DR. JOANNE GERENSER: Let's talk now about specific language differences in autism spectrum disorders, in terms of areas that are very unique, oftentimes, to children on the spectrum and what those language deficits mean to individuals on the spectrum. So first, we're going to start with echolalia. And I'll spend a little bit of time talking about this because, for many people working with kids on the spectrum, this often challenges them for a while.

There are two different types of echolalia. There's immediate echolalia, which is very much what it sounds like. I say, hi, Johnny. How are you? And he says, hi, Johnny. How are you? So he basically repeats back, or she repeats back pretty much what I say.

The other echolalia is delayed echolalia. So this could be things like a child could say, do you want a cookie? when he wants a cookie, because somewhere days, weeks, hours earlier, somebody said, do you want a cookie? And a cookie miraculously appeared. Or it could be what some people refer to today as scripting, which is where they repeat back videos, TV shows, conversations that they've heard weeks, hours, in some cases, years ago. But the point is it's repetition after a significant delay.

Mitigated echolalia is not really-- the term isn't used much anymore. But it's where they're repeating back what they heard but not exactly. So they may delete words. They may use their own intonation. Restructured imitation is something that we used to use to describe mitigated echolalia. So it's very similar.

You'll hear terms-- "echoic behavior," for those that are much more in the behavioral world, the Skinnerian world, where it's echoing back. It's part of normal development. Typically developing children go through a stage of echoic behavior. And it's part of-- when you're working with kids with autism, you will teach echoics. You'll teach them to imitate speech.

Metaphoric speech is what we would use to talk about when they're actually seeming to use echolalia but contextually relevant or contextually appropriate. So the child who says, do you want a cookie? when he really wants a cookie is using his echolalia in a contextually relevant time.

Now echolalia is very much consistent with autism. But there are some other populations. Sometimes we see it in adult aphasics. Or post-epileptic, you might see it for a brief period of time.

You see it in typical development. I work with a very young staff. And many of them are having babies. And they work with kids with autism. So they're like hawks watching their children's development.

And there is a typical stage where typically developing babies will start to echo. And they're like, oh, my God, my child's echolalic. It's a normal stage. The problem is that for kids with autism, it persists. It becomes extremely predominant.

There's a lot of, still, unknowns. It's funny because I was updating this course. And I was trying to find very new literature on echolalia. And I didn't find very much, which I find interesting because it's still a very, very interfering, difficult thing for some of us to work with. And it doesn't appear to be an overly researched or overly interested area. And so there's still a lot of unanswered questions.

In some cases, we see that, as the echolalia decreases, the child's typical language or appropriate language increases, which would make sense. In some cases, the echolalia seems to be environmentally or situation specific. It only occurs at certain times and in certain situations, maybe if anxiety goes up or if the situation becomes too difficult.

Some have viewed echolalia as being a positive prognostic variable or indicator. And others see it as very interfering and not really a very positive thing. I look at it like, if you have something to work with, it's a lot easier than working with nothing and trying to establish it to begin with.

So again, some people view echolalia as positive and functional. And in the old days, the behavior analysts saw it as undesirable and problematic. Obviously, we kind of now know that the answer is in between. Some echolalia is very positive and prognostic of good things and functional. And some is interfering.

If you have a child who's engaging in repetitive TV talk all day long, you know what I'm talking about. That is not going to be helpful. And it's going to be significantly interfering with their ability to function.

So the answer is not one or the other. It's in the middle. And it's our job as good therapists to do an analysis and say, what's functional, and what's not? What should we build on? And what should we work to reduce or even eliminate?

The old theories were that echolalia was, in the psychoanalytic world, this expression of anger or hostility, which we kind of recognize is not really very relevant. It does appear, though, that some of the old work is relevant. So we do think that kids are echolalic because they lack other responses. We know that because as we teach more appropriate responses, the echolalia goes away.

But if we-- so for example, if I taught a child to answer his name, and I said, hi, Johnny, or I said, what's your name? and he said, Johnny, it's not echolalic. But if I said, who's the president? and he doesn't know the answer, he might revert back to, who's the president? So you can see that it's an absence of alternative responses.

It does also appear consistent with poor language comprehension. And we know that some echolalia is actually self-stimulatory. And a more complex way to say self-stimulatory is to say non-socially mediated automatic reinforced behavior. It's just another way of saying self-stimulatory. And it may have to do with cognitive processing limitations or some type of interactional variables or variables that are in the context.

Again, in typical development, we see it very briefly. It's referred to as echoic behavior. But by 28, 30, 34 months of age, it's gone. But in autism, it persists. It just keeps going.

