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. Author manuscript; available in PMC: 2026 Mar 1.
Published in final edited form as: Autism Res. 2025 Jan 7;18(3):528–540. doi: 10.1002/aur.3298

Reports of Echolalia and Related Behaviors in Autism From Parents, Teachers, and Clinicians: Evidence From the Simon Simplex Collection

Margaret L McAllister 1, Tyler McFayden 2, Clare Harrop 1,3
PMCID: PMC11929604  NIHMSID: NIHMS2046095  PMID: 39764573

Abstract

Echolalia, the immediate or delayed repetition of speech, is a core diagnostic criterion for autism spectrum disorder. It has been studied for over 50 years and is well-described; however, no consensus on prevalence estimates exists for echolalia’s occurrence in autistic youth. The current study sought to (1) describe endorsement of echolalia-related items using parent-, teacher-, and clinician-reports in a well-validated sample of autistic youth and (2) characterize relations between echolalia and other key factors, including age, language ability, and repetitive behaviors. Participants (n = 2555, 4–17 years, 13% female, 78% White) from the Simon Simplex Collection provided data from multi-informant ratings of echolalia and related behaviors. Nine parent-, clinician-, and teacher-report items were extracted from five measures to broadly capture echolalia through a composite score. Results indicated that as many as 90% of autistic individuals express echolalia at some point in their development. Hierarchical linear regression was conducted to evaluate relations between echolalia, verbal ability, and repetitive behaviors, controlling for age, sex, and autism severity. Results indicated the main effects of verbal ability and repetitive behaviors. A significant interaction qualified this main effect wherein age was negatively associated with echolalia for children with higher verbal ability, but not those with lower verbal ability, suggesting that adolescents with less generative speech may leverage echolalia as a communicative strategy. Echolalia was positively associated with repetitive behaviors across development. These associations support a dualistic interpretation of echolalia as functional communication and as a form of repetitive behavior. Future research is needed to understand the developmental trajectories of echolalia and develop affirming support for this autistic behavior.

Keywords: autism spectrum disorder, communication, echolalia, language, stereotyped behavior

1 |. Introduction

Echolalia, the immediate or delayed repetition of speech, has consistently been a core diagnostic criterion for autism spectrum disorder (hereafter, autism; American Psychiatric Association 1980, 1994, 2013). Echolalia was initially described by Leo Kanner, alongside other aspects of language, and is now classified as a repetitive behavior for diagnostic purposes (Rosen, Lord, and Volkmar 2021). Repetition of speech is not unique to autism, but occurs during early language development for most toddlers and is theorized to facilitate the acquisition of new phonemes (Boksa and Kominek 2022). In contrast, echolalic expression in autism often extends into later childhood and even adulthood and is associated with cognitive, communicative, and self-regulative functions (Marom, Gilboa, and Bodner 2023; Stiegler 2015). Echolalia is very common among autistic individuals and is expressed across communication modalities, including autistic Deaf signers (Shield, Cooley, and Meier 2017), augmentative and alternative communication (AAC) users (Chavers et al. 2021), and speaking individuals. Despite widespread acknowledgement of echolalia, current prevalence estimates in autistic youth are based on extremely small samples and vary widely from 25% to 91% (Sutherland et al. 2024). Because of this variability many researchers still reference prevalence estimates that predate current diagnostic criteria, many of which rely on citations from the 1960s (McFayden, Kennison, and Bowers 2022; Rutter, Greenfeld, and Lockyer 1967; Sutherland et al. 2024; Wing 1971). Therefore, this study seeks to characterize echolalia in a large sample of autistic youth ages 4–17 using a combination of parent-, teacher-, and clinicians-reported data.

An additional complication to understanding echolalia in autism is that definitions and conceptualizations vary widely over time and across disciplines (McFayden, Kennison, and Bowers 2022). Some definitions stipulate that repetition must be socially inappropriate, awkward, noncommunicative, or automatic to fit the term (Boksa and Kominek 2022; Xie, Pascual, and Oakley 2023), whereas other definitions identify communication as a function of echolalia (Cohn et al. 2022; Marom, Gilboa, and Bodner 2018; Pruccoli et al. 2021; Sterponi, de Kirby, and Shankey 2015). Definitions are further clouded by other terms such as repetitive speech, vocal imitation, and verbal stereotypy that may overlap with echolalia (Blackburn et al. 2023) depending on the context and operationalization of each (Cook and Rapp 2020; Foxx et al. 2004; Neely et al. 2016). In fact, since many studies of echolalia feature behavioral coding of repetitive speech, there are almost as many distinct operational definitions of echolalia as there are studies. Some studies include self-repetitions under echolalia (Gladfelter and VanZuiden 2020) while others categorize them separately (van Santen, Sproat, and Hill 2013). Delayed echolalia has been defined both as repetitions with a source outside of the recording period (Xie, Pascual, and Oakley 2023) and as a repetition occurring after two conversational turns (Gladfelter and VanZuiden 2020; van Santen, Sproat, and Hill 2013). Studies vary greatly on the specifics of echolalia coding from including nonword sounds (Xie, Pascual, and Oakley 2023) to excluding single-word repetitions (Marom, Gilboa, and Bodner 2018). Songs and sounds are also controversial in echolalia coding (Gladfelter and VanZuiden 2020; Maes, La Valle, and Tager-Flusberg 2024). Further, studies vary in their methodology for capturing echolalia, ranging from semiautomated transcript coding (Fusaroli et al. 2023; Gladfelter and VanZuiden 2020) to in-depth analysis of prosody and tone from audio or video recordings (Marom, Gilboa, and Bodner 2018; Sterponi and Shankey 2014; Xu et al. 2024). To add to this complexity, echolalia has been conceptualized by researchers as both a repetitive behavior (Neely et al. 2016) and as social communication (Stiegler 2015). Qualitative research supports both of these views by indicating that parents and autistic individuals recognize echolalia as both an automatic and enjoyable repetitive behavior and also a socially directed communication strategy (Cohn, McVilly, and Harrison 2023; Marom, Gilboa, and Bodner 2023).

