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Crafting a Revision Plan

Instructions

When revising your text, follow this process:

First, read the entire document. Don’t make any notes. Don’t correct any mistakes. Just read the text.
Then, write one or two sentences that summarize what you have just read. Next, read the text again.
This time, stop after each paragraph or section, and write one or two sentences that summarize what you have just read in that section or paragraph.
Finally, look at the various summaries you have created. Do they all relate to each other? Are there sections where you need to clarify more? Are there areas that need more support material or explanation?

Make notes on your text in the margins.

Continuing the Process

Moving on, take your document and your notes and begin to revise the document. Some find that starting with a fresh piece of paper or Word document is more helpful then working on the same draft. Whatever works for you, just start revising.

Helpful Suggestions for Revising

Work with a friend or peer. Ask your friend or peer to follow the steps above when reading your paper. Ask them to explain what your paper is about. Remember: it is always a good idea to let others read your work. In fact, the Capella Writing Center offers wonderful services to writers. Go see them. There is a link in the resources for this unit’s discussion.

If you are using Microsoft word, there is a “track changes” program that allows you to add comments and make changes to texts without changing the original. This is helpful when revising.

Reflection and Revision

At this point in the course, reflect on your writing process. To conduct a reflection on the process, you will want to review a variety of documents and texts from the course. Start by doing the following:

Collect and read the feedback your peers have given you.
Collect your various drafts and outlines.
Review the comments your instructor has made.

As you read all the information, make note of the various areas your readers have commented on or critiqued. Do you see either similarities or differences in the comments and critiques offered to you?

Now, craft a revision plan based on the comments and observations you have collected and reviewed. This revision plan needs to include the following:

A listing of three areas that need improvement.
A detailed timeline of work still to be completed.
A list of any elements of the writing process that you feel you need more information on to complete the revision.

The revision plan should be at least two pages.

Your plan will scored on the following criteria:

Create a revision plan that refers to comments from instructor and peer.
Identify three areas for improvement.
Craft a schedule that addresses elements of the writing process.

Note: Your instructor may also use the Writing Feedback Tool to give you feedback on your writing. In the tool, click the linked resources for helpful writing information.

Resources

Crafting a Revision Plan Scoring Guide.

AUTISM SELF MANAGEMENT TREATMENT 1

AUTISM SELF MANAGEMENT TREATMENT 8

Autism is defined to be a category of developmental disabilities that may lead to significant social behavioral and communication challenges. The people affected by autism are known to communicate, interact and behave in different manners from the rest of the people. The abilities to solve the problem, think, and learning for people with autism spectrum disorder may range to quite challenging. This would call for help from the people since such people require special attention from other needless individuals. The diagnosis of the autism spectrum disorder is composed of various conditions that are applicable to be diagnosed separately that as a pervasive developmental disorder, autistic disorder, or Asperger syndrome. In the self-management treatment, the inappropriate language replacement with the verbal labeling tends to be more functional compared to the normal verbaling.

Psychologists may assist in the process of assessment and diagnosing autism condition. He/she works in a diagnostic group with a psychiatrist and a speech pathologist to diagnose Autism Spectrum Disorder. In this case, diagnosis is much based on the grounds of observations to a specific arrangement of behaviors.

Additionally, psychologists may help with the management of the mental health of an individual with autism or who has been suspected to have Autism. Assessments may be done at any level of the individual’s life and may involve input from different health professionals.

General health care has the capacity of referring an individual to a psychologist when suspected to have autism or even seem to have a concern to mental health. Also, self-referrals may be made to the psychologist.

There occur some kinds of rejection towards the children who seem to have been affected by autism. Bullying studies may be considered as a major empirical case about potential traumatization of the children living with Autism. Previous researches have shown the existence of cognitive and neurological differences that may contribute to social impairment. In this case, rejection in the social interactions involves the presence of more than one individual as the social difference may happen from the children living with an autism spectrum disorder, judgment, perception as well as the social decisions that are made by the people surrounding them.

The first impression of the individuals living with autism is derived from what happens in the real world of social behavior which is viewed to be associated with the minimized intentions to achieve social interaction for such people. These kid of behaviors towards the people living with autism occurs within little time, an increased exposure may not change rather it persists in the child groups.

Such biases may only end when impressions based on conversational content that has an inefficiency of audio – visual cues that has the capability of driving negative impression of the autism spectrum disorder. People living with autism are featured by deficiency during the social interactions hence contributing to huge social disabilities and poor social functional results.

Out of rejection and biases, this form of deficiency has an association with smaller social networks and fewer friends, hardship in securing a retain employment. Loneliness and generally reduced quality of life are some of the difficulties that people living with autism face.

The increase in the number of students, who have developed autism spectrum disorder, has pressed a need to have a designed learning environment that fits their needs. This will be friendlier with the simplified form of learning skills. The recent research reveals between 1% and 2% of school-age children have been noted to be living with autism. This has brought the attention of professionals with the knowledge to schooling as well as parents to identify ways of managing the challenge of the learners with an autism spectrum disorder. There have been teacher-managed interventions to respond to the challenges posed by learners living with autism. However, such interventions have been limited to only control the behaviors rather than equipping skills to those learners. Through using the self-management strategies, it has been effective to offer skills to children with deficit disorders, learning disabilities as well as autism spectrum disorders.

To enhance communication between children living with autism and other or between themselves, there is need to follow some tips that will ensure communication occurs; persisting in a resilient manner by ensuring your feelings are not hurt when the child fails to respond as one would expect as the children with autism have a challenge controlling their emotions. Being positive is another way as such children would respond to positive reinforcement.

Enhancing interaction via physical activities will assist in communication with the children living with autism. Since such children have a short span of attention, playing around with them would make them relaxed and even calmer. A show of love to them will boost their ability to communicate though they endure trouble to show their feeling but still need to realize that you love them.

Visual support for the children living with autism may be through drawings, written words, photographs, and objects. This form of support works better when used as a way of communication. The visual supports are applied for the children living with autism spectrum disorder for the following purposes;

Since children with autism spectrum syndrome may not be in a position to understand the social cues while they interact with the rest of the people. Visual supports offer such assistance to them. They may also fail to grasp the social expectations such as the start of the conversation, ways of responding, and the manner of changing behavior based on social rules. Therefore, the visual supports offer to teach the social skills and assist children living with the autism spectrum apply them to social situations.

Consequently, through visuals, parents are assisted to communicate what such children would expect. This is because such children find it hard to understand and follow the spoken instructions hence not able to make a clear expression of what they would want. Through the help of visual supports, there is a reduced instance of frustrations thus decreasing the problem behaviors that may have resulted from hardship in communication.

For the children living with an autism spectrum disorder, the ability to monitor an error may appear to be significant to regulate the autistic symptomology such as both the functional and structural abnormalities which may have contributed towards the repetitive and restricted behaviors in autism spectrum syndrome.

The self-monitoring interventions are associated with a decrease in stereotypic behaviors and an increase in social skills. In general, people living with autism showcase poor monitoring of an error compared to the people who have typical development. In this case, people with autism disorder tend to show fewer ERN amplitudes resulting in less recognition of the errors.

The behavioral interventions strategies are much focused on the improvement of social communication skills. This is more significant to the children who would gain such skills naturally. In some cases, both speech and occupational therapy would be of great assistance to young age children. Undergoing medication and offering social skills training play a significant role in the intervention measures for children living with autism. However, the treatment for autism syndrome is variant with the age of the child, strengths, and challenges.

In times when the health professionals, parents of the children living with autism disorder work mutually bringing into this relationship their personal needs, priorities, as well as the responsibilities. The level to which a family adjusts to the diagnosis of autism depends to a large extent on the pre-existing stability and cohesion within the family. The disruption of the family cohesion may increase stress where a child with autism is born. Both the external and internal coping strategies are useful to deal with stress in such a family which is more of spiritual and social support.

The autism disorder for children appears to cause stigma to such children and their parents due to the stereotyping that may end up in isolation, and rejection. This may be avoided by undertaking such children through treatment courses that will enable them to raise their self-esteem. All through education to the public and creating awareness, the public tends to accept and embrace such people and not looking down on them.

Motivation acts towards the parents and the children living with autism ought to be applied and embraced to avoid cases of isolation and exclusion. This will reduce the stigmatization of the members of society.

References

Healy, O., & Leader, G. (2011). Assessments of rituals and stereotypy. In J. L. Matson & P. Sturmey (Eds.), International handbook of autism and pervasive developmental disorders (pp. 233–245). New York: Springer.

Hetzroni, O. E., & Tannous, J. (2004). Effects of a computer-based intervention program on the communicative functions of children with autism. Journal of Autism and Developmental Disorders, 34, 95– 113. doi:10.1023/B:JADD.0000022602.40506.bf.

Howlin, P. (1982). Echolalic and spontaneous phrase speech in autistic children. Journal of Child Psychology and Psychiatry, 23, 281–293. doi:10.1111/j.1469-7610.1982.tb00073.x.

Iwata, B. A., Dorsey, M. F., Slifer, J. J., Bauman, K. E., & Richman, G. S. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197–209. doi:10.1901/jaba.1994. 27-197 (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3–20, 1982).

*Karmali, I., Greer, R. D., Nuzzlo-Gomez, R., Ross, D. E., RiveraValdes, C. (2005). Reducing palilalia by presenting tact corrections to young children with autism. Analysis of Verbal Behavior, 21, 145–153. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/ journals/609/

Kavon, N. M., & McLaughlin, T. F. (1995). Interventions for echolalic behavior for children with autism: a review of verbal prompts and the cues pause point procedure. B.C. Journal of Special Education, 19(2–3), 39–45. Retrieved from:

http://eric.ed.gov/?id=EJ519927

Kennedy, C. H. (2005). Single-case designs for educational research. Boston, MA: Allyn and Bacon. *Laski, K. E., Charlop, M. H., Schriebman, L. (1988). Training parents to use the natural language paradigm to increase their autistic children’s speech. Journal of Applied Behavior Analysis, 21, 391–400. doi: 10.1901/jaba.1988.21-391.

Light, C., Roberts, B., Dimarco, R., & Greiner, N. (1998). Augmentative and alternative communication to support receptive and expressive communication for people with autism. Journal of Communication Disorders, 31, 153–180. doi:10.1016/S0021-9924(97)00087-7.

Lovaas, O. I., Koegel, R. L., Simmons, J. Q., & Long, J. S. (1973). Some generalization and follow-up measures on autistic children in behavior therapy. Journal of Applied Behavior Analysis, 6, 131–166. doi: 10.1901/jaba.1973.6-131.

WRIT6088
U05A1 – DRAFTING YOUR TEXT
LEARNER:

INSTRUCTIONS

Use the following scoring guide, along with the project information, for evaluating each learner’s work.

Top of Form

OVERALL COMMENTS

Hi,

Please note that the absence of in-text citations will result in a low score on the revision of this paper. Remember, any time you quote, summarize or paraphrase source material, citations must appear both within the text of the essay as well as on the references page.

Important note to ALL students as your revise your draft in the coming weeks: Remember, the main focus of your text (essay) for this course should be to focus in on and explore a topic within your field of study that can be supported by the literature. The essay should be supported by ample research which is always cited appropriately, both within the text of the essay and on the references page. Your position on this topic should be clear in the thesis statement as well as in the overall essay itself. Always be sure to read and follow all specific directions carefully for each unit.

For this assignment, you were to write a 5-8 page draft of your paper. This draft needed to include context, a thesis, support from your research sources, and a clear argument. That said, it was graded as a draft and not a final, polished text. Thus, a high grade on this draft will not necessarily translate to a high grade on the final submission.

I enjoyed reading this, and I look forward to seeing it continue to develop further in the coming weeks!

See the scoring guide for specific notes on how this draft was graded.

Best, Nicole

RUBRICS

CRITERIA 1

Introduce thesis within context for appropriate audience.(25%)COMPETENCY

Develop academic content that demonstrates critical thinking.

NON_PERFORMANCEDoes not introduce thesis within context for appropriate audience.BASICIntroduces thesis, but the context is not clearly connected to the appropriate audience.PROFICIENTIntroduces thesis within context for appropriate audience.DISTINGUISHEDIntroduces thesis within context for appropriate audience, providing a clear connection to the topic, purpose, and aspects.

COMMENTS:

You did a nice job of introducing your thesis here, and this was done within the context of writing for an appropriately targeted audience. A clear connection to topic, purpose, and aspects of your argument was evident throughout.

CRITERIA 2

Incorporate evidence with coherent placement that supports structure of arguments.(25%)COMPETENCY

Convey concepts and perspectives through organized, logical structure.

NON_PERFORMANCEDoes not incorporate evidence with coherent placement that supports structure of arguments.BASICIncorporates evidence in only a basic fashion, lacking evidence-based reasoning.PROFICIENTIncorporates evidence with coherent placement that supports structure of arguments.DISTINGUISHEDIncorporates evidence with coherent placement that supports the structure of arguments, using clear and direct reasoning.

COMMENTS:

Unfortunately, it’s not possible to know where evidence is presented and from which source(s) without in-text citations.

