Journal of Autism and Childhood Sch&ophrenia, Vol. 5, No. 2, 1975

Brief Report

An Operant Procedure to Teach an Echolalic,

Autistic Child to Answer Questions Appropriately'

Betty Jo Freeman, 2 Edward Ritvo, and Revel Miller Division of Mental Retardation and Child Psychiatry, The Neuropsychiatric Institute, University of California, Los Angeles, School of Medicine

A n operant conditioning procedure to teach an aut&tic patient with rapid immediate echolalia to answer questions correctly was devised. The proce- dure involved positively reinforcing the patient immediately after a correct response and preventing incorrect responses. I t i s simple to implement and eliminates some o f the structure and constraints inherent in previously de- scribed operant methods. This allows the procedure to be administered by a variety o f therapeutic personnel and parents and in a varie@ o f living situa- tions.

Echolalic speech, or repeating the exact words of others, is observed fre- quently, though not exclusively, in children diagnosed as having early infantile autism (Stone & Church, 1957). Griffith and Ritvo (1967) de- scribed three types of echolalic s p e e c h - immediate, delayed, and negative. Immediate echolalia is the type in which the child restates at once what another has said. Delayed echolalia occurs when verbatim reproduction of remarks made to the child hours, days, weeks, or months previously are made. Negative echolalia refers to the addition by the patient of negative or hostile affective tone to his echolalic repertoire.

Several operant techniques have been devised to establish or shape speech in autistic patients (e.g., Lovaas, 1966, 1967; Risley, 1966). A few have been concerned with procedures to decrease echolalic speech. For ex- ample, Risley and Wolf (1967) described an operant procedure which decreased the echolalic speech of autistic and other echolalic children. Their

'This study was supported in part by Maternal Child Health Grant #927, U.S. Department of Health, Education and Welfare.

2Requests for reprints should be sent to Dr. Betty Jo Freeman, The University of California, Neuropsychiatric lnstitute, 760 Westwood Plaza, Los Angelr California 90024.

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170 Brief Report

procedure involved positively reinforcing the child for spontaneous correct responses (nonecholalic) and removal of all positive reinforcers for incorrect responses (echolalic response) and/or disruptive behaviors (e.g., temper tan- trums). The latter was accomplished through a combination of extinction and timeout procedures. In addition to the above procedure, children in their experiment were trained to label objects appropriately by use of a prompting procedure. The experimenter would hold up an object and say, "What 's this?" Ifthe child did not make a response in rive seconds, he was verbally prompted by the experimenter and the prompts were then gradually faded out. If the child made an incorrect response (echolalic response), a timeout was programmed, thus removing all positive reinforcers.

In 1971, Tramontana and Shivers reported a modification of the Risley and Wolf (1967) procedure. They described a patient who repeated words too quickly (rapid immediate echolalia) to employ the above de- scribed procedure. However, he could read and use was ruade of this skill. The experimenter asked a question and simukaneously held up correct an- swers printed on a card. If he read the correct answer, a positive reinforcer was given. The visual prompts were then gradually faded, as were the verbal prompts in the Risley and Wolf procedure.

The present study describes a technique developed to teach an autistic boy with rapid immediate echolalia to answer questions appropriately. The procedure involves the use of only positive reinforcers, prevents incorrect responses, and is easily administered.

METHODS

Subject

The patient, a five-year-old black male was hospitalized at the Neuropsychiatric Institute throughout this study. Diagnostic evaluation in- cluded routine medical and neurological testing augmented by a 500-item research history questionnaire and special metabolic studies. Psychiatric ex- amination by two independent child psychiatrists established the diagnosis of autism according to previously published criteria (Ornitz & Ritvo, 1968). Review of the history revealed no familial psychiatric diseases or retarda- tion. Pregnancy was uneventful, full term, and ended in an uncomplicated vaginal delivery. Birth weight was six pounds, eight ounces. The postnatal course was unremarkable as was the general pediatric history. The follow- ing symptoms indicative of the syndrome of perceptual inconstancy were re- ported:

Developmental Delays. Although the patient sat at 6 months and walked at 12 months without support, he failed to grasp objects at 10

Brief Report 171

months, refused solid foods at 8 months, and failed to develop language and social skills.