An unfortunate outcome of variability in echolalia definitions is similar variability in associations between echolalia and factors such as sex, age, developmental quotient (DQ), nonverbal intellectual quotient (NVIQ), and metrics of verbal ability. Although one study reported sex differences in the type of echoes expressed by children (Wardyn and Galkowski 2002), these have not been consistently found (Bishop, Richler, and Lord 2006; van Santen, Sproat, and Hill 2013). There is more clarity in associations between echolalia, age, and NVIQ with two studies reporting that older verbal children and those with high NVIQ echoed less frequently (Bishop, Richler, and Lord 2006; Maes, La Valle, and Tager-Flusberg 2024); however, this association was not consistently found across all studies (Gladfelter and VanZuiden 2020; van Santen, Sproat, and Hill 2013). Additional conflicting evidence exists for the relationship between DQ and echolalia. One study reported less echolalia expressed by children with low DQ (Cervantes et al. 2014) while another reported the reverse association, higher DQ with less echolalia (Wardyn and Galkowski 2002). Associations between language ability and echolalia are similarly unclear, with both negative associations (Maes, La Valle, and Tager-Flusberg 2024; Roberts 1989; van Santen, Sproat, and Hill 2013) and no associations (Gladfelter and VanZuiden 2020) reported by different studies. With regard to echolalia’s relationship to social skills and autism severity, conflicting evidence continues (Gladfelter and VanZuiden 2020; Grossi et al. 2013; Maes, La Valle, and Tager-Flusberg 2024; van Santen, Sproat, and Hill 2013).

Taken together, the lack of consistent associations between echolalia, autism characteristics, and demographic and developmental variables highlights the need for more consistent research approaches and definitions of echolalia. As indicated by Sutherland et al. (2024), the lack of consistent prevalence estimates of echolalia is a “longstanding and entrenched problem” that needs addressing to better inform support for autistic people. Across the forementioned studies, echolalia has been captured using parent report (Bishop, Richler, and Lord 2006) and behavioral coding (Gladfelter and VanZuiden 2020; Marom, Gilboa, and Bodner 2018; Shield, Cooley, and Meier 2017; Sterponi and Shankey 2014; van Santen, Sproat, and Hill 2013), with variations in the context, communication partner, and structure of the task (Grossi et al. 2013; Maes, La Valle, and Tager-Flusberg 2024; Marom, Gilboa, and Bodner 2018; Xie, Pascual, and Oakley 2023)—factors known to impact the presence and type of echolalia (Bernard-Opitz et al. 2000; Cohn et al. 2022; Pruccoli et al. 2021; Sterponi, de Kirby, and Shankey 2015). Therefore, it is likely that this variability in methods contributes to contradictory findings.

Currently, there is no gold-standard assessment or standardized approach to measuring echolalia. However, repetitive speech is captured on individual items across several standardized assessments and questionnaires. The goal of this study is to leverage information collected on existing measures and amalgamate across reporters to broadly describe the prevalence of echolalia in a large, well-characterized dataset and characterize the associations between echolalia, demographic factors, autism severity, language ability, and repetitive behaviors.

The current study investigates two aims:

  1. To describe the endorsement rates of parent-, teacher-, and clinician-reported items that could indicate or overlap with echolalia in a well-validated sample of autistic youth from the Simons Simplex Collection (SSC; Fischbach and Lord 2010), and;

  2. To determine the amount of variance in the composite echolalia and related behaviors score accounted for by child factors: sex, age, autism severity, language, and repetitive behaviors.

2 |. Method

2.1 |. Sample

SSC provided data for this analysis. The SSC is a large, multisite study that included individuals aged 4–17 years who met DSM-IV criteria for an autism diagnosis based on the Autism Diagnostic Observation Schedule (ADOS; Lord et al. 2002) and Autism Diagnostic Interview-Revised (ADI-R; Rutter, Le Couteur, and Lord 2003). Participants did not have first-, second-, or third-degree relatives with an ASD diagnosis. Individuals were included in the SCC dataset if they had a nonverbal mental age greater than 18 months, and no severe neurologic deficits or sensory deficits, such as hearing loss or visual impairments. SSC data collection included extensive behavioral assessment, parent- and teacher-report of behavior, and genetic testing (see Fischbach and Lord (2010) for further details). All procedures of the study were reviewed and approved by the institutional review board of the Cleveland Clinic and informed consent was obtained at each site.

