Echolalia

Etiology

Echolalia is a salient speech disturbance characteristically described in children with autism spectrum disorder (ASD).[1] It was first described in 1943 by Kanner in eleven children with autism.[2][3][4] Apart from autism, echolalia has also been described in several other disorders.[5][6][7][8][9][10][11][12][13][14]

• Aphasia
• Autoimmune disorders
• Closed head injury
• Congenital blindness
• Cortico-basal degeneration
• Delirium
• Dementia
• Encephalitis
• Primary familial brain calcification
• Gilles de la Tourette syndrome
• Intellectual disability
• Language delay
• Latah reaction/phenomenon
• Pick disease
• Frontotemporal dementia
• Progressive supranuclear palsy
• Schizophrenia
• Stroke
• Confusional states
• Postepileptic status

Epidemiology

The prevalence of echolalia is unclear as it is a heterogeneous symptom seen in various pathological states. As mentioned above, echolalia can be a normal part of language development in toddlers. Approximately 75% of children with ASD exhibit echolalia.[15]

Pathophysiology

The exact etiopathogenesis of echolalia is not entirely understood. Speech imitation and repetition is a part of normal language development in toddlers. Echophenomena improves over the first two years of life. Self-regulation in speech and language develops around the age of 3 years.[16]

Pathological echolalia persists beyond the age of 3 years. Some researchers have postulated a “broken mirror neuron system” and “wealth of stimulus” hypothesis to explain the imitative language behaviors seen in ASD.[17] Dopaminergic dysregulation has also been hypothesized as a neurobiological mechanism leading to echo phenomena. Echolalia is possibly related to dysfunction of the frontal lobe. Echolalia has been reported in lesions of the left medial frontal lobe and supplemental motor areas.[18][19]

History and Physical

Patients should undergo a detailed history and evaluation. Echolalia has several subtypes. There are two major types of echolalia:[20][21]

• Immediate echolalia: This refers to the repetition of speech immediately after the utterance.
• Delayed echolalia: This refers to the repetition of speech sometime after the utterance.

Historically, echolalia was described as a meaningless speech disorder. However, recent literature suggests echolalia may have a communicative function. Both immediate and delayed echolalia can be communicative (repetition with an apparent meaningful or communicative purpose) or semi-communicative (repetition with no clear communicative purpose).

Echolalia can also be classified based on the features of speech repetition.[1]

• Unmitigated echolalia refers to verbatim or exact repetition of speech.
• Mitigated echolalia refers to the repetition of speech in altered form.

As the language and comprehension improve in children with autism, more mitigated echolalia may be observed. The child learns to make a change in the speech or intonation instead of repeating verbatim. Mitigated echolalia may have a higher functional category.

Echolalia can also be classified based on the nature of the stimulus. The speech repetition can be person-directed or non-person directed.

• Ambient echolalia refers to the repetition of words or sentences from the environment (e.g., television, bike, car, fan).[11]
• Echoing approval refers to the situations where patients echo, in positive or negative intonations, replying to questions instead of repeating the whole or part of sentences. Sometimes they may respond to questions that were not addressed to them.[22]

Evaluation

Echolalia, a form of imitation, is a useful component of language acquisition. Echolalia is common in toddlers as they learn to speak. Echolalia becomes less and less prominent as language skills develop. A disorder may be suspected if automatic speech imitation persists or reemerges after the age of three.

Marge Blanc, a clinical speech-language pathologist, proposed the six stages of natural language development for childhood autism.[16]

1. Stage 1: Unmitigated echolalia or the use of whole language gestalts. For example, “Let’s get out of here,” “Want some more?”, “Are you okay?”
2. Stage 2: Mitigated echolalia or altering the gestalts into syntactic units and recombining the units. For example, “Want out of here.”
3. Stage 3: Isolation of single words, mix, and match of single words, generating two-word phrases. For example, “Get more,” “Want out.”
4. Stage 4: Generation of a first simple sentence. For example, “I get out.”
5. Stage 5: Generation of complex sentences with grammar. For example, “I want to get out.”
6. Stage 6: Generation of more complex sentences with advanced grammar. For example, “How long do you want to play outside?”

