter et al. (1967) found echolalic language in over 75%of psychotic children.

Yet echolalic or imitative language is not unique to childhoodautism. Fay (1966) notes that echolalia has been reported in thelanguage of children with mental retardation, developmentalaphasia, and acquired aphasia, as well as in the midacquisition stage

Dr. Cantwell IS Associate Professor. Department of Psychiatry. Division of Mental Retardation andChild Psychiatry. and Dr. Baker is Research Associate. Department of Psychiatry. Division of MentalRetardation and Child Psychiatry. Neuropsychiatric Institute. University of California at Los Angeles.(760 Westwood Plaza, Los Angeles. CA 90024), where reprints may be requested.

This study was supported in part by the following grants: NIMH Special Research FellowshipIF03MH 52205-01. MH 08467-13, MCH 927, Scottish Rite Foundation. and USPHS IROI. MH27919-0IAJ.

We would also like to thank Dr. Michael Rutter, Ms. Patricia Hotolin, and Rosemary Hemsley. whoprovided valuable assistance in an earlier phase of this study.

0002-7138/78/1704-0614 $00.77 C' 1978 American Academy of Child Psvchiarry.

614

Imitations and Echoes in Autistic Children 615

of language development of normal children. Indeed, the questionof establishing a differential diagnosis between autism and de­velopmental dysphasia is a difficult one which has interested manyinvestigators (Bartak et aI., 1975; Churchill, 1972; Cohen et aI.,1976; de Hirsch, 1967; Millman and Canter, 1972; Sahlmann,1969).

Echolalic language consists of different types of echoes, andthese have been categorized in the literature according to one ormore of four parameters: who is echoed (self or other), when theecho occurs (delayed or immediate), what the structure of the echois (exact or modified), and whether the echo has a communicative,socialized function. Rutter et al. (1967) distinguish between utter­ances that are immediate repetitions of the preceding utterancesand utterances that are delayed echoes. Cunningham (1968) distin­guishes between immediate echoes that are repetitions of thespeaker's earlier utterance and immediate echoes that are repeti­tions of someone else's earlier utterance. Wolff and Chess (1965)suggest four categories of echoes: immediate versus delayed andcommunicative versus noncommunicative. Shapiro et al. (1970)class echoes into five categories according to their structure: "con­gruent imitations" are exact repetitions of the whole or of part ofthe utterance; "nongrammatic imitations" involve repeating someof the utterance, but in a syntactically impermissible word order;'Jargon imitations" involve the addition of nonsense words; "tele­graphic imitations" involve the deletion of words or morphemesfrom the original utterance; and "mitigated imitations" involvesome grammatical restructuring of the utterance.

There have been suggestions in the literature that the study ofthese subtypes of echoes may provide insights into both the diag­nosis and prognosis of autism. It is possible, for example, that thesubtypes of echoes used may distinguish autistic from aphasic lan­guage. Simon (1975) suggests that it is delayed echolalia that par­ticularly characterizes autistic language. Hermelin and O'Connor(1970) state that autism is characterized by imitations that consist ofthe last part of the sentence. Shapiro et al. (1970) remark that theimitations of young schizophrenic children are typically "rigid" and"stereotyped." Yet, despite these statements, and despite attemptsof investigators such as Cunningham and Dixon (1961) and Wolffand Chess (1965) to tabulate the echoes of autistic children, therehas been no success in formally defining "autistic language" interms of numbers and types of echoes found.

616 Dennis P. Cantwell and Lorian Baker

The suggestion that the different subtypes of echoes may havesome prognostic relevance has received more attention. Early ef­forts consisted of attempts to characterize the level of developmentof "ego organization" from the types of imitations being made.Although there have been few studies aiming to correlate the levelof ego organization (as revealed through language) with prognosis,this is a logical next step if these ego models are to be taken seri­ously. One such model is the work of Griffith and Ritvo (1967) whostate that the use of negative echolalia is indicative of disturbedobject relationships. Ekstein (1964), in another ego model, pro­posed that delayed echoing during psychotherapy is indicative of"primitive incorporation." The only "ego model" which is, how­ever, based upon concrete research is that of Shapiro and his col­leagues (1970). They examined the basic hypothesis that "degreesof flexibility in imitative speech could be used as an index of egoflexibility and adaptive capacity." They suggest, in particular, thatthe type of echo they call the "rigidly congruent echo" (an exact orexact-reduced repetition of the original utterance) is indicative ofthe absence of "ego flexibility." Their study involved the compari­son of 18 autistic and 18 normal children. Comparisons of lan­guage samples of these children revealed significantly more rigidlycongruent echoes among the autistic group. Further, among thecontrol group of normals, the number of congruent echoes de­creased with age and the number of mitigated echoes increasedwith age. It was concluded that congruent echoing is indicative ofpoor ego organization, whereas mitigated echoing was indicative ofincreased ego organization. These results are significant, because, ifrepeatable, they will provide a relatively simple means of classifyingautistic children according to severity of disturbance and henceprobable outcome.