2.2 |. Participants

Data were retrieved for SSC participants with complete measures of interest and demographic data central to this research question (N = 2664). Since analyses focused on echolalic expression, participants missing five or more of the nine items examined to assess echolalia (see Figure 2 and Echolalia Quantification) were excluded (n = 109). The resulting analytic sample included 2555 autistic youth (n = 343 females, n = 2212 males), aged 4–17 years (M = 8.8 years, SD = 3.4). The sample was predominantly White (78%), and non-Hispanic (88%), with household income above the national median of $50,046 (82%; Noss 2011), and collegiate maternal education (90%). Demographic information for all retrieved participants and the analytic sample is reported in Table 1.

FIGURE 2 |.

FIGURE 2 |

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Distribution of composite echolalia and related behaviors scores and distribution of complete items included in scores. Left panel shows the moderately normal distribution of composite echolalia and related behaviors scores generated by averaging the scaled responses of parent-, teacher-, and clinician-report. Right panel shows the distribution of the number of items available for score calculation. Only participants for whom five or more items were available were included in the sample.

TABLE 1 |.

Participant demographics and echolalia and related behaviors score variability.

Subsample analyzed (n = 2555)
Total sample (N = 2664)
N (%)		 Composite score
n (%) M (SD) Stat p
Sex t = −1.5 = 0.14
 Male 2302 (86%) 2212 (87%) 45 (20)
 Female 362 (14%) 343 (13%) 47 (21)
Race χ2 = 15.7 < 0.01
 White 2084 (78%) 2004 (78%) 45 (20)
 African American 110 (4%) 108 (4%) 52 (21)
 Asian 109 (4%) 100 (4%) 44 (21)
 Multiracial 208 (8%) 203 (8%) 44 (20)
 Other 132 (5%) 120 (5%) 48 (20)
 Not specified 21 (1%) 20 (1%) 46 (22)
Ethnicity t = −2 = 0.07
 Non-Hispanic 2356 (88%) 2261 (88%) 45 (20)
 Hispanic 304 (11%) 290 (11%) 47 (19)
 Missing 4 (< 1%) 4 (< 0.5%) 56 (8)
Household income χ2 = 12.3 = 0.14
 Less than $20,000 78 (3%) 71 (3%) 44 (20)
 $21,000–$35,000 129 (5%) 125 (5%) 46 (21)
 $36,000–$50,000 218 (8%) 203 (8%) 48 (20)
 $51,000–$65,000 274 (10%) 264 (10%) 47 (21)
 $66,000–$80,000 347 (13%) 330 (13%) 45 (20)
 $81,000–$100,000 416 (16%) 416 (16%) 45 (19)
 $101,000–$130,000 482 (15%) 482 (15%) 45 (20)
 $131,000–$160,000 224 (9%) 224 (9%) 43 (19)
 Over $161,000 402 (16%) 402 (16%) 46 (20)
 Missing 150 (6%) 138 (5%) 45 (19)
Maternal education χ2 = 7.4 = 0.19
 Less than high school graduate 28 (< 1%) 26 (< 1%) 45 (17)
 High school graduate/GED 217 (8%) 205 (8%) 45 (20)
 Some college 575 (22%) 548 (21%) 45 (20)
 Associate degree 212 (8%) 196 (8%) 48 (19)
 Baccalaureate degree 943 (35%) 906 (35%) 46 (20)
 Graduate/professional degree 675 (25%) 663 (26%) 44 (20)
 Missing 14 (< 1%) 11 (< 1%) 53 (10)
ADOS module χ2 = 218 < 0.001
 Module 1 513 (19%) 405 (16%) 44 (24)
 Module 2 599 (22%) 599 (23%) 56 (19)
 Module 3 1552 (58%) 1551 (61%) 42 (17)
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Note: Composite echolalia scores are shown here by demographic group and tested for significant differences using Kruskal–Wallis H test and Welch’s t-test. Participants missing demographic data were not included in these significance tests.

Abbreviation: GED, general education development.

2.3 |. Measures

2.3.1 |. Echolalia and Related Behaviors Quantification

Echolalia measurement in the field of autism is incredibly imprecise. Very few questionnaires address repetitive speech, and none specifically solicit reports of delayed echolalia. Therefore, with the goal of compiling results across all items that could capture echolalia expression, nine items across five measures of parent-, teacher-, and clinician-report were extracted and an average composite score was calculated. These measures are listed in Figure 1 and included the Aberrant Behavior Checklist (ABC; Aman et al. 1985; parent, n = 1 item), Social Responsiveness Scale (SRS; Constantino and Gruber 2005; parent and teacher, n = 2 items), Social Communication Questionnaire (SCQ; Rutter, Bailey, and Lord 2003; parent and teacher, n = 2 items), Autism Diagnostic Observation Schedule (ADOS; clinician, n = 2 items), and Autism Diagnostic Interview-Revised (ADI-R; parent and clinician, n = 2 items).

FIGURE 1 |.

FIGURE 1 |

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Example composite echolalia and related behaviors score with corresponding items and source measures. This is a fictional example of echolalia composite score calculation. Responses to these nine items were extracted and scaled such that the range of all responses fell between zero and one. In this example, the Social Responsiveness Scale was not completed by the teacher, so this item is excluded from the calculation of the composite score. The Autism Diagnostic Interview-Revised includes parent reports of current and lifetime echolalia. Response options for these two items are identical. In this example, lifetime echolalia was reported as one and current echolalia was reported as zero. Notably, both the immediate echolalia item and the stereotyped speech item were included in the ADOS because the description of stereotyped speech on the ADOS largely overlaps with examples of delayed echolalia.