Disturbances o f Perception. Disturbances included alternating reac- tion to sounds, either nonresponsive or overly reactive to soft noises; per- sistent feeling of textures; spitting out of lumpy foods; staring at spinning objects and finger flapping before his eyes; alternating limp posturing and hyperactivity; scrutinizing details alternating with nonresponsivity to visual clues; and attendance to self-induced sounds.

Disturbances o f Relatedness. The patient failed to develop a smiling response and stranger anxiety; went limp when held as an infant and did not develop anticipatory gesture to being picked up; failed to develop social imitation; and did not develop eye contact.

Disturbances ofLanguage. The patient babbled prior to 18 months and developed isolated words for labeling by 2 years; his speech remained hollow-sounding and by age 26 months he ceased using words. Following admission to the hospital, he developed an echolalic repertoire (immediate and delayed) in a language program as well as the ability to label certain words.

Disturbances ofMotility. He began hand flapping both at his side and before his eyes by age 18 months, spontaneously twirling, and occasional body rocking which persisted until admission.

In view of the history of developmental delays, disturbances of per- ception, and relatedness on history prior to age 30 months, and the persistence of these symptoms plus the language and motility disturbances noted at the time of evaluation, the diagnosis of autistic reaction was estab- lished.

Ail medical and neurol0gical tests were within normal limits with the exception of the EEG. At age 2 years, 7 months, a normal sleep and awake tracing was obtained. Following hospitalization at age 3 years, 7 months, a repeat EEG showed multifocal spikes and spike and wave disturbances. He was placed on Zarontin (250 mg/day) and a normal sleep and awake tracing was obtained at age 3 years, 11 months. No clinical history of seizures was obtained and no seizurelike behavior was observed during his hospital stay.

Psychological Assessment

Psychological assessment just prior to this study revealed a Stanford- Binet IQ equivalent of 81. On the Merrill-Palmer test, he obtained an IQ of 120. (This discrepancy is due to the fact that the Stanford-Binet test relies heavily on verbal abilities, whereas the Merrill-Palmer test primarily relies on performance abilities.)

172 Brief Report

Apparatus

The apparatus consisted of 40 action pictures (on 3-inch by 4-inch cards) and two Lafayette push-button counters.

Procedure

Phase 1. Each of the 40 pictures was presented to the patient twice, and he was asked, "Wha t ' s the girl (or boy) doing?" The number of echo- lalic, nonecholalic correct, and nonecholalic incorrect responses were re- corded.

Phase 2. Ten pictures were selected at random from the 40 originals. At the beginning of each session, probe trials as described in Phase 1 were conducted. Following this, the pictures were re-presented and the patient was asked the appropriate question. If he gave a correct response, he imme- diately received positive reinforcers (e.g, , M & M candies, raisins, or cereal). If an incorrect response occurred, the following training procedure was initiated. The experimenter repeated the answer to the question and followed the answer with the question. As soon as the child began to echo the answer, and before he could echo the question, he was reinforced, For example, the experimenter would say, "Sitting, what 's the girl do ing?" As soon as the child said "Si t t ing" he was reinforced, and thus prevented from echoing the remainder of the sentence. The next step was to again ask just the question. This sequence was followed for 4 groups of 10 pictures each. Following each picture presentation, correct or error responses were re- corded. Error responses could be either an echolalic or nonecholalic incor- rect labeling. The criterion for shifting to a new set of pictures was the attainment in three sessions of 80% or more correct responses (e.g., three sessions with 20% or less echolalic responses). Two training periods per day were used, each approximately 20 minutes in duration.

Phase 3. Ail 40 pictures were re-presented as in Phase 1.

