The developing stage of every child is marked by a series of milestones—from their first words, to the first time they crawl and, ultimately, their first steps. These developmental milestones are, for physicians as well as parents, indications of whether a child is developing within a neurotypical frame or not.
When infants enter the developmental phase of walking, some develop a pattern of walking on their toes—typically known as idiopathic toe walking.
Research studies point to an increased rate of toe walking among autistic individuals. This could lead parents to ask questions such as: Is walking on toes an additional symptom of autism? And, if a child toe walks, are they at risk of autism? There exists a wealth of information on this topic; below is what you need to know.
What is toe walking?
Just as the name suggests, toe walking is the inability of a child to make heel-to-ground contact in the initial stages of the gait cycle.
On average, an infant below the age of two will begin walking intermittently on their toes; however, this naturally phases out between six months and two years of age. Toe walking is said to be persistent if the habit continues after the age of two. At which point, possible concerns about the neurological development of the child become evident.
Clinical indications of toe walking
A systematic review of literature indicates a link between intellectual disability or language developmental delay and toe walking in patients without a diagnosis of autism spectrum disorder (ASD).
Toe walking is not only autism related, it is also found among individuals with conditions such as cerebral palsy, muscular dystrophy, Charcot-Marie-Tooth Disease, and other neuropathies and myopathies. The main reason for this is that toe walking is associated with an anatomical pathology present in these conditions.
Children who walk on their toes with non-motor development disorders differ from those with associated neuromuscular disorders. An example of neuromuscular disorders is cerebral palsy.
Causes of toe walking in children with autism spectrum disorder
Toe walking has a positive association with language disorders in children; however, research studies have failed to explain the neurophysiological cause of this association
It is uncertain what the underlying mechanism is behind the increased rate in observed toe walking present in autism—however, it is speculated to be linked to differences in tactile/sensory responses.
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Is toe walking a sign of autism?
Many infants typically begin walking between the age of 12 to 15 months. Early on, toddlers tend to have variations in their gait patterns or positions; one such pattern is walking on their toes. When the child reaches the age of 24 months, the child naturally walks flat-footed.
Research shows that children with autism represent 20% of children with idiopathic toe walking—however, a study shows that 9% of the sampled population represent ASD children diagnosed with toe walking. Yet, 0.5% represents children who walk on their toes but are not on the autism spectrum. This suggests that although a greater percentage of children who toe walk are diagnosed with autism; the habit of on its own is not a symptom of autism.
How can I stop my child from toe walking?
Persistent idiopathic toe walking can lead to damage to the lower leg and calf muscles. Early intervention can often help correct the habit of toe walking in young children.
Early intervention exercises
Static/passive stretches of the foot muscle:
- Manual calf muscle stretch
- Wall stretch
- Towel stretch—whilst in a sitting positive, use a towel around the foot and stretch towards the body
- Heel drop stretch—stand on a step; let the heel drop while the center part of the foot remains in contact with the step
Active stretches and strengthening:
- Squat play—the child plays in a squatting position or by sitting on a yoga ball making sure the foot is flat to the ground
- Bear walking—extend the foot muscle forward whilst keeping it flat to the ground
- Try out the Yoga “child pose”
- Practice heel walking
Many toe walkers undergo physical therapy or serial casting before considering medical intervention or surgery as an option. Research by Barrow, et al., proposes other treatments to correct toe walking such as casting, braces and, in some cases, Achilles tendon strengthening (the Achilles tendon is a strong fibrous cord that connects the calf to the heel bone). Children on the spectrum who toe walk and took part in the study were referred to a pediatric rehabilitation clinic for evaluation and treatment.
Alternative treatment: TAGteach
A study conducted by Persicke, et al., suggests an alternative medium for the treatment of toe walking called Teaching with Acoustical Guidance (TAGteach). This methodology uses positive reinforcement to reinforce desired behaviors through the use of auditory stimulus—such as a “click” sound—to function as a conditioned reinforcer.
Its application in the treatment of children who toe walk is aimed at decreasing the behavior. The treatment is conducted in three phases—the first phase is the correction phase, followed by the correction method paired with TAG, and finally, the “fading” phase which involves the gradual removal of the conditioned click sound for every two to four flat steps.
The rate of occurrence of toe walking is higher in children with autism than neurotypical children. Despite this fact, it is important to consider factors such as age, developmental delays or progress, and the familial genetic trend of toe walkers. Parents are advised to seek professional diagnosis for their child with the habit of toe walking to determine if he/she meets the criteria for ASD as stipulated by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
Several treatments exist for the correction of persistent toe walking. Early intervention is advised if a child shows signs of habitual toe walking.
Barrow, W.J., Jaworski, M., Accardo, P.J. (2011). Persistent Toe Walking in Autism. Journal of Child Neurology, 26(5), 619-621. https://doi.org/10.1177/0883073810385344
Beazley, E., Geno, M., LaDuca,T., Nolan, K. (n.d). Activities for Children Who Walk on Their Toes. https://www.urmc.rochester.edu/MediaLibraries/URMCMedia/childrens-hospital/developmental-disabilities/ndbp-site/documents/toe-walking-guide.pdf
Leyden, J., Fung, L., Frick, S. (2019) Autism and toe-walking: are they related? Trends and treatment patterns between 2005 and 2016.Journal of Children’s Orthopaedics, 13(4), 340-345. https://doi.org/10.1302/1863-2548.13.180160
Persicke, A., Jackson, M., Adams, A.N. (2014). Brief Report: An Evaluation of TAGteach Components to Decrease Toe-Walking in a 4-Year-Old Child with Autism.Journal of Autism and Developmental Disorders, 44, 965-968, https://link.springer.com/article/10.1007/s10803-013-1934-4