CRITERIA 3

Present a clear and complete argument.(25%)COMPETENCY

Develop academic content that demonstrates critical thinking.

NON_PERFORMANCEDoes not present a clear and complete argument.BASICPresents only a basic argument.PROFICIENTPresents a clear and complete argument.DISTINGUISHEDPresents a well-developed, clear and complete argument.

COMMENTS:

You do a nice job presenting a draft argument here, but some paragraphs are extremely short. During the revision process, I suggest reading the paper aloud and taking any feedback received into account to ensure that each paragraph fully supports your thesis and overall topic.

CRITERIA 4

Utilize proper mechanics including spelling, grammar, and APA formatting(25%)COMPETENCY

Apply correct grammar, usage, and mechanics appropriate to audience and discipline.

NON_PERFORMANCEDoes not utilize proper mechanics including spelling, grammar, and APA formatting.BASICUtilizes most, but not all, proper mechanics including spelling, grammar, and APA formatting.PROFICIENTUtilizes proper mechanics including spelling, grammar, and APA formatting.DISTINGUISHEDUtilize proper mechanics including spelling, grammar, and APA formatting in a comprehensive and informed fashion.

COMMENTS:

Keep working on APA formatting using the excellent resources available to you here at Capella. See the documents I’ve posted in Updates & Handouts for a start with this.

Bottom of Form

ment program to reduce stereotypic (repetitive) behav-
iors. Four children diagnosed with autism were referred
because of high frequency of stereotypic behaviors (e.g.,
arm flapping, finger flexing, humming, nonsense vocal-
izations). After self-management procedures were taught,
stereotypic behaviors decreased to zero levels for all chil-
dren, however, the two children with vocal stereotypies
required a longer period of self-management before de-
creases were noted. Similarly, Stahmer and Schreibman
(1992) investigated the effects of self-management pro-
cedures for a variety of target behaviors including in-
creasing appropriate play skills, and reducing stereotypic
behaviors of three children with autism. Participants were
7 to 13 years old and were referred for treatment by their
parents due to destructive and obsessive behavior with
toys in unsupervised settings. Appropriate play increased
for all three children during treatment, fading, posttreat-
ment, and follow-up observations and self-stimulatory
behavior decreased to zero levels. Results from these
studies indicated the successful use of self-management
to reduce inappropriate behaviors (R. L. Koegel &
Koegel, 1990), to increase schedule following (Newman,
Buffington, O’Grady, Poulson, & Hemmes, 1995), and

INTRODUCTION

Self-management procedures, as reported in the
literature, have incorporated components of self-
assessment, self-recording, and self-reinforcement (R. L.
Koegel & Frea, 1993). Applications of self-management
to children with autism have evolved from procedures to
(a) improve on task behaviors of children with retarda-
tion, learning disabilities, and behavior disorders; and
(b) to decrease disruptive, inappropriate, or stereotypic
behaviors (Gardner, Clees, & Cole, 1983; L. K. Koegel,
Koegel, Hurley, & Frea, 1992; Reese, Sherman, & Shel-
don, 1984; Shapiro, McGonigle, & Ollendick, 1980; Stah-
mer & Schreibman, 1992). In an exemplary study, R. L.
Koegel and Koegel (1990) assessed whether children with
autism could be taught to use a self-management treat-

Brief Reports

Brief Report: Reduction of Inappropriate Vocalizations for
a Child with Autism Using a Self-Management Treatment
Program

Catherine Mancina,1 Melody Tankersley,2 Debra Kamps,1,4 Tammy Kravits, 1

and Jean Parrett3

Self-management procedures that incorporate elements of self-assessment, self-recording, and
self-reinforcement have reduced stereotypic (i.e., repetitive) behaviors in children with autism
in clinical settings. This study examined the effects of a self-management program used to re-
duce high rates of inappropriate vocalizations (e.g., humming, tongue clucking, perseverative
and echolalic words/phrases) in a 12-year-old girl having autism served in a public school
classroom. When self-management was applied to inappropriate vocalizations in a multiple-
baseline design during leisure, prevocational, and reading tasks, the occurrence of vocaliza-
tions decreased. Implications for teaching these procedures in classroom settings are discussed.

KEY WORDS: Self-management procedures; autism; inappropriate vocalization.

Journal of Autism and Developmental Disorders, Vol. 30, No. 6, 2000

599
0162-3257/00/1200-0599$18.00/0 © 2000 Plenum Publishing Corporation

1 University of Kansas, Kansas City.
2 Kent State University, Kent, Ohio.
3 Kansas City, Kansas Public Schools, Kansas City.
4 Address all correspondence to Debra M. Kamps, Juniper Gardens

Children’s Project, 650 Minnesota Avenue, 2nd floor, Kansas City,
Kansas 66101.

to increase social behaviors (R. L. Koegel & Frea, 1993;
Stahmer & Schreibman, 1992).

The purpose of the present study was to extend
the literature on classroom-based self-management
procedures. The investigation examined the effects of
self-management procedures for a 12-year-old girl di-
agnosed with autism and moderate mental retardation.
Three inappropriate behaviors were identified for the
participant (i.e., vocalizations, facial movements,
body movements); however, self-management proce-
dures were applied to only one behavior (i.e., vocal-
izations) and collateral effects were observed for the
others. Because studies indicated that the reduction of
vocalizations requires longer durations of treatment
in children with autism (R. L. Koegel & Koegel,
1990), the amount of time required to teach the self-
management procedures and the levels to which tar-
get behaviors decreased were investigated.The present
study, therefore, focused on the reduction of vocaliza-
tions with effects noted for (a) change in the target be-
havior, (b) change in collateral behaviors, (c) the
treatment effects across tasks, (d) the accuracy of the
student’s self-recording, and (e) time required to teach
the procedures.

METHOD, STUDY 1

Participant and Settings

Target student.The participant, Keri, a 12-year-
old African American girl, was diagnosed with autism
and moderate mental retardation. Keri attended sum-
mer school in a self-contained, special education
classroom located in an urban, elementary school set-
ting. On the Wecshler Intelligence Scale for Children
(Wecshler, 1974), Keri scored a 46 on the perfor-
mance subtest. No information concerning her verbal
subtest was provided. Her estimated full IQ range was
between 42 and 55. She read sight words and simple
sentences, had good verbal comprehension, and re-
sponded correctly to yes/no questions. She indepen-
dently participated in prevocational and leisure
activities. Of primary concern to her teacher was her
verbal behavior. Keri’s verbal communication (two-
to-three-word phrases) was continuously interrupted by
noises (humming, whistling, tongue clucking); and per-
severative vocalizations. She also exhibited stereotypic
body and facial movements. Assessments and inter-
views indicated that these behaviors were primarily
maintained by sensory stimulation. Keri’s teachers re-
ported that her vocalizations were very disruptive, and
interfered with her academic and social learning. Keri

600 Mancina, Tankersley, Kamps, Kravits, and Parrett

was most attentive in quiet environments with one-to-one
teaching situations.

Treatment Providers/Observers.All three indi-
viduals who participated in this study including the first
author, a research associate, and a doctoral student had
at least 5 years experience using behavioral techniques
to teach children with autism, behavior disorders,
and/or other developmental disabilities. Treatment
providers also served as observers for the study.

Setting. The experimental sessions were con-
ducted in a special education classroom (20 × 40 m),
located in a public school, 4 to 5 days a week. Sessions
lasted 5 minutes each. Four to six sessions were con-
ducted every morning within a 3-hour period. Keri fol-
lowed her regular morning schedule of activities with
self-management sessions conducted during typical
tasks (i.e., leisure, prevocational, and reading). Keri
was seated at her own desk located in the back of the
classroom. One treatment provider and one observer
sat in chairs placed on each side of her, and five stu-
dents were also working at individual desks.

Dependent Variables and Measurement

Dependent Variable/Target Behavior.The ob-
server recorded occurrence or nonoccurrence of three
categories of behavior: (a) vocalizations, (b) facial
movements, (c) and body movements during 10-second
intervals for 5 minutes. Occurrence of self-injurious be-
havior within 10-second intervals was also recorded.
The occurrence of vocalizations was identified as the tar-
get behavior, however, all three behaviors were mea-
sured to examine collateral effects of the self-management
procedures. Vocalizations were defined as (a) noises such
as humming, whistling, tongue clucking, and (b) perse-
verative (repeated) and echolalic words or phrases. Fa-
cial movements were recorded as any nonfunctional
movements of the face including exaggerated eye
blinks, rolling eyes, noncontextual smiling, tongue pro-
trusions, and raising and lowering of eyebrows. Body
movements were defined as any nonfunctional body
movements including hand and finger manipulations,
stomping feet, head butts, elbow jabs, and head jerks.
Any occurrence of self-injury, such as hand biting or
hitting her head, was recorded.

Observations.Data were collected by the treat-
ment providers. They randomly rotated between teach-
ing and supervising the self-management procedures
and recording the data. Data were collected using a 10-
second whole interval recording procedure to record
the occurrence or nonoccurrence of (a) target vocal-
izations, (b) facial movements, (c) and body move-

ments. When a self-injurious behavior was observed,
the observer placed a circle around the interval to in-
dicate the occurrence of a self-injurious behavior. Data
were recorded during leisure, prevocational, and read-
ing tasks. Data were not taken during self-reinforcement
(see Procedures).

Reliability. Interobserver reliability was collected
for each behavior during baseline and treatment
phases, for 38% (n = 36) of all sessions, using video-
tapes of sessions. The primary observer and the treat-
ment provider viewed the tapes simultaneously, while
scoring independently. An agreement was scored if
both observers recorded a “+” or when both recorded
a “−” for each behavior in an interval. Reliability was
measured by calculating the number of agreements be-
tween the two observers divided by the number of
agreements and disagreements, multiplied by 100. The
mean percentage of reliability for vocalizations was
95% (R = 63–100%), 87% (R = 63–100%) for facial
movements, and 89% (R = 75–100%) for body move-
ments.

Experimental Design and Procedures, Study 1

A multiple-baseline design (Kazdin, 1984) across
tasks was used to teach Keri to use self-management
procedures. Occurrences of the inappropriate vocal-
izations and collateral behaviors were recorded during
experimental conditions: baseline (A) and treatment
phases (B). Treatment (self-management) was only ap-
plied to inappropriate vocalizations, as the teacher de-
termined this to be the most problematic behavior.

Baseline (A).Data were collected during Keri’s
participation in leisure, prevocational, and reading tasks,
as included in her IEP and presented to her by the class-
room teacher. Baseline data were collected over 11 days
for the leisure task, 20 days for the prevocational task,
and 32 days for the reading task, Leisure task materials
included coloring and sticker books, drawing boards,
memory match games, photograph albums, and puzzles.
Prevocational materials/activities included sorting,
stamping, and collating items. Materials used during the
reading tasks included flash cards, worksheets, and the
student’s Edmark® reading book.

Treatment Phases (B).Self-management proce-
dures, adapted from a training manual by R. L. Koegel,
Koegel, and Parks (1990), were implemented first dur-
ing leisure tasks followed by, prevocational, and read-
ing tasks. The treatment procedures incorporated the use
of (a) the same classroom materials as used in baseline
tasks, (b) self-management materials, and (c) the teach-
ing of self-management including: identification of be-

Reduction of Inappropriate Vocalizations 601

haviors, self-recording, self-reinforcement, independent
use of the program, and assessing student accuracy.

Teaching the self-management programtook place
in Keri’s summer school classroom. Self-management
materials served as stimuli for Keri to perform the
self–management procedures and included a Timex dig-
ital watch with a repeat alarm to signal 10-second in-
tervals, self-recording sheets (i.e., a sheet of paper with
12 empty boxes with the words “quiet” and “noisy”
written beside them), visual prompts (i.e., 4 inch × 6
inch quiet card), and reinforcers. Keri was taught to
correctly identify her target behavior (i.e., vocaliza-
tions) through modeling. The treatment provider mod-
eled quiet and noisy behavior, asked Keri “Was I quiet
or noisy?” (with gestures toward cards with the words
quiet and noisy), reinforced correct responses and cor-
rected errors. When Keri responded correctly during 8
of 10 trials for five consecutive sessions, Keri was then
required to model quiet and noisy behavior in 8 of 10
trials (emphasis on quiet behavior), for three consecu-
tive sessions (emphasis on quiet).

Keri was then taught to assess target behavior
using the self-recording sheet. Training and continued
practice followed the instruction (i.e., “Get ready, show
me quiet.”) and an instruction to record in the quiet
box (or noisy box). Once Keri consistently marked the
box that described the behavior she was modeling, she
was taught self-recording using the watch, with initial
intervals of 5 seconds, as the longest observed dura-
tion that Keri could work, play, or sit without dis-
playing the target behavior (vocalizations). The watch
was started when the treatment provider gave the in-
struction to work quietly (“Get ready. Show me quiet
when you color.”). When the watch beeped, the treat-
ment provider stopped the watch, and Keri was asked
“Were you quiet or noisy?”. When Keri responded
(“quiet” or “noisy”) she was instructed to check that
particular box (e.g., “That’s right. You were quiet.
Check the quiet box.”). If Keri was incorrect in her re-
sponse, she was verbally corrected and instructed to
mark the appropriate box. Keri often said the word
“quiet” during the interval. This was considered an ap-
propriate verbalization. During intervals when Keri
was noisy, the treatment provider prompted her to be
quiet (e.g., “That’s noisy. Show me quiet. That’s bet-
ter. That’s quiet.”).