Ignoring the issue of ego organization, other authors have alsosuggested a relationship may exist between prognosis and type oramount of imitations found in the language. Stengel (1947) wasfirst to note the prognostic value of the form of imitations; heobserved that in adult aphasics, mitigated echoes are correlatedwith progress in regaining language. After studying language­delayed children, Fay (1967) and Fay and Butler (1968) concludedthat echoing is correlated with poorer language acquisition thannonechoing, and that echoers who had a high incidence of miti­gated echoes had a higher verbal ability than those who employed

Imitations and Echoes in Autistic Children 617

other types of echoes. The suggestion that echoing is associatedwith poorer language acquisition than nonechoing is rejected, how­ever, by Lovaas (1966) and Risley and Wolf (1967) who believe thatthe presence of echolalia is a necessary first step in the language­acquisition task, and that echoers therefore will be more likely tohave good language acquisition than nonechoers.

One attempt to examine these issues is found in Baker et al.(1976). In this work, children with "high" and "low" levels of lan­guage (defined by scores on the Peabody Picture Vocabulary Test)are compared according to the amount and type of language theyuse. It was found that the amount of echoing was higher for the"high" language group. One possible explanation for this finding,however, was that the "low" language group had extremely littleexpressive language of any kind, usually only one-word utterances.The present work attempts to examine this same issue using chil­dren who have a minimum amount of expressive language consist­ing of at least two-word phrases.

Examining the types of echoes employed by language-disturbedchildren may also provide insights into the actual linguisticmechanisms involved in the disturbance. A preponderance of"exact" echoing in which the whole utterance of another speaker isrepeated word for word, without any appropriate grammatical orintonational changes, suggests an inability to segment utterances,which may be the result of a left hemisphere disturbance in thetemporal processing mechanism. The exact echoer may actually be"hearing" sentences as whole, unsegmented structures, much as thenormal adult often perceives sentences in unknown foreign lan­guages as consisting of long words with no "spaces" between them.Reduced echoes (in which one or more significant words, ratherthan the whole utterance, are repeated) suggest, if not actual com­prehension, at least the ability to segment utterances, and (in caseswhere stressed words are repeated) the ability to perceive stress.

In cases where reduced echoes consist of the last word of theutterance, rather than the most highly stressed or more significantword of the utterance, an impairment of short-term memory maybe indicated. Expanded and mitigated echoes are indicative of aless disturbed linguistic system in which integration is possible. Aprevalence of echoes of any of these types may thus provide valu­able clues as to which type of language-training procedures are bestindicated.

618 Dennis P. Cantwell and Lorian Baker

The aim of this paper is to investigate the following questions:1. Can the measurement of types of echolalia be used to distin­

guish autistic from dysphasic children?2. Does the prevalence of certain types of echolalic language

provide any clues as to the nature of the disorder?3. Can the measurement of types of echolalia be used with

language-impaired children to identify those with higherlevels of language acquisition?

SUBJECTS AND METHOD

The subjects for this study consisted of 24 males between the agesof 6; 6 and 11; 6, with a nonverbal IQ of at least 70, and a disorderof language comprehension which had been present from infancyand which was not due to overt neurological disorder or peripheraldeafness. (A detailed description of the subject population andtheir selection is reported by Bartak et aI., 1975.)

The subjects fell into two groups, matched for age (mean age9; 6), IQ (mean nonverbal IQ, 92), and sex. Nonverbal IQs weredetermined by using the WIse Performance Scale. Twelve of thesubjects met the criteria of Rutter (1974) for infantile autism: aprofound and general failure to develop social relationships, ritu­alistic and compulsive phenomena, as well as a receptive languagedefect. These children are referred to as the "autistic" group. Theother 12 children were diagnosed as showing an uncomplicateddevelopmental language disorder which included an impairmentin the comprehension as well as in the production of language.These children are referred to as the "dysphasic" group.