Again, echolalia and echoic behavior look the same in early life. It does increase. A baby will be more echoic with novel stimuli. It will increase with novel situations.

But for typically developing children, it does not persist beyond two and a half, three years of age. And it does differ in quantity. You're not going to see anywhere near as much.

So now I want to just take a few minutes to talk about what we do, how we treat it. There are very different ways of looking at echolalia. So there are the functional approaches, which come more in the SCERTS or the Developmental, Individual Differences, the DIR. The developmental approaches would look at echolalia as much more functional.

Then, there's the behavioral treatments, which, again, doesn't eradicate or eliminate the idea that some echolalia is functional. But we just, as a behavioral approach, we wouldn't look at-- and I tend to be more in the behavioral world, which is why I use the term "we." We tend to look at echolalia as trying to identify the underlying function, and that not all of it will be functional.

So in terms of the functional approach, they're looking at-- again, I refer to Barry Prizant and Amy Wetherby and the people who developed SCERTS because they're kind of the people who have looked at it the most and published the most on it. Again, it's not all that new, the research. But it's what's available to us.

So Prizant and Duchan and Wetherby had looked at children. And they found in their research-- but again, they only looked at four children. But they found that of all of the echolalia that they looked at, only about 4% of it appeared nonfunctional.

And I'm not sure. I can see that as the case. But this is how they looked at it. And they developed this whole intervention based on the idea that a large proportion, almost 95%, of the echolalia that you see in children is functional.

And what they did when they were looking at immediate echolalia was they identified seven possible functional categories. So they, for example, thought it would be to indicate yes or no. Or that the child was rehearsing. I need to rehearse the words in my head.

Or I'm requesting. So I say, do you want a cookie? And the child says, do you want a cookie? But he really wants a cookie, so he's requesting it.

Declarative. Again, you can look at these. Taking turns, self-regulatory. And then, non-focused is what they would use for nonfunctional.

They basically talk about, well, how do you know what the function is? So they talk about looking at the gaze, looking at the body orientation, looking at the way the child says it, the volume or prosody. Is there an accompanying gesture?

So for example, if I say, do you want a cookie? and the child says, do you want a cookie? but reaches for the cookie, that might mean that it's, I want the cookie. It's either yes, no, or a request.

And what they talk about for their treatment-- first of all, they say never, never, never punish the child. Never ignore the child's behavior. And again, punishment is a very, very loosely used term in my humble opinion.

Punishment simply means that you're doing something to reduce the frequency of a behavior. Don't confuse punishment with aversives. I suspect that everybody, at some point or another, uses punishment. What's important to know is that you actually are using it, that you are actually doing-- so for example, if you say, no, you can't go to the playground, it's punishment. If you say, I'm going to put this behavior on extinction, that's punishment.

So there are times in a more behavioral approach that we would punish, if you want, echolalia behavior by, for example, removing a token. But we're not going to be using aversives. We're not-- so but in the functional approach, remember, they don't believe that much of echolalic behavior is self-stimulatory or non-useful.

And they really believe that you need to attend to and reinforce the echolalic behavior as functional, as attempts to communicate. And so their perspective is simplify your language to make their comprehension easier. And respond to all of their echolalia as functional, as having communicative intent.

Now behavioral approach is different. Their perspective is that, you know what, some echolalia might not be functional. And that nonfunctional echolalia might actually interfere with the development of new skills. It can certainly interfere with social interaction.

I mean, if you're three years old, and you're in a daycare center, and another child runs up and says, hey, my name's Johnny. What's your name? And the kid says, hey, my name's Johnny. What's your name? That's not going to win friends and influence people. Lots of times, kids are like, wow, what's wrong with this kid?

So there are reasons why we think echolalia may not be something overly functional in all cases. But to assume it's all nonfunctional, again, is throwing the baby out with the bath water. But what we want to do is we want to do a functional assessment, determine what's functional and what's really simply self-stimulatory.

And then, there are different ways in which we would go about treating it. One might be to teach functional equivalence. Give the child something more appropriate to say in a situation where we know that he's being echolalic because he doesn't really know what to say. Teach the child, for example, to say, I don't know. Rather than if I say, what's this? the child will say, what's this? But rather than doing that, we teach them to say, I don't know.

We would use what's called a stimulus fading. I would provide a verbal prompt and use a stimulus fading procedure. So for example, I might say, what's your name? Say, "Johnny." And I would say "Johnny" much louder. And then he would, hopefully, repeat "Johnny." And then I would fade the prompts.