After Keri could successfully self-record her be-
haviors when signaled by the watch, she was taught
self-reinforcement.Before presentation of each new
self-recording sheet, a variety of rewards (e.g., pop-
corn, cereal, stickers, raisins,) were shown to Keri.
Keri was instructed to (a) select six small rewards (six

602 Mancina, Tankersley, Kamps, Kravits, and Parrett

in the interval beeps from 5 seconds to 10 seconds. The
prompt-fading sequence was faded to, “Were you quiet
or noisy?,” to “Check it,” and finally to a gestural
prompt (a point to the paper). Also, verbal prompts to
be quiet during the interval were only given during the
intervals after Keri was noisy, and prompts were tied
to the self-management procedure and materials. Cri-
teria for implementation to the second (third) task was
completion of the self-management steps, successful in-
crease to 10-second intervals, and decreases in vo-
calizations to 50% or less of the intervals for five
sessions.

pieces of cereal, popcorn, raisins), (b) write the name
of the reward at the top of the self-recording sheet,
and (c) put the rewards on her desk above her self-
recording sheet. Edibles were earned for quiet boxes.
She was instructed to do the same for the one “spe-
cial” reward (tape player, sticker, soda, or several
pieces of the smaller rewards), which she selected to
earn for reaching performance criteria (3 of 6 quiet
intervals, then 4 of 6).

Teaching independence in self-recordingfollow-
ing successful self-management, consisted of
(a) gradual fading of verbal prompts, and (b) an increase

Fig. 1. Percentage occurrence of vocalizations during leisure, prevocational, and reading tasks for Study 1.

Results and Discussion

Overall the target behavior, vocalizations, decreased
while collateral behaviors, facial and body movements,
showed variable changes with minimal generalization of
effects (Fig. 1 and Table I). During all tasks, the occur-
rence of vocalizations, facial movements, and body
movements ranged from 80–100% during baseline. Dur-
ing the treatment phase for leisure tasks (28 sessions),
self-management decreased vocalizations to 50% of the
intervals or less after 18 sessions. When self-management
was applied during prevocational tasks, the vocalizations
decreased to less than 50% occurrence after four sessions,
and continued to decrease to 20% occurrence or less. Dur-
ing reading tasks, the occurrence of vocalizations once
more decreased below 50% occurrence within the first
three sessions of self-management.

Though vocalizations remained below 50% oc-
currence, facial and body movements continued to
occur at higher rates than the target behavior. As de-
picted in Table I (means by condition, and last five ses-
sions of treatment), no change in facial movements
occurred following treatment for vocalizations during
leisure tasks, with some generalization of effects to
final sessions during prevocational and reading tasks.
Limited generalization was noted in the occurrence of
body movementsfollowing treatment for vocalizations.
Keri’s self-injurious behavior was recorded during
baseline and intervention. A total of 49 instances of
self-injury were noted during sessions. The frequency
was similar during baseline and treatment.

Results from Self-Management Procedures

Keri’s accuracy in self-recording her quiet and
noisy behavior was recorded during treatment phases
(5 sessions for leisure tasks, 3 sessions for prevocational

Reduction of Inappropriate Vocalizations 603

tasks, and 4 sessions for reading tasks). She averaged
85% accuracy per session with a range of 78–92%. The
initial teaching of the self-management steps required
6 days of intensive instruction for an average of 3 hours
a day, with training continuing during the leisure tasks
until Keri’s vocalizations decreased to 50% occurrence
or less. Keri required 2 days of teaching before vocal-
izations decreased to 50% occurrence during the prevo-
cational tasks, and required only 1 day of teaching during
reading. While vocalizations decreased, she did not reach
independence, still needing verbal and gestural prompts
to use the program.

STUDY 2: SELF-MANAGEMENT WITH THE
TEACHER AS TREATMENT PROVIDER

A continuation of self-management was conducted
with Keri in Study 2, beginning in the fall term with in-
corporation of the following procedures: (a) training the
classroom teacher as treatment provider in the self-man-
agement procedures, (b) lengthening the duration of the
interval for quiet behavior, (c) increasing the number of
intervals on the self-recording sheet, (d) gradually fad-
ing verbal prompts to increase independence, (e) fading
tangibles to natural reinforcers, and (f) fading the prox-
imity and presence of the treatment provider.

Participant, Setting, Design, and Procedures

The teacher, a paraprofessional, and five students
with autism, were present in the classroom. The class-
room teacher had 11 years of teaching experience in
special education classroom settings. Self-management
procedures were implemented during scheduled class-
room tasks involving leisure, prevocational, and read-
ing activities, as in Study 1. Self-management procedures
were conducted approximately 20–30 minutes a day,
four to five times a week.

Dependent Measures and Design.Dependent mea-
sures were identical to those in Study 1 with the same
definitions for the target and collateral behaviors. Oc-
currence of inappropriate vocalizations, facial and body
movements were recorded during continuous 10-second
observations for 5-minute sessions. Observers for Study
2 included the first author and a research assistant with
9 years of teaching experience with children with
autism. Reliability was computed for 9% of the data
files (14 of 137 sessions). Mean agreement was 91% (R
= 83–100%) for vocalizations, 83% (R = 52–100%) for
facial movements, and 80% (R = 67–100%) for body
movements. A multiple-baseline design was used to
evaluate treatment effects across tasks.

Table I. Means for Facial and Body Movement, Self-Injurious
Behavior Across Conditions During Study 1

Task Baseline Treatment for vocalizations

Mean percentage occurrence—Facial Movements
Leisure 89 83 (87, final 5 sessions)
Pre-Voc 92 74 (68, final 5 sessions)
Reading 94 84 (73, final 5 sessions)

Mean percentage occurrence—Body Movements
Leisure 83 84 (79, final 5 sessions)
Pre-Voc 87 79 (82, final 5 sessions)
Reading 95 89 (81, final 5 sessions)

Frequency of self-injurious behavior
Leisure 0.250 0.285 (0.00, final 5 sessions)
Pre-Voc 0.060 0.625 (0.00, final 5 sessions)
Reading 0.176 0.100 (0.20, final 5 sessions)

Baseline. Baseline observations occurred during
Keri’s regular leisure, prevocational and reading tasks
with the same materials used in Study 1 and no self-
management procedures.

Self-Management Procedures.In Study 2, the role
of the treatment provider was transferred to the class-
room teacher. Teacher training included (a) task analy-
sis of each component of self-management procedures,
(b) videotaped examples of the student using self-man-
agement procedures, (c) modeling of prompting and self-
management procedures by the first author, and (d)

604 Mancina, Tankersley, Kamps, Kravits, and Parrett

monitoring and feedback concerning her performance as
treatment provider for 5 days of training. Once the
teacher training was completed, self-management pro-
cedures identical to those used in Study 1 were imple-
mented: (a) identification of target behavior, (b)
recording of the target behavior, (c) self-recording using
the watch, and (d) self-reinforcement.

During the treatment phase, the number of self-
recording boxes per page was increased from 6 to 10.
The duration of intervals ranged from 10–40 seconds,
and was variable throughout all treatment phases. If Keri

Fig. 2. Percentage occurrence of vocalizations during leisure, prevocational, and reading tasks for Study 2.

Reduction of Inappropriate Vocalizations 605

exhibited vocalizations and was not successful (i.e., did
not earn a reward using the self-management procedures)
on three consecutive self-recording sheets, the duration
of the interval was lowered. Also, the number of suc-
cessful (i.e., quiet) intervals required to receive a reward
was increased to 8 of 10 quiet intervals.

In Study 2, limited independence with self-man-
agement procedures was obtained. Verbal prompts and
gestural prompts were faded; however, Keri frequently
required gestural prompts toward the end of the ses-
sions. Because Keri continued to require prompts to re-
main on-task, proximity by the treatment provider was
limited to the area within the classroom.

Results and Discussion

In Study 2, vocalizations decreased, facial move-
ments remained unchanged, and body movements de-
creased. As depicted in Figure 2, baseline levels of
vocalizations were high (76–97%), with a decrease to
41% occurrence in the first treatment session, and con-
tinued decreases to near zero levels. Self-management
during prevocational tasks decreased vocalizations to
below 20% after the first treatment session, with zero
levels during several sessions of the treatment phase.
During reading, vocalizations decreased to lower lev-
els; however, the decrease was variable, ranging from
0–60% occurrence. An increase in final sessions ap-
peared to be related to task difficulty. Facial movements
showed some variability but continued to occur at
higher rates than vocalizations. Body movements de-
creased to lower levels during treatment for vocaliza-
tions, indicating some generalization of treatment
effects. Self-injurious behavior was somewhat lower

during the Study 2 period, except during frustrating
tasks (see Table II).

GENERAL DISCUSSION

Similar to positive findings in prior research (e.g.,
R. L. Koegel & Koegel, 1990; Reese, Sherman, & Shel-
don, 1984), self-management was highly effective in
decreasing inappropriate vocalizations. In general,
treatment effects were slower during the initial program
(Study 1, Task 1) with quicker results for the second
and third tasks and during Study 2. In addition, both
teachers reported that Keri was much quieter with more
appropriate behavior when using the self-management
program. Generalization of treatment effects were noted
for one of two collateral behaviors. Though the findings
were encouraging, a limitation was that Keri did not learn
complete independence, nor were procedures able to be
faded within the period of study. Larger changes in tar-
get and collateral behaviors may have been obtained with
(a) the use of behavioral programming to address behav-
iors such as noncompliance, (b) an augmentative com-
munication system, and (c) programs to increase social
competencies. Longer treatment may also be necessary
for students with (a) lower cognitive ability, (b) high
rates of challenging behaviors, rates, and (c) a long his-
tory of behaviors with insufficient interventions (R. L.
Koegel, Koegel, Van Voy, & Ingham, 1988).

ACKNOWLEDGMENT

This research was supported by the Office of Spe-
cial Education and Rehabilitation Services, U.S. De-
partment of Education, Grant H023C00024 to the
University of Kansas.

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Table II. Means for Facial and Body Movements, Self-Injurious
Behavior Across Conditions During Study 2

Task Baseline Treatment for vocalizations

Mean percentage occurrence—Facial Movements
Leisure 71 72 (62, final 5 sessions)
Pre-Voc 84 82 (89, final 5 sessions)
Reading 83 80 (78, final 5 sessions)

Mean percentage occurrence—Body Movements
Leisure 71 52 (35, final 5 sessions)
Pre-Voc 82 66 (58, final 5 sessions)
Reading 85 74 (59, final 5 sessions)

Frequency of self-injurious behavior
Leisure 0.000 0.090 (0.00, final 5 sessions)
Pre-Voc 0.000 0.000 (0.00, final 5 sessions)
Reading 0.420 1.500 (2.80, final 5 sessions)

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Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the

individual use.

REVIEW PAPER

Treatment of Echolalia in Individuals with Autism Spectrum
Disorder: a Systematic Review

Leslie Neely1 & Stephanie Gerow2 & Mandy Rispoli3 & Russell Lang4 & Nathan Pullen4

Received: 15 October 2015 /Accepted: 25 November 2015 /Published online: 4 December 2015
# Springer Science+Business Media New York 2015

Abstract Echolalia can lead to communication breakdowns
that increase the likelihood of social failure and stigmatization
in children with autism spectrum disorder (ASD). In an effort
to facilitate evidenced-based intervention and inform future
research, this systematic review analyzes peer-reviewed stud-
ies involving the treatment of echolalia in individuals with
ASD. Using predetermined inclusion criteria, a total of 11
studies were identified, reviewed, and summarized in terms
of the following: (a) participant characteristics (e.g., verbal
and cognitive functioning), (b) type of echolalia (e.g., delayed
or immediate), (c) intervention procedures, (d) intervention
outcomes, (e) maintenance and generalization of outcomes,
and (f) research design and other indicators of rigor (i.e., cer-
tainty of evidence). Nine studies successfully reduced echola-
lia in a total of 17 participants. However, only six of those nine
studies met criteria to be classified as providing the highest
level of certainty (i.e., conclusive). The findings of this review
suggest that a number of treatment options can be considered
promising practices for the treatment of echolalia in children
with ASD. Although no single treatment package can be de-
scribed as well-established evidence-based practice, all 11
studies involved behavior analytic intervention components,
suggesting strong support for operant-based treatments. In
particular, behavior analytic interventions demonstrating

conclusive levels of evidence included cues-pause-point, dif-
ferential reinforcement of lower rates of behavior, script train-
ing plus visual cues, and verbal modeling plus positive rein-
forcement for appropriate responses. Implications for practi-
tioners and directions for future research are offered.

Keywords Autism spectrum disorder . Echolalia .