Responses to all nine items across the five measures were retrieved when available. SRS, ADI-R, and ADOS item responses ranged from 0 to 3 while SCQ and ABC responses were binary. All responses for items scaled from zero to three were divided by three so that the highest possible report on each item was one and the lowest was zero. All complete items for each participant were averaged and multiplied by 100 to generate a continuous estimate of echolalia endorsement. Values were roughly normally distributed with a slight positive skew and ranged from 0 to 100, with 100 representing the highest possible report of echolalia across all available reports. See Figure 2 for the distribution of echolalia and related behaviors scores generated from this sample.

Two important factors are worth noting about our quantification of echolalia: (1) the highly variable phrasing of items included across measures (Figure 1), and (2) the variable sample size for each measure (Table 2). Each of these measurement concerns was addressed using sensitivity analyses. First, five of these echolalia items are particularly broad in their phrasing (SRS, SCQ, and ADOS-stereotyped). For instance, delayed echolalia during the ADOS is reported by clinicians under the stereotyped language code, but this item could also be endorsed for other unconventional language use, such as invented words or using overly formal language. Additionally, the parent and teacher reported SRS item “talking about the same thing over and over” could be endorsed from observation of echolalia or could be endorsed because of other forms of repetition, such as ruminating on a particular subject. Lastly, the item included from the parent and teacher report of the SCQ could capture immediate echolalia or a related behavior, soliciting repetition from a conversation partner. While this composite metric is imprecise, it is capable of broadly capturing reports of immediate and delayed echolalia. Related unconventional language behaviors may also be represented in this estimate. To probe the validity of the broader items extracted (SRS, SCQ, ADOS-Stereotyped), we repeated analyses with a narrowly defined echolalia and related behaviors composite score consisting of clinician (ADOS-Echolalia) and parent (ABC, ADI-R) items that specifically assess echolalia or repetitive speech. These results were not significantly different from the larger conceptualization of echolalia (Tables S1–S3); resultingly, the full echolalia classification is presented here. Items completed by teachers and clinicians provide information on current echolalia since the context in which these reporters observed the participants was time-limited, whereas parent report items spanned both lifetime and current echolalia.

TABLE 2 |.

Sample size by measure and frequency of endorsement.

Measure, reporter, and response options Endorsed
N %
ABC (n = 2552), parent, lifetime
 0 971 38%
 1 739 29%
 2 520 20%
 3 322 13%
SCQ (n = 1933), parent, lifetime
 0 750 39%
 1 1183 61%
SCQ (n = 1303), teacher, current
 0 779 60%
 1 524 40%
ADI-R (n = 2332), parent, current
 0 350 15%
 1 761 33%
 2 1191 51%
 3 30 1%
ADI-R (n = 2335), parent, lifetime
 0 228 10%
 1 487 21%
 2 1239 53%
 3 381 16%
SRS (n = 2551), parent, lifetime
 0 276 11%
 1 534 21%
 2 848 33%
 3 893 35%
SRS (n = 1329), teacher, current
 0 299 22%
 1 343 26%
 2 369 28%
 3 318 24%
ADOS-echolalia (n = 2486), clinician, current
 0 1567 63%
 1 609 24%
 2 297 12%
 3 13 < 1%
ADOS-stereotyped (n = 2381), clinician, current
 0 358 15%
 1 1091 46%
 2 886 37%
 3 46 2%
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Note: Total sample size for each measure does not include ADI-R and ADOS items for which a score of “not applicable” was recorded.

Abbreviations: ABC, aberrant behavior checklist; ADI-R, autism diagnostic interview-revised; ADOS-echolalia, autism diagnostic observation schedule, echolalia item; ADOS-stereotyped, autism diagnostic observation schedule, stereotyped speech item; SCQ, social communication questionnaire; SRS social responsiveness scale.

Second, sample size varied by measure due to incomplete measures (SRS, SCQ, and ABC) and to the coding schemes of the ADOS and ADI-R (clinicians automatically score echolalia-related items as “not applicable” if previous items indicate that the child has limited spontaneous speech). Participants for whom fewer than five items were available to calculate an echolalia and related behaviors score (n = 109) were excluded from analyses. This cut-off maximizes sample size and avoids exclusion of children who have low verbal ability and are therefore missing items on the ADOS and ADI-R due to “not applicable” codes. The distribution of the number of items available to calculate the composite echolalia and related behaviors score can be found in Figure 2, and sample size and endorsement rate for each item are presented in Table 2. To probe the impact of missing items on results, analyses were rerun on the full sample (n = 2664) and with only participants for whom all nine items were available (n = 967). Results were similar (Tables S1,S4,S5); therefore, the sample of participants for whom five or more echolalia-related items were available (n = 2555) is presented here.

2.3.2 |. Autism Severity

The ADOS (Lord et al. 2002) is a semistructured series of activities between a clinician and child that has been designed to elicit behaviors indicative of autism in children and adults. One of four ADOS modules is selected for each child or adolescent based on their expressive language and developmental level. The ADOS module administered and child’s age are used to convert the algorithm scores to a calibrated severity score (ADOS-CSS) that is comparable across modules (Gotham, Pickles, and Lord 2009).