Several tools have been studied for quantifying the repeats in children with echolalia.[15][23]

Treatment / Management

Treatment of echolalia depends on the etiology. The management of echolalia related to autism requires a multidisciplinary team, including parents, neurodevelopmental specialists, therapists, psychologists, and special educators. The key to managing echolalia in children is to know the reason for speech repetition, the meaning behind the repetition, and responding in a manner to help the child learn to communicate. Observing, listening, and waiting during the child’s interaction and talking helps gather messages behind the echolalic speech. While interpreting the child’s echolalia, the ideal response is to “say it exactly how the child would if he or she could.”

A speech-language pathologist plays a pivotal role in treating echolalia in childhood autism. Applied behavior analytic interventions for echolalia in ASD include cues-pause-point training, script training, visual cues, gestalt learning, verbal modeling, self-monitoring training, differential reinforcement of lower rates of behavior, and positive reinforcement for appropriate responses.[16][24][25] Similarly, echolalia related to aphasia include interventions like constraint-induced aphasia therapy. Music therapy has also been incorporated into the assessment and treatment of echolalia.

Pharmacotherapy may be indicated in older children, where the echolalia is triggered by stress and anxiety. Selective-serotonin reuptake inhibitors have been used in echolalia secondary to stroke.[26]

Differential Diagnosis

Echolalia is one of the most common echo phenomena and is a non-voluntary, automatic, and effortless pervasive behavior. Other examples of echo phenomena include echopraxia (the involuntary repetition of movements), echolalioplasia (repetitive sign language), echomimia (imitative facial actions), echographia (written repetition of speech), coprolalia (automatic repetition of obscene and socially inappropriate words), klazomania (compulsive shouting), and palilia (repetition of one’s own words).[27] Echolalia is a heterogeneous symptom seen in various pathological states which must be differentiated.

• Autism spectrum disorder: Recent studies have shown that echolalia is a coping mechanism for children with autism to communicate when they cannot produce spontaneous speech. Prizant et al. have reported echolalia as evidence of "gestalt" processing in children with ASD to acquire language.[18][21] Autism spectrum disorders are a group of pervasive neurodevelopmental disorders characterized by impaired social functioning, communication, and restricted, repetitive behaviors. It usually manifests before three years of age, and there is a wide variation in severity of clinical presentation.
• Gilles de la Tourette syndrome: Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder characterized by vocal and motor tics. Echolalia, coprolalia, and echopraxia are some features of TS. Motor tics present in TS include jerks, twitches, and tics. The disorder has a wide range of severity and is associated with other behavioral and psychiatric disorders. TS is often associated with attention deficit hyperactivity disorder and obsessive-compulsive disorder. Tourette syndrome has a waxing and waning course. Cognitive-behavioral therapy is the first-line treatment for TS. Pharmacotherapy is used if behavioral therapy alone does not work. Medications like clonidine, risperidone, fluoxetine have been used.[28]
• Stroke: In adult patients, echolalia after stroke is seen in transcortical motor aphasia. Positron emission tomography scans can show increased uptake in frontal, temporal, and parietal lobes.

Prognosis

Many years ago, echolalia was regarded as negative, meaningless, stereotypic behavior. However, several researchers have recently studied the communicative function of echolalia. Echolalia is an adaptive response of patients to their language learning difficulties. It is considered a positive prognostic sign for potential future language growth. Some of the functional categories of echolalia include turn-taking, declarative, requesting, self-regulation, rehearsal, situation association, calling, affirmation, requesting, verbal completion, interactive labeling, and directives. Echolalia should be taken advantage of to facilitate language acquisition and generalization.[29]

Complications

Echolalia can impair social interactions and learning. It can be a barrier to forming and maintaining social relationships.

Echolalia can lead to multiple complications in children with ASD.[30]

• Aggression, anxiety, and depression
• Caregiver stress and family conflict
• Learning difficulty and poor school performance
• Peer victimization
• School absenteeism
• Social isolation because of bullying and non-acceptance