Treatment . Systematic review

Autism spectrum disorder (ASD) is a developmental disorder
characterized by deficits in social communication skills and
excesses in repetitive and restrictive patterns of behaviors
(Diagnostic and Statistical Manual of Mental Disorders [5th
ed.; DSM-5]; American Psychiatric Association [APA] 2013).
The combination of behavioral excesses and deficits can man-
ifest as a repetitive, restricted pattern of vocal behavior called
echolalia (Stribling et al. 2007). Echolalia is typically defined
as the socially awkward or inappropriate verbatim repetition
of part or all of a previously spoken utterance (Karmali et al.
2005; Stribling et al. 2007; Valentino et al. 2012). The initial
utterance, that is then repeated, may come from another per-
son in the environment or from a recording (television or
audio source) and maybe immediate or delayed. Immediate
echolalia occurs when the latency between initial utterance
and repetition is within a few seconds, whereas delayed
echolalia occurs when the time between the initial utterance
and the repetition involves longer durations, inclusive of
repetitions occurring days after the initial utterance being
echoed (Foxx et al. 2004; Hetzroni and Tannous 2004).
Another form of echolalia is palilalia. Palilalia involves the
repeating of one’s own words in a quiet whispered voice
immediately following the initial typical volume utterance
(Karmali et al. 2005).

* Leslie Neely
leslie.neely@utsa.edu

1 Department of Educational Psychology, The University of Texas at
San Antonio, 501 W. Cesar E. Chavez Blvd., San
Antonio, TX 78207-4415, USA

2 Texas A&M University, College Station, TX, USA
3 Purdue University, West Lafayette, IN, USA
4 Texas State University, San Marcos, TX, USA

Rev J Autism Dev Disord (2016) 3:82–91
DOI 10.1007/s40489-015-0067-4

http://crossmark.crossref.org/dialog/?doi=10.1007/s40489-015-0067-4&domain=pdf

Although language repetition is part of typical child
development (Howlin 1982). some children with ASD en-
gage in echolalia that persists past the early childhood
developmental period (Barrera and Sulzer-Azaroff 1983;
Neely 2014; Fay 1969). In addition, children with ASD
often engage in echolalia that lacks social context Lovaas
et al. 1973) and occurs at a higher rate than in typically
developing children (Fay 1973).

Echolalia may (a) complicate educational programs de-
signed to improve speech, (b) contribute to communication
breakdowns, (c) increase the likelihood of social failure or
stigmatization, and (d) increase the risk of challenging behav-
ior (Light et al. 1998; Valentino et al. 2012). For example,
Valentino et al. (2012) identified a 3-year-old male with
ASD who repeated the instruction Bsay^ during echoic train-
ing. The immediate echolalia was interfering with instruction
and complicating the educational program aimed at teaching
the child to tact. Previous research aimed at identifying the
operant function of echolalia suggests that the complete range
of functions found to maintain other behaviors (e.g., automatic
reinforcement, socially mediated positive reinforcement, and
socially mediated negative reinforcement) may also reinforce
and maintain echolalia (Goren et al. 1977; Healy and Leader
2011).

A descriptive review by Kavon and McLaughlin (1995)
identified two interventions with preliminary support for the
treatment of echolalia (i.e., cues-pause-point and more general
verbal prompting interventions). Cues-pause-point is a behav-
ioral intervention that has been evaluated for the treatment of
immediate echolalia. Cues-pause-point was introduced by
McMorrow and Foxx (1986) in their treatment of a 21-year-
old male with ASD. The cues-pause-point intervention con-
sists of a trainer providing a visual cue to the learner to remain
silent (cue). The trainer then maintains the visual cue while
providing instructions about the upcoming teaching session.
The trainer poses a question and provides a short pause fol-
lowing the question (pause). Finally, the trainer points to a
card to prompt the learner to verbalize the answer to the ques-
tion (point). For example, to teach the individual with ASD to
respond appropriately to the question, BWhat is your name?,^
the trainer held up an index finger to cue silence (cue), stated,
BI’m going to ask you some questions, do your best to answer
them correctly^ (pause), asked the question, pointed to a card
with the person’s name prompting the correct response
(point), and then provided reinforcement contingent on the
correct response. Following the initial study by McMorrow
and Foxx, follow-up studies extended the procedure to indi-
viduals with less developed language skills (McMorrow et al.
1987) and individuals with intellectual disabilities (Foxx,
Faw, McMorrow, Kyle, & Bittle 1988) and then demonstrated
that reductions of echolalia following cues-pause-point could
be maintained up to 57 months following the cessation of the
intervention (Foxx and Faw 1990).

Kavon and McLaughlin’s (1995) review categorized the
remaining interventions as verbal prompting intervention

Studies in that category used a combination of reinforcement,
prompting, and error correction to reduce echolalia but did not
utilize the more specific sequence of cues-pause-point (e.g.,
Freeman et al. 1975; Lovaas 1977). For example, Freeman
et al. (1975) used positive reinforcement for correct
responding to questions and an error prevention procedure
(consisting of interrupting the echolalia) to treat the echolalia
of a 5-year-old male with autism. The intervention produced
decreases in echolalia that maintained following the with-
drawal of intervention. Although the review by Kavon and
McLaughlin provides evidence in support of these interven-
tions, additional studies have emerged over the last 20 years
and an updated systematic review appears warranted.

Therefore, the purpose of this review is to update and ex-
tend the previous review by Kavon and McLaughlin by (a)
utilizing broader inclusion criteria not limited to behavioral
(operant) approaches, (b) conducting a systematic review of
the literature, (c) rating each included study’s certainty of ev-
idence (quality of research design and controls) so results can
be considered in light of each study’s methodological rigor,
and (d) identifying advances in treatment that may have de-
veloped since the previous review. A review of this nature is
intended to offer directions for future research and to provide
guidance to practitioners interested in the use of evidence-
based treatments for echolalia in children with ASD.

Method

Search Procedures

Four electronic databases were searched to identify potential
studies for this review: ERIC (EBSCO), Medline, Psychology
and Behavioral Sciences Collection, and PsycINFO. There
were no limitations on publication year, but results were lim-
ited to English language, peer-reviewed research. Terms to
describe individuals with an ASD were combined with terms
to describe echolalia. The terms for individuals with an ASD
included BAsperger,^ Bautis*,^ Bdevelopmental disab*,^
BASD,^ and BPDD-NOS.^ The terms searched to describe
echolalia included Becholal*,^ Brepetitive speech,^ Brepetitive
verbal*,^ Brepetitive talking,^ Brepetitive communication*,^
and Bpalilalia.^ Following the initial search, the last name of
the first author of each included study was also entered into
PsychINFO to identify any other potentially relevant studies
that had been published by that author. Finally, the reference
list of Kavon and McLaughlin (1995) was examined for ad-
ditional studies meeting inclusion criteria.

These search procedures were conducted in May 2014,
updated in April 2015, and yielded a total of 568 articles
(534 from the original search and 34 from the updated search).

Rev J Autism Dev Disord (2016) 3:82–91 83

The title and abstracts of the 568 articles were screened using
the predetermined inclusion criteria (see BInclusion Criteria^
section) to identify articles for potential inclusion in this re-
view. Following this screening of title and abstracts, a total of
46 articles were identified for further review.

Inclusion Criteria

The 46 articles were then downloaded and evaluated based on
the pre-set inclusion criteria. Studies were included if they (a)
included a participant diagnosed with ASD or was described
as an individual with Bautistic-like behaviors^ (included due
to the age of the literature base), (b) implemented an interven-
tion and reported outcomes for echolalia (inclusive of palilalia
and defined as repetition of a previously spoken word or
phrase) as a dependent variable, (c) employed an experimental
design (inclusive of single-case and group experimental de-
signs), and (d) echolalia outcomes for the individual with
ASD could be disaggregated from participants without ASD
and target behaviors other than echolalia. Studies which im-
plemented interventions for individuals with ASD who uti-
lized echolalic speech but did not present outcomes related
to the echolalia were excluded (e.g., Barrera and Sulzer-
Azaroff 1983; Charlop-Christy and Kelso 2003; Charlop
1983). Studies which evaluated echolalia under different con-
ditions but did not implement an intervention to address echo-
lalia were also excluded (e.g., Rydell and Mirenda 1994;
Violette and Swisher 1992). In addition, studies which imple-
mented interventions to treat other repetitive speech (i.e.,
noncontextual vocal stereotypy, such as a sound rather than a
word or phrase) were excluded (e.g., Mancia et al. 2000; Ahearn
et al. 2000; Taylor et al. 2005). Studies excluded because data
on echolalia were not disaggregated from other outcomes in-
volving other topographies of behavior were Arntzen et al.
(2006) and Mancia et al. (2000). For example, Arntzen et al.
(2006) taught a 44-year-old woman functional verbal responses
and tracked subsequent decreases in aberrant verbal behavior.
Although aberrant verbal behavior included repetitive echolalic
responses, the aberrant verbal behavior also included
Bpsychotic^ verbalizations and results for the two were
collapsed into one dependent variable. Finally, Cohen (1981)
was excluded because the figure referenced in the article was
not included in the article and was not accessible to the authors
after multiple attempts to locate the figure through university-
based library services. Ultimately, a total of 11 studies met
inclusion criteria and were included in this review.

Descriptive Synthesis

Included studies were reviewed and summarized based on the
following categories: (a) participant characteristics (e.g., ver-
bal and cognitive functioning), (b) type of echolalia (e.g., de-
layed or immediate), (c) intervention procedures, (d)

intervention outcomes, (e) maintenance and generalization
of outcomes, and (f) research design and other indicators of
rigor (i.e., certainty of evidence). Participant description in-
cluded the number of participants with ASD, their ages, and
gender. Participant verbal and cognitive functioning was cod-
ed using reported standardized assessments or was gleaned
from detailed descriptions of participant functioning.
Echolalia was coded as either immediate, delayed, or palilalia,
and when noted in the reviewed study, the operant function of
echolalia was noted. Various procedural aspects were coded to
identify intervention protocols or components (e.g., cues-
pause-point protocol, script training, or reinforcement
procedures)

Intervention outcomes were summarized and coded as nega-
tive, mixed, or positive. As all 11 studies employed single-case
research designs, study outcomes were determined based on vi-
sual analysis criteria for single-case research outlined by
Kennedy (2005). A study was rated as having negative results
if there was no reduction observed in echolalia as indicated by a
flat or increasing trend in the intervention phase as compared to
the baseline phase. Studies were coded as having mixed results if
some, but not all, of the participants demonstrated a reduction in
echolalia during the intervention phase relative to the baseline
phase. Positive results indicated that echolalia decreased in all
participants during intervention phase as relative baseline.

The study’s capacity to provide a certainty of evidence was
rated as suggestive, preponderant, or conclusive, with conclu-
sive being the highest rating (Schlosser 2009; Simeonsson and
Bailey 1991; Smith 1981). Studies rated as conclusive had the
following: (a) an experimental design capable of establishing
experimental control (e.g., ABAB, multiple-baseline design,
alternating treatments design), (b) sufficient interobserver
agreement (IOA) collected on the observed educator behav-
iors (i.e., agreement coefficients above 80 % and IOA collect-
ed for a minimum of 20 % of the sessions), (c) intervention
procedures detailed enough to promote replication of the pro-
cedures, (d) operationalized descriptions of the dependent var-
iable, and (e) demonstrated convincing effects of the interven-
tion for every participant (i.e., received a rating of positive
results). A study rated as preponderant met most of the criteria
for a Bconclusive^ study, but results may have demonstrated
Bmixed^ effects of the intervention for some or all of the
participants with ASD. Any study that (a) lacked an experi-
mental design capable of establishing experimental control,
(b) did not meet the minimum IOA criterion, (c) did not
operationally define the intervention procedures, (d) or did
not operationally define the dependent variable were auto-
matically rated as offering suggestive evidence.

Interrater Reliability

Inclusion Criteria To ensure accurate application of the in-
clusion criteria, two raters reviewed each of the 46 articles,

84 Rev J Autism Dev Disord (2016) 3:82–91

resulting from the systematic search and initial title/abstract
review, for potential inclusion. Agreement was reached on
whether to include or exclude a study on 100 % of the articles.

Descriptive Synthesis To establish interrater reliability (IRR)
for the data summaries, two independent raters coded five of
the 11 included articles (46 %). A third rater reviewed the
independent data summaries and made a decision as to wheth-
er the summaries agreed. IRR was calculated based on wheth-
er the two raters agreed on the extracted data. There were a
total of 30 items in which there could be agreement or dis-
agreement (i.e., five studies with six data categories each).
IRR was calculated using percent agreement by dividing the
total number of agreements by the sum of the agreements and
disagreements and multiplying by 100 % to convert to a per-
centage. Initial agreement for the coding of studies was 90 %.
In instances of disagreement, the raters discussed until 100 %
agreement was reached.

Results

Table 1 created from the coded study summarizes and displays
each study according to the following: (a) participant charac-
teristics (e.g., verbal and cognitive functioning), (b) type of
echolalia (e.g., delayed or immediate), (c) intervention proce-
dures, (d) intervention outcomes, (e) maintenance and gener-
alization of outcomes, and (f) research design and other indi-
cators of rigor (i.e., certainty of evidence).