2.3.3 |. Verbal Intellectual Quotient

Full-scale intelligence quotient scores (FSIQ), verbal IQ (VIQ), and nonverbal IQ (NVIQ) were acquired through the administration of instruments appropriate to the age and developmental level of each child. Tests administered included Differential Ability Scales, 2nd Edition (DAS-II; Elliott 1990), Mullen Scales of Early Learning (MSEL; Mullen 1995), or Wechsler Intelligence Scale (Wechsler 1999, 2004). For further information about the decision tree for choosing IQ assessments in the SSC, see Fischbach and Lord (2010). In some cases, a participant was not able to establish a basal on a cognitive test and was administered a test for which standard scores were not available for their age. To obtain a comparable score across participants, mental age was divided by chronological age. Ratio scores were computed for FSIQ, VIQ, and NVIQ. Ratio VIQ scores are included in these analyses to assess verbal ability.

2.3.4 |. Repetitive Behaviors

Repetitive behaviors were assessed through overall scores from parent report on the Repetitive Behaviors Scale—Revised questionnaire (RBS-R; Bodfish et al. 2000). The RBS-R includes 43 items with a four-point Likert scale of response. Higher numbers indicate that behaviors occur at a higher frequency and intensity. The RBS-R contains 6 subscales and an overall composite score. Overall scores for this measure have a moderate, positive skew in this sample.

2.4 |. Analytic Approach

Data analysis was conducted using R Studio (Version 2023.12.0), considering a significance value of at least 0.05 for inferential analysis.

2.4.1 |. Missing Data

We investigated the impact of data missing due to incomplete SRS, SCQ, or ABC and responses of “not applicable” on ADOS and ADI-R items. An ANOVA was used to check for demographic differences in participants missing 0–4 of the items included in the average echolalia and related behaviors score. The sample size for these comparisons varied due to missingness of ethnicity (n = 4), maternal education (n = 11), and household income (n = 138). There were no significant differences in missing items across demographic variables of sex, F(1, 2553) = 2, p = 0.16, ethnicity, F(1, 2549) = 0.1, p = 0.78, maternal education, F(5, 2538) = 1.6, p = 0.15, or household income, F(8, 2408) = 1.6, p = 0.12, but there were significant differences in missing items and race, F(5, 2549) = 2.3, p < 0.05.

Chi-squared test of independence was conducted to examine the relationship between race and availability of each of the nine items retrieved across measures. The analysis revealed a significant association for race and codes of “not applicable” on the ADI-R current echolalia χ2(5, n = 2552) = 48, p < 0.001, ADI-R lifetime echolalia χ2(5, n = 2555) = 50, p < 0.001, and ADOS stereotyped speech, χ2(5, n = 2555) = 22, p < 0.001. Missingness on these items is associated with lower spontaneous expressive language and is explained by underlying racial differences in verbal ability in this sample, H(5) = 96, p < 0.001. A visualization of missing data on each measure ordered by echolalia and related behaviors composite score can be found in the supporting materials (Figure S5).

2.4.2 |. Aim 1: Echolalia Endorsement

To address the primary aim of evaluating the endorsement of echolalia-related items in autistic youth ages 4 to 17 years, rates of endorsement for parent-, teacher-, and clinician-report items were examined and described along with composition and distribution of the calculated echolalia and related behaviors composite score. Echolalia and related behaviors score differences in sex, race, ethnicity, household income, maternal education, and ADOS module were explored using Welch’s t test and Kruskal–Wallis H test due to unequal group sizes.

2.4.3 |. Aim 2: Characterize Associations With Echolalia

To test the multivariate impact of verbal ability and repetitive behaviors on echolalia while controlling for age, sex, and autism severity, a five-level hierarchical multiple regression analysis was conducted with echolalia and related behaviors score as the dependent variable. All continuous predictors were z-scored prior to inclusion in the regression analyses. Age in months and sex (0 = male, 1 = female) were entered into level 1 as demographic control variables. Autism severity (ADOS-CSS), repetitive behaviors (RBS-R), and verbal ability (ratio VIQ) were added in levels 2, 3, and 4, respectively, to assess their unique contributions to variance in echolalia and related behaviors score. Level 5 probed interactions between significant demographic variables and covariate predictors. Level 5 was repeated excluding any non-significant predictors and interaction terms. Predictors were assessed for multicollinearity (VIF < 1.1, tolerance > 0.9).

3 |. Results

3.1 |. Aim 1: Echolalia Endorsement

Rates of echolalia varied by informant: parents endorsed at least one item for 96% of participants (2453/2555). Teachers endorsed at least one item for 75% of participants (1100/1466). Clinicians endorsed one item on the ADOS for 87% of participants (2165/2486).

In this sample, parents reported on the ADI-R that 90% (2107/2335) of participants had expressed echolalia at some point in their lives. This dropped slightly to 85% (1982/2332) when parents reported whether the repetition was current. Other measures for which both current and lifetime reports were available (SCQ and SRS) were completed by teacher and parent, respectively, and therefore are not directly comparable. However, the two items reported by teachers were endorsed at lower rates than equivalent items on parent lifetime reports. Stereotyped speech on the ADOS was endorsed with greater frequency (85%, 2023/2381) than immediate echolalia (37%, 919/2486).

