Echolalia: Paying attention to a forgotten clinical feature of primary progressive aphasia

Frequency and characteristics of echoes and self-repetitions in minimally verbal and verbally fluent autistic individuals

Background and aims

Nongenerative speech is the rote repetition of words or phrases heard from others or oneself. The most common manifestations of nongenerative speech are immediate and delayed echolalia, which are a well-attested clinical feature and a salient aspect of atypical language use in autism. However, there are no current estimates of the frequency of nongenerative speech, and the individual characteristics associated with nongenerative speech use in individuals across the autistic spectrum are poorly understood. In this study, we aim to measure and characterize spontaneous and nongenerative speech use in minimally verbal and verbally fluent autistic children and adolescents.

Methods

Participants were 50 minimally verbal and 50 verbally fluent autistic individuals aged 6 to 21 years. Spontaneous and nongenerative speech samples were derived from SALT transcripts of ADOS-2 assessments. Participants' intelligible speech utterances were categorized as spontaneous or nongenerative. Spontaneous versus nongenerative utterances were compared between language subgroups on frequency of use and linguistic structure. Associations between nongenerative speech use and a series of individual characteristics (ADOS-2 subscale scores, nonverbal IQ, receptive vocabulary, and chronological age) were investigated over the whole sample and for each language subgroup independently.

Results

Almost all participants produced some nongenerative speech. Minimally verbal individuals produced significantly more nongenerative than spontaneous utterances, and more nongenerative utterances compared to verbally fluent individuals. Verbally fluent individuals produced limited rates of nongenerative utterances, in comparison to their much higher rates of spontaneous utterances. Across the sample, nongenerative utterance rates were associated with nonverbal IQ and receptive vocabulary, but not separately for the two language subgroups. In verbally fluent individuals, only age was significantly inversely associated with nongenerative speech use such that older individuals produced fewer nongenerative utterances. In minimally verbal individuals, there were no associations between any of the individual characteristics and nongenerative speech use. In terms of linguistic structure, the lexical diversity of nongenerative and spontaneous utterances of both language subgroups was comparable. Morphosyntactic complexity was higher for spontaneous compared to nongenerative utterances in verbally fluent individuals, while no differences emerged between the two utterance types in minimally verbal individuals.

Conclusions

Nongenerative speech presents differently in minimally verbal and verbally fluent autistic individuals. Although present in verbally fluent individuals, nongenerative speech appears to be a major feature of spoken language in minimally verbal children and adolescents.

Implications

Our results advocate for more research on the expressive language profiles of autistic children and adolescents who remain minimally verbal and for further investigations of nongenerative speech, which is usually excluded from language samples. Given its prevalence in the spoken language of minimally verbal individuals, nongenerative speech could be used as a way to engage in and maintain communication with this subgroup of autistic individuals.

Mapping the parent experience of echolalia in autism spectrum disorder onto a conceptual taxonomy

PURPOSE

Echolalia, the repetition of previously heard speech, is prevalent in a variety of neurologic and psychiatric disorders. Within the context of echolalia in autism spectrum disorder (ASD), research and intervention historically assume a clinical standpoint with two opposing paradigms: behaviourism and developmentalism. The literature is largely silent on how those other than researchers and clinicians understand echolalia. This study examined how parents experience echolalia through their children with ASD. The aim of the study was to ascertain if the parental perception of echolalia in ASD aligns with, or offers alternative perspectives to, current clinically-orientated views.

METHOD

We employed online semi-structured interviews to document the experiences of 126 parents, reflecting on their children with ASD aged 3 to 34 years of age, to determine if the parent experience could be mapped onto existing clinical frameworks, or if they might offer new perspectives. We used hermeneutic phenomenological data analysis in an abductive framework.

RESULT

Echolalia has predominantly been represented in literature through the perspectives of behaviourism or developmentalism. We found however, that echolalia is a phenomenon that is experienced by parents in a variety of different ways to that of the current clinically-orientated understandings. Such new ways of understanding echolalia that emerged from our analysis include one understanding which is dependent upon how echolalia is heard, and one in which parents are "waiting for echolalia to evolve."

CONCLUSION

The traditional dichotomous clinical positions do not resonate with all parents, and reliance on these traditional perspectives alone may impact effective engagement with parents and the success of interventions and support strategies. Our findings have implications for future research, the education of clinicians and educators, and the design of support and intervention for those who have echolalia.

Echolalia from a transdiagnostic perspective

Background & aims

Echolalia, the repetition of one's or others' utterances, is a behavior present in typical development, autism spectrum disorder, aphasias, Tourette's, and other clinical groups. Despite the broad range of conditions in which echolalia can occur, it is considered primarily through a disorder-specific lens, which limits a full understanding of the behavior.

Method

Empirical and review papers on echolalia across disciplines and etiologies were considered for this narrative review. Literatures were condensed into three primary sections, including echolalia presentations, neural mechanisms, and treatment approaches.

Main contribution

Echolalia, commonly observed in autism and other developmental conditions, is assessed, observed, and treated in a siloed fashion, which reduces our collective knowledge of this communication difference. Echolalia should be considered as a developmental, transdiagnostic, and communicative phenomenon. Echolalia is commonly considered as a communicative behavior, but little is known about its neural etiologies or efficacious treatments.

Conclusions

This review is the first to synthesize echolalia from a transdiagnostic perspective, which allows for the direct comparisons across and within clinical groups to inform assessment, treatment, conceptualization, and research recommendations.

Implications

Considering echolalia transdiagnostically highlights the lack of consensus on operationalization and measurement across and within disorders. Clinical and research future directions need to prioritize consistent definitions of echolalia, which can be used to derive accurate prevalence estimates. Echolalia should be considered as a communication strategy, used similarly across developmental and clinical groups, with recommended strategies of shaping to increase its effectiveness.

Case Report: Barely Able to Speak, Can't Stop Echoing: Echolalic Dynamic Aphasia in Progressive Supranuclear Palsy

The diagnostic criteria for progressive supranuclear palsy (PSP) incorporate two speech-language disturbances (SLDs), non-fluent/agrammatic primary progressive aphasia and progressive apraxia of speech, but overlook the inclusion of other SLDs, including dynamic aphasia (DA). Thus, there is a need to reappraise the broad spectrum of SLDs in PSP to include other presenting phenotypes. Here we report findings from the study of two elderly patients with PSP presenting with DA and irrepressible echolalia. Both patients had markedly impoverished verbal production, but their performance in other tasks (repetition and naming) and auditory comprehension were preserved or only mildly impaired. Experimental tests of DA revealed impaired word and sentence generation in response to verbal and non-verbal stimuli. Additional language and cognitive testing revealed different types of echolalia (mitigated, automatic, and echoing approval) as well as impaired inhibitory control and social cognition (mentalizing). Both patients had negative neuropsychiatric alterations (i.e., apathy, aspontaneity, and indifference/emotional flatness). Brain magnetic resonance imaging in both patients showed atrophy of the midbrain tegmentum and superior medial frontal cortex suggestive of PSP, yet further evaluation of the neural correlates using multimodal neuroimaging and neuropathological data was not performed. However, based on the already known neural basis of DA and echolalia in PSP and stroke, we suggest that, in the present cases, neurodegeneration in the midbrain tegmentum, superior medial frontal lobe, and caudate nucleus was responsible for DA and that decreased activity in these regions may play a permissive role for eliciting verbal echoing via disinhibition of the perisylvian speech-language network.