One-hour-Iong language samples of the children and theirmothers were obtained during routine interactions in the home.The method for obtaining and analyzing these samples is describedin detail in Howlin et aI. (l 973). The language samples were tran­scribed and analyzed according to the linguistic structures whichappeared. Based on this analysis, the 6 children with the mostlanguage (3 from the "autistic" group and 3 from the "dysphasic"group) were selected. The two groups of children were of compa­rable age, with mean age being 8; 6 years. The "high" languagechildren were all able to form correct noun phrases, verb phrases,prepositional phrases, and noun-phrase plus verb-phrase sen­tences. In addition, they were able to use simple transformationssuch as question-inversion, do-support, negation, and a range of

Imitations and Echoes in Autistic Children 619

morphological structures including plural, past tense, possessiveand pronoun case. The 6 children selected were the only childrenfrom the pool of 24 children with all of these abilities. The 6 "low"language children were able to form some phrases, but were un­able to form noun-phrase plus verb-phrase sentences. With theexception of occasional use of the plural form, they had virtuallyno command over morphological structures, and their use of trans­formations was limited to the imperative. The 6 children selectedwere the only ones with this configuration of abilities.

Analysis of Echolalia

From the transcriptions of the children's language during interac­tions with their mothers, all examples of repetitions or echoes wereextracted. These were then categorized according to:

1. whether the echo was immediate or delayed2. whose utterance was echoed (the child's or his mother's)3. whether the echo was appropriate or inappropriate4. the structure of the echo: whether exact, reduced, "mitigated"

(the term mitigated is used here to mean "restructed," whichdiffers slightly from th e usage of Stengel and Fay), expanded ,or "congruent" (= exact or reduced).

For each child, the percentage of total utterances consisting of eachecho type was computed. Raw frequencies were not used to makecomparisons because the overall number of utterances varied con­siderably between subjects. Matched t-tests indicate that percent­ages of utterance types are comparable between the children(Cantwell et al., 1978). From these figures, the mean occurrences ofeach echo type were then computed for the autistic, dysphasic,"high" language, and "low" language groups.

RESULTS

Establishing a Differential Diagnosis:The AutisticlDysphasic Comparison

The results of the autistic/dysphasic comparisons are presented intables 1 and 2. The autistic children did more delayed echoing andmore inappropriate immediate echoing of themselves. However,there was no significant difference between the autistic and dys­phasic groups in amount of exact, reduced, expanded, mitigated,or congruent echoes.

620 Dennis P. Cantwell and Lorian Baker

Table I

Tvpcs of Echoes for Autistic and Dysphasic Groups

% of Total UtterancesAutistic Dysphasic

mean S.D. mean S.D.Immediate repetitions of self

appropriate 0.83 1.19 1.67 1.37

inappropria tc 1.75 8.28 0.75 1.06"total 558 8.07 2.12 1.68

Immediate repetitions of others

appropriate 7.!12 7.60 !I.2" 8.90inappropriate 1.17 1.3·1 \.!i8 2.78total 9.09 7.91 10.83 9.74

Delayed repetitions

appropriate 2.50 6.29 0.08 0.29inappropriate 2.7" 5.50 0.00 0.00total r: r)'" 7.83 0.08 0.29".,._:)

Total appropriate imitations & echoes 11.2,; 8.21 11.00 9.23

Total iuappropia tc imitations I\: echoes 8.67 10.57 2.33 3.23

Total imitations I\: echoes 19.!I2 !/.II 13.33 10.09

"p < .0" (\\' ilcoxon test)

Table 2

Structure of Rvpct it ious for Autistic and Dysphasic Groups

Exact repetitiousReduced repetitionsExpanded repetitionsMitigated repetitionsCongruent repetitions

Xonc significant to .05 level.

% of TotalAutistic

mean S.D.

150 5.813.7:; 1.710,42 0.670.12 1.168.50 7.89

UtterancesDysphasic

mean S.D.

7.50 8.702.08 1.931.25 1.910.00 0.009.58 9.17

In both groups, congruent repetitions were the most commontype, followed by exact repetitions, reduced repetitions, and miti­gated and expanded echoes. It appears that in both of these disor­ders there is a difficulty in breaking down utterances and generat­ing new forms.