There were no significant differences by sex, ethnicity, household income, or maternal education in echolalia and related behaviors scores (Table 1). Echolalia and related behaviors scores varied across racial groups, H(5) = 15.7, p < 0.01. Post hoc pairwise comparisons using Dunn’s test with a Bonferroni correction revealed that African American participants had significantly higher echolalia and related behaviors scores than White, p < 0.01, and multiracial, p < 0.05, participants. To investigate whether sampling bias might underly race differences in echolalia endorsement, we conducted the same tests of VIQ and found significant differences across racial groups, H(5) = 488, p < 0.001. Post hoc pairwise comparisons using Dunn’s test with a Bonferroni correction indicated that White participants in this sample had higher VIQ than three other groups: African American, p < 0.001, Asian, p < 0.001, and other, p < 0.05. Additionally, multiracial participants had higher VIQ than three other groups: African American, p < 0.001, Asian, p < 0.05, and other, p < 0.05. Echolalia and related behaviors scores also varied across ADOS module, H(2) = 218, p < 0.001. Post hoc pairwise comparisons indicate significant differences between all three modules, p < 0.01.

3.2 |. Aim 2: Echolalia and Associations With Verbal IQ, Autism Severity, and Repetitive Behaviors

A five-level regression model was conducted to assess the impact of repetitive behaviors and verbal ability on echolalia and related behaviors scores after controlling for age, sex, and autism severity. The final level included interaction terms between age and significant covariates from levels 2–4. The final model was significant, AdjR2 = 0.201, F(8, 2546) = 81.25, p < 0.001, and had a significant change in explained variance from the fourth level, ΔAdjR2 = 0.016, F(3, 2546) = 18.467, p < 0.001. Accordingly, the final model was interpreted: age, β = −1.601, p < 0.001, ADOS-CSS, β = 4.544, p < 0.001, VIQ, β = −1.837, p < 0.0001, and RRBs, β = 5.696, p < 0.001, emerged as significant main effects. Three interactions were included between age and significant covariates (VIQ, ADOS-CSS, and RBS-R). Of these, the interaction between age and verbal ability, β = −2.565, p < 0.001, was significant, such that older children with higher verbal abilities had less reported echolalia (Figure 3). The final level was rerun excluding nonsignificant predictors and revealed stable results. Results for all models are displayed in Table 3.

FIGURE 3 |.

FIGURE 3 |

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Significant predictors in final stepwise linear regression model. The left panel shows a significant interaction of VIQ and age in predicting echolalia and related behaviors composite score in the final regression model. Autistic participant’s verbal ability (VIQ) interacted with age to significantly predict composite echolalia scores such that older children with the lowest quartile of verbal ability (Q1) had higher reported echolalia and older participants with greater verbal ability (Q2, Q3, and Q4) had lower reported echolalia. The right panel shows the significant predictors of RRBs and autism severity in predicting echolalia and related behaviors composite score in the final regression model.

TABLE 3 |.

Summary of multiple regression analysis for variables predicting echolalia and related behaviors composite score (N = 2493).

Model 1: age & sex
 Model 2: autism severity
 Model 3: verbal ability
 Model 4: RRBs
 Model 5: interactions
Variable β SE β SE β SE β SE β SE
Sex (0 = male) 1.855 1.15 1.722 1.105 1.245 1.095 1.584 1.043 1.612 1.034
Age −1.261** 0.392 −1.225** 0.377 −1.378*** 0.373 −1.169** 0.356 −1.601*** 0.359
ADOS-CSS 5.503*** 0.377 4.866*** 0.382 4.628*** 0.364 4.544*** 0.361
VIQ −2.961*** 0.383 −2.257*** 0.367 −1.837*** 0.368
RRB 5.788*** 0.358 5.696*** 0.356
Age×ADOS-CSS 0.284 0.362
Age×VIQ −2.565*** 0.365
Age×RRB −0.289 0.359
R 2 0.004 0.081 0.101 0.184 0.201
ΔR2 0.004*** 0.076*** 0.021*** 0.083*** 0.016***
F for ΔR2 7.919*** 245.316*** 67.328*** 266.119*** 18.467***
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Note: Values for adjusted R2, delta-adjusted R2, and the F-stat for delta-adjusted R2 are displayed in the table above.

Abbreviations: ADOS-CSS, autism diagnostic observation schedule calibrated severity score; RRB, restricted and repetitive behaviors; VIQ, verbal intellectual quotient.

**

p < 0.01.

***

p < 0.001.

4 |. Discussion

The goals of this study were to (1) estimate the prevalence of reported echolalia and (2) characterize relationships between echolalia and child factors of sex, age, autism severity, language ability, and repetitive behaviors in a large sample of autistic youth. Overall, we found high endorsement of individual extracted items ranging from 35% to 90% with the highest rate of endorsement by parents for lifetime estimates. This estimate is higher than previous historical estimates (Wing 1971) and shows a similar range to current estimates (Sutherland et al. 2024). Echolalia item endorsement varied across measures, reporters, and contexts. Parents endorsed echolalia-related items at higher rates than teachers and clinicians, which may reflect rich knowledge of their child’s language expression across social as well as developmental contexts. Additionally, teacher and clinician endorsement of echolalia-related items may be lower as they are limited to current observations in the school setting or during a clinic visit. The large difference between clinician endorsement rate of immediate echolalia (35%) and stereotyped speech (85%) that includes delayed echolalia points to the need for more precise measurement of delayed echolalia, as there is a lack of such measures. Interestingly, there was a large discrepancy in parent report of current echolalia (85%) and clinician observation of echolalia during the ADOS assessment (37%). Since echolalia varies with both context and conversation partner (Charlop 1986; Cohn, McVilly, and Harrison 2023), it is possible that reliance on ADOS recordings or transcripts may underestimate echolalia frequency (Gladfelter and VanZuiden 2020; La Valle, Plesa-Skwerer, and Tager-Flusberg 2020; Maes, La Valle, and Tager-Flusberg 2024; Shield, Cooley, and Meier 2017; van Santen, Sproat, and Hill 2013). The high prevalence of echolalia in this large, well-validated sample indicates that echolalia is a core feature of autism across childhood and adolescence. Prevalence rates and developmental trajectories of this central autistic behavior remain understudied and future research is needed to accurately and precisely estimate echolalia.