Participant Characteristics

The 11 studies included a total of 25 participants with ASD.
Ten of the 11 studies reported the gender of their participants
with 17 male and 5 female participants. One study did not
report participants’ gender (Laski et al. 1988). All of the stud-
ies reported the participants’ ages, with a mean reported age of
8 years (range 3–21 years) across studies.

Ten studies (90 %) reported information regarding partici-
pants’ verbal or cognitive functioning. Four studies (36 %)
reported results from standardized cognitive assessments
(i.e., Stanford-Binet, Merrill-Palmer, and Peabody Picture
Vocabulary Test (PPVT)) with three studies including four
participants with extremely low cognitive functioning (16 %;
Handen et al. 1984; McMorrow and Foxx 1986; Nientimp and
Cole 1992) and one study including one participant with
below-average to average cognitive functioning (4 %;
Freeman et al. 1975). Three studies (27 %) reported results
from standardized language assessments (i.e., Alpern-Boll
and PPVT-III) indicating extremely low verbal abilities and
below-average cognitive functioning for eight of the 25 par-
ticipants (32 %; Foxx et al. 2004; Karmali et al. 2005; Palyo
et al. 1979). Five of the studies reported descriptive

information regarding the language functioning of partici-
pants, all of which suggested below-average verbal abilities
for 16 of the 25 participants (64 %; Ganz et al. 2008; Hetzroni
and Tannous 2004; Karmali et al. 2005; Laski et al. 1988;
Valentino et al. 2012).

Type of Echolalia

Across the 11 studies, five targeted immediate echolalia only
(45 %; Foxx et al. 2004; McMorrow and Foxx 1986;
Nientimp and Cole 1992; Palyo et al. 1979; Valentino et al.
2012), two targeted delayed echolalia only (18 %; Ganz et al.
2008; Handen et al. 1984), and three studies (27 %) targeted
both immediate and delayed echolalia (Freeman et al. 1975;
Hetzroni and Tannous 2004; Laski et al. 1988). Finally, one
study targeted palilalia (Karmali et al. 2005). No study report-
ed operant functions of target behaviors.

Intervention Procedures

All of the 11 studies employed an intervention with behavioral
analytic components (e.g., differential reinforcement, model-
ing, prompting). Five of the 11 studies (45 %) evaluated the
effects of specific treatment package on echolalia (i.e., cues-
pause-point; Natural Language Paradigm, and computer-
based intervention). Cues-pause-point was the most frequent
treatment package evaluated (n=3; 27 %; Foxx et al. 2004;
McMorrow and Foxx 1986; Valentino et al. 2012). For exam-
ple, Valentino and colleagues (2012) evaluated the use of
cues-pause-point to treat a 3-year-old male child who echoed
the instruction say during echoic training. Decreased echolalia
and increase appropriate responding (e.g., repeating the target
word without echoing say) were noted.

Laski et al. (1988) trained parents to implement the Natural
Language Paradigm within a clinical setting and then assessed
the effects of the parent implemented program on child com-
munication outcomes. Parents were taught to use direct rein-
forcement of verbal attempts, to promote turn-taking with play
items, to vary stimuli and exemplars, and to utilize shared
control (i.e., rotating between child-led and parent-led activi-
ties). Although appropriate vocalizations were the primary
dependent variable, child engagement in echolalia was mea-
sured as an ancillary variable with mixed results noted for the
effects of the Natural Language Paradigm on echolalia.

The final treatment package was a computer program enti-
tled BI Can Word It Too^ that was available in both Arabic and
Hebrew (Hetzroni and Tannous 2004). The program presented
participants with a simulated situation in which a parent asked
the participant a question. The participant would then choose
the appropriate sentence or question option, and an animation
of their choice would be played. For example, if the question
was Bwhat would you like to play with^ and the participant
selected the option BI want to play ball with you,^ an

Rev J Autism Dev Disord (2016) 3:82–91 85

T
ab

le
1

In
te
rv
en
ti
on
s
st
ud
ie
s
to

d
ec
re
as
e

ec
h
o
la
li
a

fo
r
in
d
iv
id
u
al
s

w
it
h

A
S
D

A
rt
ic
le

P
ar
ti
ci
p
an
t
ch
ar
ac
te
ri
st
ic
s

T
y
p
e
o
f
ec
h
o
la
li
a

In
te
rv
en
ti

o
n

p
ro
ce
d
u
re

In
te
rv
en
ti
o
n

o
u
tc
o
m
es

M
ai
n
te
n
an
ce

an
d

g
en
er
al
iz

at
io
n

o
f
o
u
tc
o
m
es

C
er
ta
in
ty

o
f
ev
id
en
ce

F
o
x
x

et
al
.

(2
0
0
4
)

n
=
2
;
m
al
es
;
5
an
d
6

y
ea
rs

P
1
:
P
P
V
T
-I
II
4
0
(s
ta
n
d
ar
d
sc
or
e)
;

E
O
W
V
T
5
5
(s
ta
n
d
ar
d
sc
o
re
);

C
A
R
S
3
7
;
G
A
R
S
A
u
ti
sm

Q
u
ot
ie
n
t
9
7

P
2
:
P
P
V
T
-I
II
4
0
(s
ta
n
d
ar
d
sc
or
e)
;

E
O
W
V
T
5
8
(s
ta
n
d
ar
d
sc
o
re
);

C
A
R
S
4
0
;
G
A
R
S
A
u
ti
sm

Q
u
ot
ie
n
t
8
3

R
ep
ea
te
d
w
o
rd
s
co
n
ta
in
ed

in
an

as
k
ed

q
u
es
ti
o
n
;

m
ed
ia
te

ec
h
o
la
li
a

C
ue
s-

p
au
se

-p
o
in
t

P
os
it
iv
e

P
o
si
ti
v
e

u
si
n
g
a
g
ra
d
u
al

in
te
rv
en
ti
o
n
fa
d
in
g

p
ro
ce
d
ur
e)
/
p
o
si
ti
v
e

ac
ro
ss

n
o
v
el
se
tt
in
g
,
an
d

n
o
ve
l

tr
ai
ne
r

C
o
n
cl
u
si
v
e

F
re
em

an
et
al
.

(1
9
75
)

n
=
1
;
m
al
e;
5
y
ea
rs

N
o
st
an
d
ar
d
iz
ed

la
n
g
u
ag
e

as
se
ss
m
en
t;
IQ

as
se
ss
m
en
ts

ra
n
g
ed

fr
o
m
8
1
(S
ta
nf
o
rd
-B
in
et
)

to
1
2
0
(M

er
ri
ll
-P
al
m
er
).

Im
m
ed
ia
te
an
d

d
el
ay
ed

ec
h
o
la
li
a

P
o
si
ti
v
e

re
in
fo
rc
em

en
t

fo
r
co
rr
ec
t
an
sw

er
s

an
d
er
ro
r
co
rr
ec
ti
o
n

p
ro
ce
d
u
re

to
b
lo
ck

ec
h
o
la
li
a
P
os
it
iv
e

N
o
t
re
p
o
rt
ed
/

n
o
t

re
p
o
rt
ed

S
u
g
ge
st
iv
e;
A
B
A

d
es
ig
n
;
IO

A
w
as

n
o
t
as
se
ss
ed

G
an
z
et
al
.

(2
0
08
)

n
=
2
m
al
es
;
7
an
d
1
2

y
ea
rs
b

N
o
st
an
d
ar
d
la
n
g
u
ag
e

as
se
ss
m
en
ts
.

N
o
co
g
n
it
iv
e
as
se
ss
m
en
ts
.

P
1
:
d
if
fi
cu
lt
y
w
it
h
W
h
–
q
u
es
ti
o
n
s;

ag
e-

ap
p
ro
p
ri
at
e

p
h
o
n
o
lo
g
ic
al

an
d
se
m
an
ti
c

sp
ee
ch

P
2
:
A
g
e-
ap
p
ro
p
ri
at
e
p
ho
n
o
lo
g
ic

an
d
se
m
an
ti
c
sk
il
ls
;
ra
re
ly

in
it
ia
te
d
co
n
v
er
sa
ti
o
n
.

P
1
:
R
ep
ea
te
d
p
h
ra
se
s
fr
o
m

te
le
v
is
io
n
an
d
v
id
eo

g
am

es
;
d
el
ay
ed

ec
h
ol
al
ia

P
2
:
R
ep
ea
te
d
p
h
ra
se
s
fr
o
m

so
n
g
s
an
d
b
o
o
k
s;
de
la
y
ed

ec
h
o
la
li
a

S
cr
ip
t
tr
ai
n
in
g
an
d

v
is
u
al
cu
es

P
os
it
iv
e

N
o
t
re
p
o
rt
ed
/n
o
t
re
p
o
rt
ed

C
o
n
cl
u
si
v
e

H
an
d
en

et
al
.

(1
9
84
)

n
=
1
;
m
al
e;
1
6
y
ea
rs

N
o
st
an
d
ar
d
iz
ed
la
n
g
u
ag
e

as
se
ss
m
en
t;
m
en
ta
l
ag
e
o
f

5
y
ea
rs
11

m
o
n
th
s

(S
ta
n
fo
rd
-B
in
et
).

R
ep
ea
te
d
st
at
em

en
ts
an
d
/o
r

as
k
in
g
sa
m
e
q
u
es
ti
o
n

m
u
lt
ip
le
ti
m
es

a
d
ay
;

d
el
ay
ed
ec
h
o
la
li
a

D
if
fe
re
n
ti
al
re
in
fo
rc
em

en
t

o
f
lo
w
er

ra
te
s

P
os
it
iv
e

P
o
si
ti
v
e
at
9
an
d
1
4
m
o
n
th
s

fo
ll
o
w
-u
p
/n
o
t
re
po
rt
ed

C
o
n
cl
u
si
v
e

H
et
zr
o
n
i
an
d

T
an
n
o
u
s
(2
0
0
4
)

n
=
5
;
3
m
al
es

an
d
2
fe
m
al
es
;

7
.8
,
8
,
8
.5
,
11
.5
,
an
d
1
2
.5

y
ea
rs
N
o
st
an
d
ar
d
iz
ed
la
n
g
u
ag
e

as
se
ss
m
en
ts
.
N
o
co
g
n
it
iv
e

as
se
ss
m
en
ts
.

Im
m
ed
ia
te
an
d
d
el
ay
ed

ec
h
o
la
li
a

S
o
ft
w
ar
e
p
ro
g
ra
m

(I
C
an

W
o
rd

it
T
o
o
)

ix
ed

N
o
t
re
p
o
rt
ed
/r
es
u
lt
s

g
en
er
al
iz
ed

to
au
th
en
ti
c

se
tt
in
g
s

fo
r
so
m
e
p
ar
ti
ci
p
an
ts

S
u
g
ge
st
iv
e;
o
n
e
le
g

o
f
ev
er
y
p
ar
ti
ci
p
an
t’
s

M
B
D

d
id

n
o
t

d
em

o
n
st
ra
te
ef
fe
ct
s;

ad
d
it
io
n
al
in
fo
rm

at
io
n

n
ec
es
sa
ry

fo
r
re
p
li
ca
ti
o
n

of
in
te
rv
en
ti
on

K
ar
m
al
i
et
al
.(
2
0
0
5
)

N
=
5
;
4
m
al
e
an
d
1
fe
m
al
e;

3
to

4
y
ea
rs

N
o
rm

-r
ef
er
en
ce
d
as
se
ss
m
en
ts

in
d
ic
at
ed

sp
ee
ch

d
el
ay
s
fo
r
al
l

p
ar
ti
ci
p
an
ts
;
n
o
co
gn
it
iv
e

as
se
ss
m
en
ts
re
p
o
rt
ed

P
al
il
al
ia
w
as

al
l
re
la
te
d
to

ch
il
d
re
n
’s
m
o
v
ie
s
o
r

so
n
g
s;
d
el
ay
ed

p
al
il
al
ia

T
ac
t
m
od
el
in
g
p
lu
s

p
o
si
ti
ve

re
in
fo
rc
em
en
t

o
f
ap
p
ro
p
ri
at
e
re
sp
o
ns
es

P
os
it
iv
e

N
o
t
re
p
o
rt
ed
/p
o
si
ti
v
e

ac
ro
ss
se
tt
in
g
s
C
o
n
cl
u
si
v
e

L
as
k
i
et
al
.
(1
9
8
8
)

n
=
3
;
g
en
de
r
n
o
t
sp
ec
if
ie
d
;

5
.8
,
6
.2
,
an
d
8
.1
1
y
ea
rs
a

Im
m
ed
ia
te
an
d
d
el
ay
ed
ec
h
o
la
li
a

N
at
u
ra
l
L
an
g
u
ag
e

P
ar
ad
ig
m

M
ix
ed
N
o
t
re
p
o
rt
ed
/n
o
t
re
p
o
rt
ed

S
u
g
ge
st
iv
e
(e
ch
o
la
li
a
w
as

an
an
ci
ll
ar
y
d
ep
en
d
en
t

v
ar
ia
b
le
)

86 Rev J Autism Dev Disord (2016) 3:82–91

T
ab
le
1

(c
o
n
ti
n
u
ed
)

A
rt
ic
le
P
ar
ti
ci
p
an
t
ch
ar
ac
te
ri
st
ic
s
T
y
p
e
o
f
ec
h
o
la
li
a

In
te
rv
en
ti
o
n
p
ro
ce
d
u
re
s

In
te
rv
en
ti
o
n
o
u
tc
o
m
es
M
ai
n
te
n
an
ce

an
d

g
en
er
al
iz
at
io
n

o
f
o
ut
co
m
es

C
er
ta
in
ty
o
f
ev
id
en
ce
N
o
st
an
d
ar
d
iz
ed
la
n
g
u
ag
e

as
se
ss
m

en
ts
;

P
1:

co
u
ld

im
it
at
e

so
un
d
s
an
d
a
fe
w
w
o
rd
s
o
n

re
q
u
es
t,
ra
re
ly

in
it
ia
te
d
,
an
d

re
ce
p
ti
v
e
v
o
ca
b
u
la
ry

le
ss

th
an

1
5
w
o
rd
s.
P
6
an
d
P
8
:
Bl
ar
g
er

v
o
ca
b
u
la
ri
es
^
an
d
us
ed

sh
o
rt

p
h
ra
se
s;
ra
re
ly

sp
o
k
e

sp
on
ta
n
eo
u
sl
y.