Or we would use what's called a cues-pause-point, which is an approach developed by Richard Foxx and some of his colleagues, where you're actually providing the cue, pausing, and then pointing to the child. So the child learns to answer when he's pointed at so that there's a moment for him to process the prompt. And we work on eliminating the word "say" because, oftentimes, kids echo that.

Marjorie Charlop talked about actually using echolalia in learning, so this concept of mediated generalization where the child actually does use the echolalia as a rehearsal. And what she found was that she can actually use echolalia to enhance the skill acquisition, particularly in word learning and in object ID.

So here would be an example where the child is actually requesting. So if I were using a functional approach, the child says, do you want popcorn? And the-- I mean, the therapist says, do you want popcorn? The child says, do you want popcorn? while reaching for the popcorn. Me, as a functional therapist, I would say, "want popcorn," because what I want to do is give the child something more appropriate to echo that I can then reinforce. And again, if I were a behavior analyst working with a child with autism, and I said, do you want popcorn? and he clearly wants the popcorn, I would do the same thing. I would try and provide him with a more appropriate statement in the natural environment to echo that I would then reinforce.

Here's an example of, what's your address? The child doesn't know his address. I know he doesn't know his address. So I'm teaching him a functional equivalent.

So I'd say, what's your address? Say, "I don't know." And he says, "I don't know." And I reinforce it.

And then, I fade, say, I don't know, eventually. So I say, what's your address? And he says, I don't know. And I would use these various prompts in order to teach him in the same concept.

Now let's talk about delayed echolalia, because I think immediate echolalia is a little bit easier to understand, assess, and treat. Delayed echolalia becomes very complicated. Oftentimes, when I'm doing a consultation or I'm interacting with staff, they'll talk about the fact that when I say, well, what's your most difficult challenge? They bring up the child who's doing a lot of video rewind or scripting, as they like to call it.

And they have a really hard time figuring out how to reduce this. It's an extremely difficult behavior to treat, delayed echolalia. And again, we would look at delayed echolalia very much the way we would look at immediate echolalia, which it's a continuum. Some of it is non-communicative and nonfunctional. And some of it might be very communicative and very functional.

And very much like immediate echolalia, there's a range of treatments. So Prizant, Rydell, and Wetherby will look at most of it as being functional and communicative. Some would look at it as being self-stimulatory or automatically positively reinforced. And others would look at it as having multiple functions. Maybe it's actually escape-maintained. Maybe, I'm actually trying to work with Johnny, and he's trying to get rid of me.

I used to do this with my brother in the back of the car on long road trips. My brother would annoy me. And so then I would start the whole-- my brother would say, why don't you give me that? And I'd go, why don't you give me that.

And then, he'd go, stop mimicking me. And I'd say, stop mimicking me. And then he would leave me alone because I would annoy him so much.

So we have to be very smart about how we're looking at delayed echolalia and assessing the functions, because it might actually be escape-maintained. It might be attention-getting. It might be socially, automatically reinforced or self-stimulatory. And it might be functional or communicative.

Now it's interesting because Prizant and Rydell took their seven functions for immediate echolalia and turned it into 14 functions for delayed echolalia, which I think has to be pretty overwhelming if you're trying to assess the function. And again, you can read these. It ranges from rehearsal to calling somebody or practicing or directive. But I think it would be very complicated to actually distinguish these.

And again, what they expect that you do is that you carefully assess the functions, try and determine-- I'm just going to go back for second. Try and determine which of these it falls into. Look at whether it's self-initiated or respondent. Did it happen because they just picked it out of the natural environment? And their perspective is that if you look at it, it will give you some information about their emerging language skills. And their treatment is very much the way they would treat the immediate echolalia, respond functionally, assume that there's a communicative intent, try and respond to it based on one of the 14 functions that you identified and placed it into its category.

Now if we look at a functional assessment, which is what a behavior analyst would do, what you're going to end up finding is that it's very likely that some of it is self-stimulatory, some of it is escape or protest, and some of it might be functionally communicative. So here's a child-- every time I hold up the camera for some of my kids, as soon as they see the camera, they go, say cheese. That's delayed echolalia. But it's functionally relevant. It's not really communicatively appropriate. But it's functionally relevant.

Or here's a kid. I used to work with this kid. And when I would sit down to work with her, I can't say she loved working with me. She would go, say goodbye, Barney. And she was basically saying to me, I'm done. I want you to leave, because this video that she used to watch, at the end, they would all say, say goodbye, Barney. And then the video would end. So I would respond to that by giving her a more appropriate way to try and end the session.