Significant demographic differences emerged in the composite echolalia and related behaviors score related to race. This difference is due to underrepresentation in the sample across racial groups. This sampling issue, wherein racially minoritized samples are not accurately represented across verbal intelligence abilities, is a significant problem in terms of identification and diagnosis (Hilton et al. 2010; Mire et al. 2024). Thus, we conclude that the racial differences in echolalia found in this sample are likely not a true reflection of echolalia differences between racial groups, but instead a reflection of an older sample that does not include sufficient racial representation. Endorsement of the two ADOS items included in the composite echolalia and related behaviors score may also capture racial bias (Harrison et al. 2017).

Our results also evidenced a significant, negative association between echolalia and age, wherein younger participants had a higher frequency of echolalia. On the surface, this negative association between echolalia and age contrasts with a previous non-significant, positive association between immediate echolalia, and age in a younger cohort (van Santen, Sproat, and Hill 2013). However, methodological differences may account for discrepant findings, as van Santen, Sproat, and Hill (2013) had a significantly younger sample (4–8 years) and found this association for only immediate and not delayed echolalia.

We observed no significant sex differences in echolalia prevalence, suggesting that in this unbalanced dataset, autistic males and females both demonstrate a high frequency of echolalia across reporters. The lack of observed sex differences supports previous work that indicated no sex differences in the quantity of echolalia but did note significant sex differences in the type of echolalia (Wardyn and Galkowski 2002). Although echolalia function/type was not measured in the current study, future work may seek to elucidate sex differences in echolalia presentations, especially in light of potential social communication differences between autistic females and males (McFayden et al. 2023).

Results from our second aim sought to understand predictors of echolalia across demographic characteristics. Variance in echolalia was positively associated with autism severity (ADOS-CSS), aligning with previous marginal evidence that echolalia is a central feature of autism (Maes, La Valle, and Tager-Flusberg 2024; van Santen, Sproat, and Hill 2013). After controlling for the variance in echolalia that was accounted for by autism severity, echolalia was significantly associated with both verbal ability and repetitive behaviors.

Variance in echolalia was negatively associated with verbal ability after controlling for age, sex, and autism severity. In other words, youth with higher language abilities presented with lower rates of echolalia. These results are aligned with previous studies indicating that expressive language is negatively associated with echolalia (van Santen, Sproat, and Hill 2013). In addition to the main effect of expressive language level, a significant interaction between verbal ability and age emerged that qualified this main effect. Older children with lower verbal ability maintained high levels of reported echolalia, compared to older children with high verbal ability for whom less echolalia was reported. Interestingly, the interaction between verbal ability and age found in this sample is similar to the negative association between NVIQ and age reported by Bishop, Richler, and Lord (2006) for older, but not younger children and the negative association found by Maes, La Valle, and Tager-Flusberg (2024) between echolalia and age in verbal but not nonverbal autistic children. Taking the current associations between VIQ and previous associations with NVIQ together, it seems that for older children with higher verbal and cognitive ability, echolalia expression decreases, potentially due to their use of more flexible communication strategies. Importantly, echolalia may decrease in later adolescence, yet it remains a prevalent repetitive behavior in this population. Older children in this study with lower language ability had echolalia levels similar to younger children in the sample, suggesting that adolescents with limited verbal strategies may leverage echolalia’s communicative potential and strategically employ it as a skill in their repertoire.

Variance in echolalia was also associated with repetitive behaviors. The connection between repetitive behaviors and echolalia is not novel; in fact, previous conceptualizations of echolalia considered it part of the repetitive behavior constellation of autistic traits, as it has a repetitive nature (Blackburn et al. 2023; Neely et al. 2016). Our findings demonstrate this positive relation between repetitive behaviors and echolalia, suggesting that youth who have higher reported repetitive behaviors also tend to have higher reported echolalia. This finding holds after controlling for age, sex, and autism severity, indicating that this relationship is not merely a function of higher autism severity. Repetitive behaviors were once thought to require mitigation, but are now largely understood to be functional and even enjoyable for autistic individuals (Marom, Gilboa, and Bodner 2023; McCormack, Wong, and Campbell 2023; Price 2022). Current recognition of the functions of repetitive behaviors closely match the noncommunicative functions of echolalia described in previous research (Cohn et al. 2022; Marom, Gilboa, and Bodner 2018; Prizant and Duchan 1981).