M
cM

o
rr
o
w

an
d
F
ox
x
(1
9
8
6
)

&
F
o
x
x
an
d
F
aw

(1
9
9
0
)

n
=
1
;
m
al
e;
2
1
y
ea
rs

N
o
st
an
d
ar
d
iz
ed
la
n
g
u
ag
e

as
se
ss
m
en
t.
N
o
v
er
b
al

in
it
ia
ti
on
s;
d
id

n
o
t
re
sp
o
n
d
to

q
u
es
ti
o
n
s;
n
ea
rl
y
al
l

v
er
b
al
iz
at
io
n
s
w
er
e
ec
h
o
la
li
c.

IQ
o
f
4
0
u
si
n
g
th
e
P
P
V
T
.

R
ep
ea
te
d
st
at
em
en
ts
;

im
m
ed
ia
te
ec
h
o
la
li
a

E
x
p
er
im

en
t
1
:
cu
es
-p
au
se
–

po
in
t
an
d
th
en

p
au
se

o
n
ly

E
x
p
er
im

en
t2

an
d
3
:m

o
d
el
in
g

P
o
si
ti
v
e

P
o
si
ti
v
e
at
5
7
m
o
n
th
s
fo
ll
o
w
-u
p

(F
o
x
x
an
d
F
aw

1
9
9
0
)/
re
su
lt
s

d
id

n
o
t
g
en
er
al
iz
e
to

n
ew

q
u
es
ti
o
n
(c
u
es
-p
au
se
-p
o
in
t

n
o
t
u
se
d
in

g
en
er
al
iz
at
io
n

p
ro
b
es
)

C
o
nc
lu
si
v
e

N
ie
n
ti
m
p
an
d

C
o
le

1
9
9
2

n
=
3
;
2
m
al
es

an
d
1
fe
m
al
e;
1
2
,

1
2
.8
,
1
3
.4

y
ea
rs
N
o
st
an
d
ar
d
iz
ed
la
n
g
u
ag
e

as
se
ss
m
en
t.
A
ll
d
es
cr
ib
ed

as
v
er
b
al
b
u
t
p
ro
m
p
t
d
ep
en
d
en
t.

P
1
:
IQ

3
8
an
d
P
2
:
IQ

3
2

(S
ta
n
fo
rd
-B
in
et
).
N
o
IQ

o
n

fe
m
al
e
p
ar
ti
ci
p
an
t

R
ep
ea
te
d
al
l
o
r
p
ar
t
o
f
a

g
re
et
in
g
;
im

m
ed
ia
te
ec
h
o
la
li
a

C
o
n
st
an
t
ti
m
e
d
el
ay

an
d

co
n
ti
n
g
en
t
v
er
b
al
pr
ai
se

P
o
si
ti
v
e

P
o
si
ti
v
e
fo
r
tw
o
o
f
th
e

p
ar
ti
ci
p
an
ts
d
u
ri
n
g

im
m
ed
ia
te
w
it
h
d
ra
w
al
o
f

in
te
rv
en
ti
o
n
/m

ix
ed
w
it
h

g
en
er
al
iz
at
io
n
to

n
o
v
el
p
ee
rs

fo
r
tw
o
o
f
th
re
e
p
ar
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v
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w

Rev J Autism Dev Disord (2016) 3:82–91 87

animation of a father and child playing ball would appear.
The participant was then observed in their classroom, and
data were collected on appropriate and inappropriate verbal
behavior. Results were mixed with some participants
demonstrating improvement in echolalia and some demon-
strating no improvement.

The remaining six studies employed a variety of behavior
analytic interventions to treat echolalia. Behavioral compo-
nents included error correction and differential reinforcement
(n=2; Freeman et al. 1975; Palyo et al. 1979). differential
reinforcement of lower rates (n=1; Handen et al. 1984).
modeling and positive reinforcement (n=2; Karmali et al.
2005; Palyo et al. 1979). modeling (n=1; McMorrow and
Foxx 1986). time delay and differential reinforcement (n=1;
Nientimp and Cole 1992). and visual cues with differential
reinforcement (n=1; Ganz et al. 2008). For example,
Handen and colleagues (1984) implemented differential rein-
forcement of lower rates (DRL) of behavior to decrease the
echolalia of a 16-year-old male with ASD. The intervention
occurred over an 18-month time frame and involved pro-
viding the participant with tokens for engaging in lower
rates of echolalia than a predetermined criterion. When
the participant engaged in echolalia below the target
rate, he exchanged the tokens for a tangible item from
his reinforcement menu. The intervention was effective
in reducing the participant’s engagement in echolalia;
however, after intervention was removed, the partici-
pant’s echolalia returned to baseline levels.

In another study, Ganz et al. (2008) taught two children
with ASD who engaged in echolalia to engage in reciprocal
social-communicative responses (e.g., compliments, ques-
tions, and statements corresponding to the current activity).
Responses were taught by providing visual scripts of the target
response and systematically fading scripts over three phases.
To reduce echolalia, a visual cue was presented which sig-
naled to the participant that they should cease talking (i.e., a
3″×3″ line drawing of a face with a finger in front of the
mouth indicating Bquiet^). This visual cue was introduced
only if the participant engaged in echolalia. Results indicated
clear decreases in echolalia.

Intervention Outcomes

The data from nine of the studies indicated that the results
were positive for all participants (Foxx et al. 2004; Freeman
et al. 1975; Ganz et al. 2008; Handen et al. 1984; Karmali et al.
2005; McMorrow and Foxx 1986; Nientimp and Cole 1992;
Palyo et al. 1979; Valentino et al. 2012). Data from two of the
studies suggested mixed results with some participants dem-
onstrating improved behavior and some demonstrating no im-
provement (Hetzroni and Tannous 2004; Laski et al. 1988).
The first study( Laski et al. 1988) measured echolalia as an
ancillary dependent variable and provided pre- and post-

treatment means for echolalia, with no differences noted in
one setting (i.e., the break room). The second study
(Hetzroni and Tannous 2004) utilized a multiple baseline de-
sign across settings to evaluate the effects of their technology-
based intervention on participant echolalia. However, de-
creases in echolalia were not demonstrated for all three set-
tings for any of the participants undercutting the experimental
control of the multiple baseline design. The two studies with
mixed results represented 8 of the 25 participants.

Maintenance and Generalization

Five of studies assessed maintenance of behavior change
(Foxx et al. 2004; Handen et al. 1984; Nientimp and Cole
1992; Palyo et al. 1979; Valentino et al. 2012). and one study
was published as a long-term follow-up to the McMorrow and
Foxx study (1986; Foxx and Faw 1990). The timing of the
collection of maintenance data ranged from immediately fol-
lowing the conclusion of the intervention (Foxx et al. 2004;
McMorrow and Foxx 1986; Nientimp and Cole 1992) to
57 months after the intervention (Foxx and Faw 1990). All
studies reported that echolalia levels at maintenance were be-
low baseline levels. Seven studies assessed stimulus general-
ization (Foxx et al. 2004; Hetzroni and Tannous 2004;
Karmali et al. 2005; McMorrow and Foxx 1986; Nientimp
and Cole 1992; Palyo et al. 1979; Valentino et al. 2012) in-
cluding generalization across settings, people, materials, and
different preceding utterances (questions). Four studies report-
ed positive results for generalization (Foxx et al. 2004;
Karmali et al. 2005; Palyo et al. 1979; Valentino et al.
2012). Two studies reported that generalization occurred for
some participants but not for all (Hetzroni and Tannous 2004;
Nientimp and Cole 1992). One study found that results did not
generalize for the participants (McMorrow and Foxx 1986).

Certainty of Evidence

Six of the studies were categorized as offering a conclusive
level of evidence with positive results, sufficient research de-
sign and IOA data, and detailed procedural descriptions (Foxx
et al. 2004; Ganz et al. 2008; Handen et al. 1984; Karmali et al.
2005; McMorrow and Foxx 1986; Valentino et al. 2012). Five
studies were categorized as suggestive (Freeman et al. 1975;
Hetzroni and Tannous 2004; Laski et al. 1988; Nientimp and
Cole 1992; Palyo et al. 1979). Of the five studies, three did not
demonstrate experimental control (Freeman et al. 1975;
Nientimp and Cole 1992; Palyo et al. 1979). two studies had
mixed results (Hetzroni and Tannous 2004; Laski et al. 1988).
and one study did not assess IOA (Freeman et al. 1975). None
of the studies was classified at the preponderant level of
evidence.

88 Rev J Autism Dev Disord (2016) 3:82–91

Discussion

The purpose of this review was to identify promising practices
for decreasing echolalia in individuals with ASD. This sys-
tematic literature review synthesized 11 studies which
employed a variety of behavioral interventions. Of the 11
studies, nine reported positive results for 17 participants, and
two of the studies reported mixed results for two participants.
When examining the quality of the literature base, six of the 11
studies were classified as providing conclusive evidence.
Ultimately, the findings of this review indicate that the litera-
ture base cannot conclusively support any one approach for
the treatment of echolalia in individuals with ASD.

Implications for Research

The first purpose of this review was to update the previous
review by Kavon and McLaughlin (1995) to identify effective
interventions for the treatment of echolalia in individuals with
ASD. Although no single intervention procedure or package
met any of the commonly used criteria for classification as a
well-established or evidence-based practice (e.g., Chambless
and Holland 1998; Odom and Wolery 2003). a number of
themes emerged. First, of the six studies classified as conclu-
sive, all contained behavioral analytic intervention compo-
nents (e.g., programmed reinforcement contingencies) sug-
gesting support for operant-based treatments in the reduction
of echolalia for individuals with ASD. When considering im-
mediate echolalia, the cues-pause-point intervention was iden-
tified as effective in three studies (Foxx et al. 2004;
McMorrow and Foxx 1986; Valentino et al. 2012). This con-
clusion supports the previous descriptive review identifying
cues-pause-point as a potentially effective intervention for im-
mediate echolalia. Of note, only two studies have evaluated
the effects of cues-pause-point since the previous review
(Kavon and McLaughlin 1995) highlighting the need for more
research in this area.

Conclusive studies evaluating interventions for delayed
echolalia also utilized behavioral analytic components. Three
interventions, DRL of behavior (Handen et al. 1984). script
training plus visual cues (Ganz et al. 2008). and tact modeling
plus positive reinforcement for appropriate responses
(Karmali et al. 2005). were all identified as effective for de-
layed echolalia. Of particular interest is the study by Ganz
et al. (2008) which utilized visual cues to signal to the partic-
ipant that they should cease talking. In addition, visual scripts
were provided to prompt the target response. Although not
inclusive of all the elements of cues-pause-point, Ganz et al.
did implement a cue to remain silent and a point to prompt the
correct answer. In addition, the DRL of behavior intervention
by Handen et al. (1984) utilized differential reinforcement
which was a contingency in effect in the cues-pause-point
interventions. Overall, the research combined provides

preliminary support for operant-based behavioral interven-
tions in general and cues-pause-point in particular.

As the interventions evaluated in these studies align with
the operant conditioning paradigm, it is alarming that none of
the studies assessed the operant function of echolalia. In other
forms of challenging behavior (e.g., aggression, property de-
struction, and self-injury), identifying the function of the be-
havior via a functional analysis procedure (Iwata et al.
1982/1994; Lydon et al. 2012) is associated with better re-
sponse to treatment (e.g., Didden et al. 2006). Of particular
concern is that echolalia may serve various social as well as
non-social communicative functions for individuals with ASD
(Goren et al. 1977; Healy and Leader 2011). If echolalia is
reduced during treatment but a functionally equivalent re-
placement behavior is not taught, this could limit the mainte-
nance and generalization of the behavioral change
(Schreibman and Carr 1978). In addition, as there is diver-
gence within the field regarding whether echolalia is nonfunc-
tional (e.g., Lovaas, Schreibman, and Koegel 1974). a neces-
sary part of developing functional communication (e.g.,
Roberts 2014). or serves a social function (e.g., Prizant and
Duncan 1981). identifying the function of echolalia would
help guide future research and practice.