Imitations and Echoes in Autistic Children 621

Determining Overall Language Level from Examination of Echoes:Comparison of "High" and "Low" Language Children

The results of the comparison of "high" and "low" language chil­dren are presented in tables 3 and 4. Statistical analysis revealed nosignificant differences between the "high" and "low" languagegroups in any of the different types of echoes.

Table :1

Tvpc« of Echoes fOI I l igh and 1.0\\' Lan~ua~l' Ch ildrcu

II igh Llng,llag,l' (;rollP I.ow l.ang,ua!!;e Croupnu.m x.l). mean x.l).

Immediale lepelil i,ms 01 sdt X.lj7 ILL; .. '.ll ·Ui:1;)..,.)Immcdi.ue IeI'd i t ions of olh«.'1"'" 11.00 I:'dJl :!I,:I:I IX.i'l

Dclavvd l'Ch()l· ... !I,:I:I :!O,!I(i 0,:,1 J.~~

Total appropriu n I!I.OO :!:I.:,(j :.!~.;)O IH,I:I

Total inuppropri.u. W.OIJ IH.:!I i.fii H.!IK

Tolal repetitious I'< c:dUJl" :!!I.I)I) :.!.",,71 :10,17 :!I.:\I

,.\11 uol sig,nific;n't 10 ,0;; Il'\ r-l.

Tablel

St rurrur« of Echo", 1'01 lIig,h and Low Language Ch iklrcu

l l ig h LanguagT (;roup 1.0\\' Lall:.tuagl' Croupmc.m S.I>. mean S.I>,

Exact lepel it ion- (j,IJIJ K.OIJ lti,OO I i,:I:\Rcd uced npct it iuus :1.11:1 Ii,il ;""H:; :,.!JI"Cungtucnt ' rcpvi itions !'.H~) 11.1i :!I,X:I Ii .:;:1Expalldl'd n-pctit ious 0.:1:\ O.X:! ~.:;:~ :\.11:\Iitigatl'd repetitious ox: :!.Ol o.i: O."

,.\11 d innl'nee's not sign ilicant to ,0:; Ie\ el.

DISCUSSION

Echolalia and Autism

Echolalia has been cited as the feature of language most typical ofchildren with autism (Shapiro et al., 1970) and perhaps the featureof language most typical of children with specific language disabil­ity, when occurring beyond the time expected (Darley, 1964). Our

622 Dennis P. Cantwell and Lorian Baker

data confirmed that echoing is prevalent in both of these types ofchildren and indicated that the two groups cannot be distinguishedby the total amount of echoing. The only significant differencesbetween the two groups were in the amount of inappropriate re­petitions of self and in the amount of delayed echoing. For both ofthese types of echoes, the incidence was higher in the autistic groupthan in the aphasic group. There were no significant differencesbetween the two groups in amount of exact, reduced, expanded,mitigated, or congruent echoes.

The fact that the most common echo structure found among theautistic children was the "congruent" echo gave some support tothe theories of Shapiro and his colleagues (1970). However, con­gruent echoing was also the structure of echo most common in thedysphasic group, hence this type of echo did not distinguish theautistic group. It is interesting to note that the echo types which dodistinguish the autistic and dysphasic children have to do with howthe echoes are used in speech, rather than with the actual form orstructure of the echoes. This finding is in agreement with otherfindings (Cantwell et al., 1978) that the social use of languageseems to be the most striking feature of the language of autisticchildren.

The fact that the different structures of echoes (exact, reduced,mitigated, expanded, and congruent) follow essentially the samepatterns of frequency for the two groups of children suggests thata similar underlying language deficit may be involved in both dis­orders.

Echolalia and Level of Language

The fact that neither the structure of echoes nor the use of echoescould distinguish the "high" and "low" language groups suggeststhat the study of echolalia may not be useful in establishing a prog­nosis for children with language disabilities such as developmentaldysphasia and autism.

The claims by Wolff and Chess (1965) and Fay and Butler (1968)that the amount of echoing is negatively correlated with linguisticability were not confirmed in the "high" and "low" language groupsexamined. Nor was there any confirmation for the claims of Lovaas(1966) and Risley and Wolf (1967) that the amount of echoing ispositively correlated with linguistic ability.

Imitations and Echoes in Autistic Children 623

Although mitigated echoing was higher in the "high" languagegroup and congruent echoing was higher in the "low" languagegroup, these trends were not statistically significant. There may. asShapiro et al. (1970) and Fay (1967) suggest, be a trend for in­creased mitigation and decreased congruence in echoes as lan­guage improves. But this trend is not sufficiently strong to be ofany prognostic value, at least for children of the age and languagelevels described here.