Taken together, these results support a dualistic view of echolalia as both functional repetitive behavior and functional communication. A singular lens that restricts repetition to one of these two categories furthers confusion around echolalia. Future research is needed to support caregivers in recognizing both the repetitive behavior functions and communicative functions of autistic echolalia. Interestingly, the functions of echolali—communication, concentration, self-regulation, and enjoyment—are also commonly understood functions of repetition in nonautistic individuals (Blackledge and Hayes 2001; Friedberg et al. 2012; Saber and Johnson 2008; Sidtis and Wolf 2015; Suryawanshi et al. 2024). The higher frequency and intensity of these repetitive utterances and not their function may define the gray boundary between autistic and nonautistic expressions of echolalia.

4.1 |. Limitations

The limitations of this study provide direction for needed future research. The dataset itself is the source of several limitations. Firstly, evaluations were conducted between 2008 and 2010 with children diagnosed based on DSM-IV autism criteria. Changes from DSM-IV to DSM-5, including the removal of the language delay requirement for diagnosis, could impact prevalence estimates of echolalia. However, echolalia itself has been a core feature of autism since Kanner’s first descriptions and has been included in diagnostic criteria since 1980 (Rosen, Lord, and Volkmar 2021). Echolalia was classified as a speech pattern in DSM-III and captured under repetitive use of language in DSM-IV but is grouped with repetitive behaviors in DSM-5 (American Psychiatric Association 1994, 2013; King et al. 2014). Secondly, the sample is predominantly male with a ratio of 8:1, substantially higher than the widely accepted prevalence ratio of 3.8:1 (Maenner et al. 2023). This overrepresentation of male autistic experiences may obscure potential sex differences in reported echolalia. Thirdly, the limited representation of non-White participants in this sample reduces generalizability of these findings as race and ethnicity are known to impact proxy report of autistic behaviors (Blacher, Stavropoulos, and Bolourian 2019; Donohue et al. 2019).

The SSC dataset was chosen for this investigation due to its large size and inclusion of multiple reporters. Broadly capturing repetition through the lens of multiple reporters is valuable, but the use of multiple measures likely captures related verbal behaviors beyond specific echolalia. Therefore the current study may present an overestimate of strictly defined echolalia prevalence. This study is also unable to identify the frequency or type of echolalia. Future work is needed to further evaluate both the typography of echolalia and associations between that typography and context structure, communication partner, and child factors. This study demonstrates the usefulness of combined parent, teacher, and clinician report of echolalia, but is limited by the fact that the items extracted for this study have not been individually validated. Questionnaires designed to assess the expression and function of echolalia are needed to validly assess echolalia through proxy- and self-report. The development of a validated echolalia measure would also allow for easier longitudinal assessment to better understand the associations between echolalia and age observed in this cross-sectional analysis.

5 |. Conclusion

This study examined the endorsement of echolalia-related items in a large national dataset of children and adolescents. Responses to individual items and this broad composite score of echolalia and related behaviors indicated that repetitive speech is extraordinarily common among autistic individuals. Despite the high prevalence and associations with autism severity, the study of echolalia is stunted by its contentious definition and diverse methods of quantification. Both repetitive behaviors and verbal ability are associated with echolalia supporting a dualistic view of echolalia as sometimes a repetitive behavior and sometimes communication. Echolalia decreases with age but remains common throughout late adolescence for individuals with lower verbal ability, reflecting the adaptability of autistic individuals. Echolalia may emerge early in development as an enjoyable and entertaining repetitive behavior and then be intentionally leveraged to support cognition, learning, and communication by autistic youth who have less conventional verbal strategies at their disposal. In conclusion, these findings show that echolalia is highly prevalent in autism, changes across development, and reflects the dynamic needs and interests of autistic individuals. Future work is needed to better understand how to support autistic development and well-being through the reception of echolalia.

Supplementary Material

supinfo

Summary.

  • The study of echolalia, the repetition of words or phrases, has been neglected relative to other aspects of autism, even though it is very common in autistic individuals.

  • In this large study, echolalia was reported by parents in 90% of the autistic participants.

  • Echolalia was related to verbal ability and repetitive behaviors supporting the idea that it performs both communicative and noncommunicative functions.

Acknowledgments

We are grateful to all of the families at the participating Simons Simplex Collection (SSC) sites, as well as the principal investigators (A. Beaudet, R. Bernier, J. Constantino, E. Cook, E. Fombonne, D. Geschwind, R. Goin-Kochel, E. Hanson, D. Grice, A. Klin, D. Ledbetter, C. Lord, C. Martin, D. Martin, R. Maxim, J. Miles, O. Ousley, K. Pelphrey, B. Peterson, J. Piggot, C. Saulnier, M. State, W. Stone, J. Sutcliffe, C. Walsh, Z. Warren, E. Wijsman). We appreciate obtaining access to phenotypic data on SFARI Base. Approved researchers can obtain the SSC population dataset described in this study (https://www.sfari.org/resource/simons-simplex-collection/) by applying at https://base.sfari.org.

Funding:

M.L.M. is supported by the Office of Special Education Programs, U.S. Department of Education (H325) and by the Royster Society of Fellows awarded by the University of North Carolina at Chapel Hill. T.M. is supported by a training fellowship from NICHD (T32HD040127). The opinions expressed represent those of the authors and do not represent the views of the Institute or the U.S. Department of Education.

Footnotes

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting Information

Additional supporting information can be found online in the Supporting Information section.

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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Supplementary Materials

supinfo
NIHMS2046095-supplement-supinfo.docx (2.1MB, docx)

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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