One potential strength of this literature base is the assess-
ment of maintenance of behavioral change following cessa-
tion of the intervention phase. Of the six articles that assessed
the maintenance of behavioral change, all reported positive
results indicating levels of echolalia maintained below base-
line levels during follow-up sessions. However, although sev-
en of the studies did evaluate the generalization of the results
across stimuli, people, and settings, results were mixed with
only four reporting successful generalization. Future re-
searchers might consider evaluating interventions to promote
sustained behavioral change (e.g., fading, multiple exemplar
training; Valentino et al. 2012).

Implications for Practice

A second purpose of this review was to offer guidance to
practitioners interested in the use of evidence-based treatments
for individuals with ASD. Given the limited number of con-
clusive studies, recommendations as to an evidence-based in-
tervention for decreasing echolalia cannot be drawn.
However, the results of this review did suggest that cues-
pause-point, which was investigated by three different studies
with positive results and conclusive levels of evidence, is po-
tentially effective for immediate echolalia (Foxx et al. 2004;
McMorrow and Foxx 1986; Valentino et al. 2012). Although
these results support the conclusions from previous research
that cues-pause-point is potentially effective (Kavon and
McLaughlin 1995). practitioners should use caution when
implementing this intervention due to the limited number of
studies. In particular, practitioners should closely monitor the

Rev J Autism Dev Disord (2016) 3:82–91 89

intervention effects through ongoing progress monitoring and
rely on objective data to evaluate the effectiveness of the
intervention.

Limitations of this Review

There are a couple of limitations of this review to consider.
First, the definition of echolalia used by the authors was
intended to distinguish echolalia from vocal stereotypy.
However, it was difficult to identify a definition of echolalia
that was accepted throughout the literature base. In addition,
as none of the studies reported the function of the target echo-
lalia behavior, it is uncertain whether echolalia was isolated
from other forms of vocal stereotypy. A second limitation is
the age of the literature base. Of the 11 studies reviewed, six of
the studies were published over 20 years ago. As research
quality indicators have evolved dramatically in the past
20 years, the age of this literature base may have been a factor
in the conclusiveness of the evidence. In addition, since the
review by Kavon and McLaughlin (1995). only five additional
studies have been published on this topic. Therefore, there is a
need to update and expand this literature base to promote the
use of evidence-based practices in the treatment of echolalia
for individuals with ASD. A third limitation is the procedures
used to code intervention outcomes as applied to this literature
base. Study results were rated as Bpositive,^ mixed, or
Bnegative^ with mixed indicating that some but not all partic-
ipants demonstrated improvements in behavior. Five of the 11
included studies contained only one subject with ASD, there-
fore restricting the rating of the outcomes to either negative or
positive. Although restricted codes could have negatively im-
pacted intervention outcome ratings, all of the studies with one
subject received positive ratings. However, the limited num-
ber of subject limits the external validity of the conclusions. A
fourth limitation is the absence of large-scale randomized con-
trol trials in the resulting literature base. Although this might
be a reflection of the exceptionality of the population, the
exclusive use of single-subject designs limits the external va-
lidity of this literature base. A fifth limitation of this review is
the focus on individuals with ASD. Future researchers might
consider expanding to include other developmental disabil-
ities to ensure a more comprehensive review. Such an analysis
might allow for distinctions relevant to the presentation and/or
treatment of echolalia in children with ASD relative to indi-
viduals with other forms of disability.

Compliance with Ethical Standards

Funding The authors report no funding for this manuscript.

Conflict of Interest The authors report no conflicts of interest.

Ethical Approval This article does not contain any studies with human
participants performed by any of the authors.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.

Treatment of Echolalia in Individuals with Autism Spectrum �Disorder: a Systematic Review

Abstract
Method
Search Procedures
Inclusion Criteria
Descriptive Synthesis
Interrater Reliability
Results
Participant Characteristics
Type of Echolalia
Intervention Procedures
Intervention Outcomes
Maintenance and Generalization
Certainty of Evidence
Discussion
Implications for Research
Implications for Practice
Limitations of this Review
References
*Indicates studies which were included in this review

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Journal of Developmental and Physical Disabilities, Vol. 16, No. 4, December 2004 ( C© 2004)
DOI: 10.1007/s10882-004-0688-5

Replacing the Echolalia of Children With Autism
With Functional Use of Verbal Labeling

Richard M. Foxx,1, 2 Kimberly A. Schreck,1 Jeffrey Garito,1

Angela Smith,1 and Shannon Weisenberger1

We evaluated the direct and generalized effects of cues-pause-point language
training procedures on immediate echolalia and correct responding in two
children with autism. The overall goal was to teach the children to remain
quiet before, during, and briefly after the presentation of questions and then
to verbalize on the basis of the cues (pictures) whose labels represented the
correct responses. A multiple baseline design across question/response pairs
demonstrated that echolalia was rapidly replaced by correct responding on
the trained stimuli and there were clear improvements in one child’s respond-
ing to untrained stimuli. These results replicate and extend previous research
with adults with mental retardation and autism which demonstrated that cues-
pause-point procedures can be effective in teaching individuals displaying
echolalia to use their verbal labeling repertoires functionally.

KEY WORDS: echolalia; autism; language training; cues-pause-point; generalization.

Echolalia can be regarded as an inappropriate language strategy (Carr
et al., 1975) which interferes with language training efforts even though it
may be functional for some individuals (Prizant and Duchan, 1981; Schuler,
1979). Historically, behavioral attempts to decrease echolalic responding to
questions have focused on either replacing echolalia with stimulus specific
responses (Carr et al., 1975; Risley and Wolf, 1967) or a generalized verbal
response (Schreibman and Carr, 1978) through the use of such procedures
as imitation training, stimulus fading, differential reinforcement, and verbal
prompts.

1Psychology Program, Penn State Harrisburg, Middletown, Pennsylvania.
2To whom correspondence should be addressed at Penn State Harrisburg, 777 W. Harrisburg
Pike, Middletown, Pennsylvania 17057-4898; e-mail: rmf4@psu.edu.

307

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308 Foxx, Schreck, Garito, Smith, and Weisenberger

A third treatment option takes advantage of individuals’ verbal label-
ing skills in order to teach them a nonecholalic strategy (Foxx, 1999; Foxx
et al., 1988a; Foxx and Faw, 1990; McMorrow et al., 1986). This training
approach involves labeling relevant cues, a response delay requirement, at-
tention training (Foxx, 1977), suppressing off task behavior, and provisions
for the transfer of stimulus control from an object to the questioner and
question.

The specific training was accomplished through the use of “cues-pause-
point” procedures that taught individuals displaying echolalia to (a) remain
quiet when the trainer held up his index finger before, during, and briefly
after the presentation of targeted questions, and then (b) use a pretrained
verbal label as the correct response when the trainer pointed to the ap-
propriate environmental cue. Several studies (Foxx et al., 1988a; McMorrow
et al., 1987; McMorrow and Foxx, 1986) demonstrated that the procedures re-
placed echolalia with correct responses and that adults and adolescents with
varying degrees of mental retardation used the trained responses: (a) when
they were presented by individuals who had not been involved in training;
(b) in settings where no training had been conducted; (c) when no prompts,
cues, feedback, or consequences were used; and (d) sometimes several years
following training (Foxx and Faw, 1990).

More importantly, the procedures produced generalized improvements
in some individuals’ responding to untrained verbal stimuli by teaching them
to use environmental cues (e.g., pictures) when they were asked questions.
That is, they seemed to learn a set of nonverbal behaviors to use when they
were presented with novel verbal input. These nonverbal behaviors seemed
to be a by-product of the “cues-pause-point” procedural sequence, because
over time trained individuals would: (a) remain silent when spoken to (i.e.,
attend to the stimulus presentation); (b) pause briefly after being spoken to;
and (c) visually scan an array of physical cues which were in the environment
before selecting one and verbalizing its label. This scanning or searching was
facilitated by ensuring that the individuals could see the correct cue/object
when the question that pertained to it was asked.

These nonverbal behaviors combined with the generalized improve-
ments in question answering and reductions in echolalia suggested that the
individuals learned a nonecholalic strategy over time wherein they would re-
spond to questions on the basis of either the cue (e.g., pictures or objects) that
were present or their established repertoires of labeling responses. In fact,
individuals were much less likely to use their echolalic strategy even though
their responses were not always correct because they used object labels from
other settings as incorrect responses. Such incorrect responding appeared to
represent a bridge between their echolalic strategy and following one where
they visually searched their environment for the correct response.

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Replacing Echolalia 309

Because of the successful application of cues-pause-point procedures
with adult populations diagnosed with mental retardation and autism, it
seemed reasonable to assume that the same procedures might benefit young
children diagnosed with autism spectrum disorders. Accordingly, the present
study was designed to replicate and extend previous research involving cues-
pause-point procedures (e.g., Foxx et al., 1988a) by applying the procedures
to young children diagnosed with autism who exhibit echolalia and evaluat-
ing the direct and generalized effects of the procedures.

METHOD

Participants

Karl, a 5-year-old male, was diagnosed with autism. Psychometric test-
ing by the authors supported this diagnosis (see Table I). Karl displayed
immediate echolalia. He was able to use some brief phrases (i.e., 2–4 words)
appropriately. Karl was enrolled in a nonstructured educational program
and received occupational therapy.

Gerry, a 6-year-old boy, was diagnosed with autism by the second author
approximately 6 months before the study (see Table I). Gerry frequently
echoed phrases, questions, and object labels. During the study, Gerry re-
ceived home- and school-based applied behavior analysis intervention.

Experimental Design

A three-leg multiple baseline across picture sets design was used.

Settings

Karl’s baseline and training trials were conducted at the University in
a 2 m × 4 m room which contained a one-way vision mirror, a table, and

Table I. Participants’ Demographic Information and Psychometric Scores

Language Autism

Child Agea Receptiveb Expressivec Clinicald Parente

Karl 5 40 55 37 97
Gerry 5 40 58 40 83
a In years.
bPeabody Picture Vocabulary Test—III (standard score).
c Expressive One Word Vocabulary Test (standard score).
d Childhood Autism Rating Scale Total Score (completed by researchers).
e Gilliam Autism Rating Scale Autism Quotient (completed by parents).

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310 Foxx, Schreck, Garito, Smith, and Weisenberger

chairs. The generalization sessions were conducted in a room across the hall.
Gerry’s sessions were conducted in his home in a 4 m × 4 m room. His gen-
eralization sessions were conducted in the family’s living room. Each setting
contained a variety of irrelevant stimuli.

Target Behaviors and Recording

In each experiment, the first word or sequence of words that followed
the initiation of a question was scored in one of three, mutually exclusive cat-
egories; echolalia, incorrect, or correct. Echolalia was defined as a repetition
of one or more of the words contained in the question regardless of whether
other verbalizations occurred. An incorrect response was scored when a ver-
balization contained a stimulus-irrelevant word(s), regardless of whether a
correct response was included. A correct response was scored when a verbal-
ization either matched the trained response or provided a different appropri-
ate answer to the question. Using these definitions, a response that contained
any combination of echolalic, correct, or incorrect verbiage was scored as an
echo and a response that included any combination of correct and incorrect
verbiage was scored incorrect. Responses were scored by the trainer imme-
diately after each question was presented. If no response occurred, it was
scored as incorrect. All sessions were either video- or audiotaped.

Reliability

Using randomly selected tapes, one of four independent raters tran-
scribed and scored responses from at least two trials in each condition. To
limit the possibility that their scoring would be influenced by the trainer’s
feedback, the raters were instructed to stop the tapes immediately after each
response (i.e. before the feedback was given). Interobserver agreement was
computed by dividing agreements on the occurrence of each behavior by
agreements plus disagreements, and multiplying by 100. Excluding the few
taped verbalizations that could not be scored because they were inaudible,
percent agreement on all target behaviors averaged 98% for Karl, and 90%
for Gerry.

Trained Stimuli and Responses

In each experiment, stimulus (i.e. question) and response (i.e. picture
card) pairs were developed by identifying pictures of objects or animals
that the participants were likely to be able to label and creating a ques-
tion that pertained to each. Question/response pairs were then arbitrarily
separated into three sets. The trained responses (i.e. picture labels) were

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Replacing Echolalia 311

one- to three-syllable words such as giraffe, gummy bears, and bed. Commer-
cially available picture cards were used (Language Builder Picture Cards,
Stages Learning Materials, Chico, CA). The questions were between four
and six words long and never contained the response or part of a response.
Examples included: “What animal has a long neck?” and “What do you sleep
on?” The participant’s responses to the questions had not been assessed prior
to the baseline conditions.

General Procedures

Response Identification Training

Prior to training the participants were taught to verbally label each
picture card that would be used. Labeling training consisted of the trainer
(a) displaying the picture cards from each set on a table; (b) verbally (“what’s
this?”) and/or gesturally (i.e. pointing to or tapping the picture) prompting
the participant to identify the objects; (c) providing feedback (i.e. “good an-
swer” for a correct response, “no, that’s not right” for an incorrect response,
a “no” for an echo, and “you didn’t answer” for no response); (d) saying the
correct label when the participant failed to do so and then prompting them
to label correctly; and (e) giving intermittent edible reinforcers for correct
responses. This training continued until each picture was correctly labeled
during three consecutive trials when the trainer simply pointed to it. Training
typically progressed quickly because the participants already could label the
majority of the pictures used.