But my functional assessment was very clear that these were very communicative delayed echolalic utterances. I would rather she say, say goodbye, Barney, than hit me or kick me, which was her alternative to end the session. So if I were just to ignore that, I would miss a real good opportunity to teach her to be more appropriate with her language.

Now if your functional assessment reveals that it's escape-maintained, then you want to do functional communication training. And so I want to teach the child, like the one where it says, say goodbye, Barney, to be more appropriate in her functional use of language.

If my functional assessment reveals automatic reinforcement, now I have my work cut out for me, because think about it. In automatically reinforced behavior, you, as a therapist, do not control the reinforcers. They're in the kid's head.

The child controls the reinforcers. He has access to them all the time. It's like he won the lottery and has $100 million in his head, which means he can buy whatever he wants. He doesn't need for you to give him anything. And that's what makes it so difficult because his reinforcers are available to him all the time. And he doesn't always have the ability to make good choices.

I have a young man, for example, that I've worked with for years. And he's now-- well, now he's in 10th grade. But when he was in eighth grade, I went in and did an evaluation because he was doing well in some of his classes but very poorly in others.

So for example, he was doing very poorly in his religion class. He was in a Catholic school. So when I talked to him-- he was very high functioning-- I said, what's up with religion? Like, why do you keep failing all of the quizzes and tests?

And he says, Joanne, truthfully, as soon as the teacher starts talking, I start thinking about World Federation Wrestling. And all of a sudden, it's the end of the class, and she hands me the quiz. And I don't know what she talked about in the lecture. And I said, but don't you understand that if you're thinking about World Federation Wrestling, you can't be thinking about what she's saying?

And he goes, I know. But I'm not interested in what she's saying. And I'm interested in World Federation Wrestling. So his ability at that moment in time to compete, he just can't do it.

So what we had to do with him was literally, he wore a JTECH device, which was a device that we could actually trigger to vibrate. And you could actually see when he starts drifting off. He's not looking at the teacher. We would vibrate his device. And that was his, I have to pay attention.

So we needed to develop a prompting system to force him to attend to the information because, for him, he could not-- the self-stimulatory motivation was far greater at that moment than paying attention to his religious instruction. And so treatment becomes unclear because the reinforcer is unclear. We don't know what to provide reinforcement.

So again, I'm just going to briefly go over some strategies. But my recommendation for those of you working with kids on the spectrum, if you have a child that's engaging in high rates of delayed echolalia or self-stimulatory, repetitive use of TV talk, you need a behavior analyst to work with you because it is very complicated. But if you don't address it, they're really going to have a time learning information. And it's going to interfere with their ability to develop social relationships. So it really does need to be treated.

First thing is you want to try and identify their preference for stimuli, because what we're going to do-- when we treat automatically self-reinforced behavior, we want to compete with their sensory consequences. We want to do a sensory matching if possible. If you're really interested in this, you can read some of the work by Cathleen Piazza, because she talks a lot about non-contingent access to the same information or the same sensory stimuli. So we're reducing the self-stimulatory behavior. I'll give you a very simple example.

If you have a child that engages in, let's say, finger play because they like the way their fingers feel together, you might actually block that finger play by having them wear a glove or gloves. And again, I wouldn't do this without really working with somebody. But then, when they're not engaging in this-- and they shouldn't want to engage in it because they're not getting the self-stimulatory behavior. When they're not engaging in it, you give them access to something that feels just as good.

Now with self-stimulatory talk, it's far more complicated, because what is it that they're getting? What is it that they like? Do they like the sound of it? Do they like the content? Do they like just talking?

And so what we would do would be to try and do a preference assessment to determine which of these three areas is primarily their motivation. Do they just really like-- so if, for example, you provide them with non-contingent access to their preferred books and videos, but you don't let them have the volume, then it might be the content. Meaning if you see their self-stimulatory behavior go down, they might just like the content. And they're bringing that content back every time they talk. But if you see high rates of self-stimulatory behavior while they're watching their videos, it's probably not the content that they're enjoying but actually just repeating the information.

And so what you're going to try and do is provide them with a sensory match and redirect all their echolalic behavior, redirect all their self-stimulatory behavior. The other thing, obviously, is the more structure you provide a child, the less likely they're going to engage in these self-stimulatory behaviors because they're too busy. And so that's why when we start with young children, we're often working one-to-one because it's very difficult to work with kids who engage in high rates of self-stimulatory behavior outside of a one-to-one.