RESULTS

In Figure 1, the percentage of echolalic responses on the initial presen- tation of all groups and pictures in ail phases of the experiment is plotted. On the first probe, 73% echolalic responses to the 40 pictures was observed. The proport ion of echolalic responses declined wi th training on each new set of 10 pictures. There was a slight but insignificant increase from training group 3 to training group 4. On the final trial of ail 40 pictures, only 3% echolalic responses were observed.

Brief Report 173

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In Figure 2, the results of the individual sessions for ail phases of the experiment are plotted. Both the percentage of echolalic responses and the percentage of nonecholalic error responses are shown. As indicated by these results, it took seven sessions to acquire appropriate nonecholalic responses (80% or more) to the first group of 10 pictures. However, for all three sub- sequent groups Of pictures , only four sessions were required to reach the 80% correct level. Interestingly, as the number of echolalic responses was declining, so were incorrect nonecholalic responses. This suggests that he was learning to give correct responses, since the percentage of correct (appropriate) answers is the mirror image of Figure 2.

In Figure 3, the initial data for ail groups of pictures during all three phases of training is shown. With presentation of each new set of pictures, echolalia decreased as incorrect nonecholalic responses increased. At the same time, as shown in Figure 4, the percentage of correct responses stayed approximately the same on all the initial trials. Also shown in Figure 4, only 30/0 correct responses occurred in Phase 1, whereas in Phase 3, 97% correct responses occurred. This confirmed that the training procedure had indeed been effective in decreasing echolalic responses to the 40 pictures.

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Brief Report 175

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176 Brief Report

DISCUSSION

The results indicate that a patient with rapid immediate echolalia could be taught to answer questions appropriately. Indeed, after training on the first group of pictures (seven sessions), he acquired appropriate re- sponses to the others in one session. The remaining three sessions used for each group of new pictures was a function of the rime required for him to reach the predetermined criterion of mastery (80~ correct responses).

The procedure described in this study is unique in that it eliminates the need to program timeouts for inappropriate verbalization. Thus it is quite flexible and, since a structure setting is not required for implementation, it can be used anywhere the child goes, i.e., classroom, playroom, outside, and elsewhere. This ease of application allows for training the generaliza- tion of appropriate speech in many settings.

An important aspect of the precedure is the ease with which it can be taught to therapeutic personnel. Parents and those with little or no training in operant conditioning per se can learn to use it quickly and accurately. Thus the many adults who care for patients can easily be taught to maintain a consistent program for establishing appropriate speech in a child who possesses rapid immediate echolalia.

In summary, an operant procedure for teaching a child with rapid immediate echolalia has been developed. It was demonstrated to work with a severely autistic child. The procedure is simple to learn and to apply. It also eliminates some of the constraints usually inherent in operant proce- dures, and allows for consistent application in a variety of living situations.

R E F E R E N C E S

Griffith, R. J., & Ritvo, E. R. Echolalia: Concerning the dynamics of the syndrome. Journal o f the American Academy o f Child Psychiatry, 1967, 6, 184-193.

Lovaas, O. I. A program for the establishment of speech in psychotic children. In J. K. Wing (Ed.), Childhood Autism. Oxford: Pergamon Press, 1966.

Lovaas, O. 1. A behavior therapy approach fo the treatment of childhood schizophrenia. In J. Hill (Ed.), Minnesota symposium on chiM development. Minneapolis: University of Minnesota Press, 1967.

Ornitz, E. M., & Ritvo, E. R. Perceptual inconstancy in early infantile autism. Archives o f General Psychiatry, 1968, 18, 76-98.

Risley, T. R. The establishment o f verbal behavior in deviant children. Unpublished disserta- tion, University of Washington, 1966.

Risley, T. R., & Wolf, M. Establishing functional speech in echolalic children. Behavior Re- search and Therapy, 1967, 5, 73-88.

Stone, J. L., & Church, J. Childhood Adolescence. New York: Random House, 1957. Tramontana, J., & Shivers, O. Behavior modification with an echolalic child. A case note.

Psyehological Report, 1971, 29, 1034.