Baseline

The baselines were conducted after the participants had been trained
to label correctly. Nevertheless, each trial during conditions where pictures
were available was started by labeling the pictures which were displayed.
After this labeling, the trainer said, “I’m going to ask you some questions
and I want you to answer them the best you can.” The trainer then asked
each of the set questions in a random order and provided response-specific
feedback following the participant’s verbalization. The feedback was the
same as in the response identification training. Participants received verbal
praise and an edible or sip of a favored drink for each correct response.

Cue-Pause-Point (Uncovered)

All of the baseline procedures remained in effect. During this condition
the trainer prompted the participant to remain silent before, during, and

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312 Foxx, Schreck, Garito, Smith, and Weisenberger

briefly after she presented the questions and then to label one of the pictures
(i.e. correct response) that was present on a table in front of the child. This
was done by having the trainer (a) hold up her right index finger at eye level
midway between the participant and herself whenever silence was desired
(i.e. during the instructions, questions, and for approximately 1 s following
the question) and say “no” or “shh” whenever a verbalization occurred (i.e.
the pause prompt); (b) move her finger so that it touched the correct cue
(picture card) approximately 2 s after the question was completed (recall that
at the end of response identification training each participant was responding
correctly to the point prompt only); and (c) use the response identification
training prompts (e.g. tapping the object, “what’s this?”) if necessary to
ensure that the labeling response occurred.

Cue-Pause-Point (Covered)

In this condition all of the uncovered procedures remained in effect,
except now the picture was covered with a folder. This was done by having
the trainer (a) cover the picture with a folder immediately after the un-
covered trial, pause prompt again, restate the question, and move her right
index finger so that it touched the folder when a correct response was de-
sired (i.e. the trainer prompted again and used the response identification
prompts if a response did not occur even though the picture was covered; and
(b) provide the same verbal feedback and consequences which were used in
the uncovered condition for the first verbalization that occurred. Because the
above training sequence relies heavily on manual prompts, verbal mediation
was kept to a minimum.

Pause Only

During this condition, the pretrial labeling was discontinued, the pic-
tures were removed from the training setting, and no point prompts were
used. The trainer simply used the pause prompt as she presented the ques-
tion and then withdrew her hand so that it was closed and in contact with her
chest when a response was desired. The feedback and consequences were
the same as before.

Baseline II

This condition was identical to the initial baseline except that the
pictures were not present. In other words, the trainers simply asked the
questions in a random order, and provided feedback and consequences as
they always had.

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Replacing Echolalia 313

Programming Generalization and Maintenance

This condition consisted of several phases. Initially, sessions were con-
ducted in the original and new settings by the original and a new trainer.
Next, all 15 questions were randomized and presented by the original and
new trainers in the original setting. Finally, all feedback and consequences
were faded by the original trainer. These trials are described in more detail
below.

RESULTS

Karl

Figure 1 shows that Karl echoed in response to between 0 and 90% of the
set one questions during baseline even though the picture cards were present
and feedback was provided after each response. He answered between 0 and
38% correctly. During the first six set two trials, he echoed in response to
between 40 and 90% of the questions and answered between 0 and 22%
correctly whereas, in set three, he echoed between 0 and 80% while correct
answering was low and only occurred in two trials. The addition of the pause
and point prompts in the uncovered condition in set one decreased echoes to
zero after three trials while correct responses increased to 100%. In sets two
and three, echoes trended downward whereas correct responses continued
upward.

In the set one covered condition, Karl only echoed in one trial and
correct responding was 100% in all but one trial. In the set two, uncovered
condition, Karl only echoed in two trials and correct responses increased to
100%. In set three, echoes reached zero and correct responses 100%.

During the pause only condition in set one, echoes were at zero dur-
ing the last 10 trials and correct responding at 100% in 9 of the 10. During
this period, in the set two covered condition, no echoes occurred and cor-
rect responding was 100%. In set three, few echoes occurred and correct
responding typically reached 100%.

In the set one baseline II condition, no echoes occurred and correct
responding was 100%. In the set two, pause only condition, Karl echoed in
trial 44 and correct responding averaged 84%. In set three, echoes remained
at zero and correct responding at 100% except for trial 46.

Generalization tests A through F (trials 48–59) were conducted as fol-
lows: (A) the original trainer T1 presented the question sets in a novel room;
(B) T1 presented the sets in the original room; (C) T2, a new trainer, pre-
sented the sets in the original setting; (D) T2 presented the sets in the novel
setting; (E) T1 presented all 15 questions in a random order in the original

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314 Foxx, Schreck, Garito, Smith, and Weisenberger

Fig. 1. The percentage of echolalic and correct responses on trained (sets one and two)
and untrained (set three) questions. GEN A–F represent different generalization
tests. MA represents the fading of feedback and reinforcement phase (see text).

setting; and (F) T2 presented all 15 questions in a random order in the
original setting. In the maintenance condition (trials 60–65) T1 presented
the questions randomly and faded the feedback and consequences. This
was accomplished in a few trials by progressively reducing the number of

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Replacing Echolalia 315

responses that were followed by feedback and consequences until they were
eliminated. Figure 1 shows that Karl’s performance on these tests was 100%
correct and zero echoing in all but four trials.

Gerry

Figure 2 shows that Gerry echoed between 20 and 70% of the set one
questions during baseline. He only answered one question correctly. During
the first six set two trials, his echoing ranged between 10 and 40% and no
correct responding occurred, whereas in set three, he echoed between 0 and
44% and correctly answered between 0 and 25%.

In the uncovered set one condition (trials 7–16), echoes decreased to
zero correct responding increased to 100%. In set two, echoing increased
and Gerry only responded to one question correctly. Responding in set three
showed little change. During the covered condition in set one (trials 17–21)
echoes were zero and correct responding 100%. In the uncovered condition
in set two, echoes decreased to 20% and correct responding reached 80%. In
set three, echoes increased somewhat and correct responding showed little
change.

Throughout the remaining training, generalization, and maintenance
trials in set one, echoing never occurred and correct responding fell be-
low 100% only four times. During the set two covered condition, echoes
were zero except for trial 26 and correct responding ranged between 60 and
100%. Set three correct responding ranged between 11 and 33% and echoing
between 11 and 22%.

In the pause only condition in set two, several problems were encoun-
tered. First, Gerry’s performance decreased when the pictures were removed
in this condition. To solve this problem, Gerry was briefly pulled out of the
design between trials 33 and 34 and returned to the covered condition with
a slight modification. Recall that in the typical covered condition, the pic-
tures were presented first uncovered and then immediately covered. The
modification consisted of chaining the pause only condition to the covered
condition (uncovered–covered–pause only) and then fading the uncovered
and covered conditions so that only the pause only condition remained.
When Gerry responded correctly to all the pause only questions, he and the
trainer “reentered the design.” Shortly thereafter another problem emerged
when Gerry began to consistently responded to one question (“what goes
back and forth?”/ “swing”) with another set two picture/label “backpack”
(what do you carry books in?). We determined that the word “back” in the
“swing” question was cuing Gerry to say “backpack.” We changed the ques-
tion to “what do you sit on that goes up and down?” and taught him to say

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316 Foxx, Schreck, Garito, Smith, and Weisenberger

Fig. 2. The percentage of echolalic and correct responses on three trained question
sets. After trial 44, each data point represents the mean of two trials except for the
last trial before each condition change (trials 57, 58, 64, and 68). GEN A through E
represents different generalization tests and each data point is shown. Each data point
also is shown for the MA (Maintenance) phase when reinforcement and feedback
were faded.

“swing.” The final problem was that echoing was still occurring at a level of
20 to 40% (trials 47–56). In trial 54, we modified the feedback for echoes by
saying “no” more firmly and slapping the table approximately 18 in. away

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Replacing Echolalia 317

from Gerry. This change in strategy was effective and by trial 57 echoes
were at zero and correct responding was 100%. At that point the baseline II
condition was implemented. In the baseline II condition, correct respond-
ing typically remained between 70 and 100% and echolalia between 0 and
20%. However, during the generalization and maintenance trials, correct
responding was always 100% and echoes were at zero.

No problems were encountered in set three during training. Gerry’s
echoing ranged between 0 to 25% and was absent during the generalization
and maintenance trials whereas correct responding ranged between 80 and
100% and was 100% throughout the last 10 baseline II and all generalization
and maintenance trials.

Generalization tests A through E were conducted as follows: (A) T1
presented the question sets in a new setting; (B) T2 presented the sets in
the original setting; (C) T2 presented the sets in the new setting; (D) T1
presented all 15 questions in a random order in the original setting; and
(E) T2 presented all 15 questions randomly. In the maintenance phase (MA),
T1 returned and faded the feedback and consequences as described for Karl.

DISCUSSION

This study replicated the results of Foxx et al. (1987, 1988a); McMorrow
et al. (1987); McMorrow and Foxx (1986) with young children diagnosed
with autism spectrum disorders. The training program rapidly replaced the
children’s echolalia with correct responses and these communicative im-
provements were maintained during conditions where the prompts, cues,
feedback, and consequences were eliminated. The only difference in the
present study was that the uncovered and covered training conditions were
implemented separately whereas in all of the previous research they were
combined. This change was made because the young children in this study
did not have the large labeling repertories that the older subjects in previ-
ous research possessed. Whether or not this change was necessary will be
determined in a future study with young children with autism.

The generalization to untrained stimuli differed between participants.
For example, Karl’s improvements in set three began to occur within a few
trials after training began on set one. Similar results occurred in set two prior
to the institution of training on this set. Furthermore, Karl never echoed and
usually responded correctly at 100% on set three questions after trial 26.
Gerry’s performance varied considerably longer on the sets even though
training was implemented on all three.

The present results also partially replicated McMorrow et al. (1987) in
that Karl, who displayed generalized effects had levels of echolalia on the

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318 Foxx, Schreck, Garito, Smith, and Weisenberger

untrained sets in the middle stages of the study that were at or near zero
even though his responses were not always correct. Another aspect of this
study that McMorrow et al. (1987) also confronted was the need to remove
a participant from the design. Recall that Gerry’s set two pause only con-
dition decrease in performance required that the pictures be reintroduced
outside the design. In McMorrow et al. (1987) a subject was removed from
the design temporarily because she began to respond “no” after virtually
every question. The other problems encountered with Gerry in set two also
were not unusual (see McMorrow et al., 1986).

In this study, the rationale for cues-pause-point language training was
that trainers of language deficient children had to greatly increase the like-
lihood that the children would respond appropriately to the trainers’ ver-
balizations. Several methods were used during structured training. First, the
trainer insured that the child had an appropriate verbal response to what-
ever the trainer might say. That is, the child could say whatever the trainer
wanted him to say. Second, the child was taught to verbalize the appropri-
ate response whenever the trainer manually prompted him to do so thereby
establishing control over when a particular verbalization would occur. In
other words, before the trainer ever presented a verbal stimulus for which
a particular response would be appropriate, the trainer had ensured that
the child could produce the appropriate response quickly and whenever the
trainer sought it. Third, the interactional situation was arranged so that a
relevant physical cue was present. Fourth, when a verbal stimulus for which
a particular response would be appropriate was presented, a set of manual
prompting procedures were used which (a) increased the likelihood that
the child would attend to the trainer’s verbal input; (b) reduced the likeli-
hood that competing inappropriate responses would occur (i.e., echolalia);
(c) directed the child’s attention to a physical cue (picture) in the interac-
tional environment; and (d) indicated when the appropriate response should
occur. Finally, once the appropriate response reliably occurred following
a particular verbal stimulus, the cues and prompts that produced it were
faded.

The trainer provided as much assistance as necessary in the beginning
to greatly increase the likelihood that the desired response would occur
and then gradually reduced the amount of assistance provided until the
child was responding appropriately without help. This feature may be one of
the primary differences between cues-pause-point training procedures and
other types of language training. Although most other training procedures
rely on shaping appropriate speech through a series of steps towards a tar-
get response, cues-pause-point procedures are intended to make the child’s
initial performances as errorless as possible. Thus, the primary goal is to
establish the necessary conditions to produce appropriate verbal responses

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Replacing Echolalia 319

quickly (i.e., the first time a particular verbal stimulus is presented) so that
the major focus of the training can be on maintaining the student verbal
behavior through a series of fading steps.

In conclusion, this study adds to the growing evidence that cues-pause-
point procedures can affect maladaptive language strategies such as echolalia
(McMorrow et al., 1987), perseverative (Foxx et al., 1988a), and delusional
speech (Foxx et al., 1988c) as well as teach signing to students who are
deaf (Foxx et al., 1988b). Future research should be conducted to determine
whether the cues-pause-point procedures can be used to teach young chil-
dren with autism to imitate the verbal responses of models (see McMorrow
et al., 1986).

ACKNOWLEDGMENT

We thank Donna LeFevre for her assistance.

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