The other thing I tell parents all the time now is delayed echolalia is not in the DSM. If you go back and you look, it's not part of the diagnostic category. But the reason, I think, kids do it is because this desire to repeat behaviors is-- and so years ago, 25, 30, 35, 20 years ago, when I started working with kids with autism, they weren't rewinding videos because they didn't have the ability. Instead, they were watching commercials over and over. So they would often repeat commercial talk.

Today, it's videos because they find a section in the video that they really like, and they rewind it, and they rewind it, and they rewind it. So I tell parents all the time, if you can avoid letting your kids discover the DVR, you're going to be ahead of the game. Let them watch live television because at least they're not going to get too caught up in, I'm going to rewind this, I'm going to rewind this, I'm going to rewind this.

Last thing, I want to talk a little bit about deictic terms. Again, this is more of a speech pathology term. But it's more than just the pronoun reversals. Deictic terms, "I," "you," "this," "that," "here," "there," are terms that change depending on who the speaker is and who the listener is.

So if I say, get me this right here-- and I'm talking about the computer. I say, get me this, and you're on the other side of the room. You would say, what? You want me to get you that?

Imagine how complicated that is for a child with autism. Is it a this? Or is it a that? Are you here? Or are you there? And in order for you to really understand deictic terms, you have to be able to understand perspectives. You have to be able to know-- and this is very difficult for kids with autism.

And so I think this whole area of theory of mind and perspective taking are the primary underlying variables that we're going to have to think about when we start thinking about teaching deictic terms. I did a consult in one of my speech departments just about a week ago. And the first thing they said to me was we've got this real problem with teaching "I," "you," "me," "you."

And I'm like, oh, my God, I remember those days when I used to work with kids with autism. It's really hard because you say, touch my shirt. And they touch their own shirt. No, no, that's your shirt. I want you to touch my shirt. So you can see how really difficult it is in order to teach that. And so we may want to think about teaching the underlying variables of perspective taking and theory of mind.

The other area of-- oops, I'm going backwards. The other area that's difficult is this whole issue of prosody. So what prosody is is suprasegmental aspects of speech-- intonation, volume. So how I say, wow, that was really cool, is an example of intonation or prosody.

And it's also a very under-researched area. Yet it was discussed by Kanner back in 1943. So it's been part of the autism spectrum characteristics from the beginning. And yet there's not enough written about it to help us as clinicians to really understand it.

And there's different aspects of intonation. There's what we call affective stress. How does the person feel? Like, if I were to say, oh, that's, what he did. That would demonstrate sadness.

There's stress. I want that cookie. Or there's syllabic. That changes the meaning of a word. Like-- I can never think of one. But if you put the intonation on the first syllable, it means one thing versus the second syllable.

Take the word "really," for example. If I say, "Really?" that means, how cool is that? If I say, "Really?" it means I don't believe you. "Really?" I'm shocked. "Really?" I'm delighted. "Really?" I'm telling you the truth.

If you take the time-- take a second, and actually try that out. I said the same word, but I just changed the way I said it. People with autism would think that meant the same thing every time I said it. Yet I changed the meaning completely. It's very difficult to function in the world if you miss what people are saying because of the way we're saying it.

We often can mislead people if we're using intonation and we don't understand it. Or we miss the entire meaning of the utterance. It's very difficult for people who have high-functioning autism because we don't necessarily give them a break. Remember, if you're working with people with high-functioning autism or Asperger's, some of them might not even be diagnosed. These are individuals who are very bright, have large vocabularies, but often respond in ways that puzzle us. Like, why would he say that? Because he missed the intonation, the prosody or maybe the gesture that goes along with it.

The other piece is their use of intonation. Many of them may have flat intonation, may sound a little bit more monotone, if you listen to some individuals. And one of the things we know is that we judge people by the way they speak.

My board chair is from India. I have a really difficult time understanding him when we're on the phone because I'm not getting all the other information. I'm just hearing-- and the reason why is because the language he speaks-- he's a very good English speaker. He's been in this country for years and years and years and years. But intonation in Indian languages is different. It's opposite of intonation.

So he tends to use the intonation of his native language on English. So it makes the words often very difficult to understand. So we may judge individuals on the spectrum as being less competent because they lack the appropriate intonation. If you take a look at the video that's at the bottom, you'll hear two individuals speaking.

And you'll really see what I mean by the differences in prosody. One young individual is much more monotone. Or he's making an effort to use prosody because he was taught how to use it. But for us, it comes naturally. No one taught you when to put intonation into an utterance. You just did it.

So take the quiz at the end of this lecture. And hopefully, you did well. And hopefully, you did well on all the quizzes. And don't forget to participate in the discussion. And I hope you enjoyed the lecture.