REFERENCES

BAKER, 1.., CANTWELL, D. P., Rurrrn. M., & BARTAK. I.. (1976), Language and autism. In:Auti"m, ed. E. R. Ritvo. New York: Spectrum Publications, pp. 121-150.

BARTAK, 1.., RUTTER, M., & Cox, A. (1975), A comparative study of infantile autism andspecific developmental receptive language disorder: I. Brit.]. Psychiat., 126: 127-145.

CANTWELL, D. P., BAKER, 1.., & Rur-n.a. M. (1978), A comparative study of infantile autismand specific developmental receptive language disorder: IV. (submitted for publication).

CHURCHILL, D. w. (1972), The relation of infantile autism and early childhood schizo­phrenia to developmental language disorders of childhood . .f. Aut. Child. Srhizo., 2: 182­197.

COHEN, D. .J., CAPARULO, B. K., & SHAYWITZ, B. A. (1976), Primary childhood aphasia andchildhood autism. This [oumal, 15:604-645.

CUNNINGHAM, M. (1968), A comparison of the language of psychotic and non psychoticchildren who are mentally retarded.]. Child Psvchol. P.rychiat., 9:229-244.

--- & DIXOS, C. (1961), A study of the language of an autistic child.]. Child Psschol.Psychiat., 2: 193-202.

DARLEY, F. I.. (1964), Diagnosis and Appraisal of Communicatiun Disorders, Englewood Cliffs,N.J.: Prentice-Hall.

m:HIRscH, K. (1967), Differential diagnosis between aphasic and schizophrenic language inchildren.]. SpePrh Hear. Disord., 32:3-10.

EKSTEIN, R. (1964), On the acquisition of speech in the autistic child. Reiss-Davis Clin. Bull.,I :6:i-80.

FAY, W. H. (1966), Childhood echolalia in delayed psychotic and neuropathologic speechpatterns. Folia Phoniatrira , 18:68-71.

--- (1967), Mitigated echolalia of children.]. Speech Hear. Res., 10:305-310.--- & BUTLER, B. V. (1968), Echolalia, IQ and the developmental dichotomy of speech

and language systems. J. Speech Hear. Res., 11:365-371.GRIFFITH, R. & RITvo, E. R. (1967), Echolalia. rs: Journal, 6: 184-193.HFRMFI.IN, B. & O'CONNOR, N. (1970), Psychological Experiments with Autistic Children, London:

Pergamon Press.HOWI.IN, P., CASTWEI.I., D. P., MARCHANT, R.. BERGER, M., & RUTrER, M. (1973), Analyzing

mothers' speech to young autistic children.]. Abnorm, Child Psvchol .. 1:317-339.KANNER, I.. (1946), Irrelevant and metaphorical language in early infantile autism. Amer. J.

Psvchiat., 10:242-246.LOVAAS, O. I. (1966), A program for the establishment of speech in psychotic children. In:

Earl» Childhood Auti"m, ed.,.J. K. Wing. London: Pergamon Press, pp. 115-144.MILLMAN, I. K. & CANTER, S. M. (1972), Language disturbances in normal and pathological

devclupment. Thi" Journal, 11:243-254.

624 Dennis P. Cantwell and Lorian Baker

RISLEY. T. & WOLF, M. (1967), Establishing functional speech in echolalic children. Behau.Res. ru«. 5:73-78.

RUTTER, M. (1974). The development of infantile autism. Psychol. Med., 4: 147-163.--- (;REENFlELl>, D., & LOCKH:R. L. (1967). A 5 to 1.1) year follow-up srudv of infantile

psychosis: II. Brit. J. Psyrhiat.. 113: 1183-1199.SAHLMANN. L. (1969), Autism or aphasia? Druelpm. Med. Child Nrurol., 11:443-447.SHAPIRO, T., ROBERTS, A., & FISH. B. (1970). Imitation and echoing in young schizophrenic

children. Thi., Journal, 9:548-567.SIMON, N. (1975), Echolalic speech in childhood autism. Arch. Gen. Psychiat., 32: 1439-1446,STENGt:J., E. (1947), A clinical and psychological study of echo-reactions. J. Mmt. Sci.,

18:598-612.WOLFF, S. & CHESS. S. (1965). An analysis of the language of fourteen schizophrenic chil­

dren. J. Child Psychol. Psychial., 6:29-41.