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Autism and Toe Walking: Causes & Solutions

December 18, 2023

A series of milestones mark the early developing stages of every child — from their first words to the first time they crawl and, ultimately, their first steps. Parents and physicians sometimes spot autism toe-walking during this key period of growth.

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? A wealth of information exists on this topic; below is what you need to know.

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How Common Is Toe Walking in Children?

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. According to Oxford Health, on average, an infant below two will begin walking intermittently on their toes.

However, this naturally phases out between six months and two years. Toe walking is said to be persistent if the habit continues after age two. Possible concerns about the child’s neurological development become evident at this point.

Associations with Toe Walking in Various Disorders

A research article published by Sage Journals indicates a link between intellectual disability or language development delay and toe walking in patients without a diagnosis of autism.

Toe walking is not only autism related but is also found among individuals with conditions such as:

  • cerebral palsy, 
  • muscular dystrophy, 
  • Charcot-Marie-Tooth Disease, and 
  • other neuropathies and myopathies.  

Children who walk on their toes with non-motor development disorders differ from those with associated neuromuscular disorders. An example of a neuromuscular disorder is cerebral palsy.

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 change 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 published by Brain & Development shows that children with autism represent 20% of children with idiopathic toe walking. However, a different 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.

Child toe walking
https://www.autismparentingmagazine.com/autism-toe-walking/

What Causes Toe Walking in Autism?

Toe walking may be linked to a malfunctioning vestibular system, commonly seen in autism.

A malfunctioning vestibular system may affect the following:

  • spatial orientation,
  • coordination,
  • balance.

Recent research indicates that many individuals with autism often experience auditory and vestibular dysfunction. This could lead to issues like postural instability, impaired gaze, and toe-walking.

How Do You Stop Toe Walking in Autism?

Persistent idiopathic toe walking can damage the lower leg and calf muscles. Early intervention is crucial in correcting the habit of toe walking in young children.

Many toe walkers undergo physical therapy or serial casting before considering medical intervention or surgery. Research proposes other treatments to correct toe walking, such as:

  • casting, 
  • braces,
  • Achilles tendon strengthening.

Let’s explore some early intervention exercises that can help with autism and toe walking.

Static/Passive Stretches of the Foot Muscle

These stretches help improve the flexibility and range of motion in the foot and ankle, which may reduce toe-walking tendencies.

Here are some of them:

  • 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.

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Active Stretches and Strengthening

Walking on toes can cause muscle imbalances and limit the movement of ankle and calf muscles. The following exercises may help stretch and strengthen these muscles:

  • Squat play – the child plays in a squatting position or by sitting on a yoga ball, making sure the foot is flat on the ground
  • Bear walking – extend the foot muscle forward whilst keeping it flat on the ground
  • Try out the Yoga “child pose”
  • Practice heel walking

Alternative Treatment: TAGteach

Research suggests an alternative medium for treating toe walking called Teaching with Acoustical Guidance (TAGteach). This methodology uses positive reinforcement to reinforce desired behaviors through auditory stimuli, such as a “click” sound.

The treatment is conducted in three phases:

  1. Correction phase, 
  2. Correction method paired with TAG,
  3. The “fading” phase (gradually removing the conditioned click sound for every two to four flat steps.)

Professional Diagnosis is Encouraged

Toe walking is more common in children with autism than their neurotypical peers. However, factors like age, developmental progress, and family history should be considered, too.

Parents are encouraged to seek a professional diagnosis based on ASD criteria in the DSM-V for children habitually toe-walking, and early intervention is recommended for persistent cases.

FAQs

Q: Is tip-toe walking a sign of autism?

A: Although it’s common among individuals on the spectrum, toe-walking isn’t always a sign of autism. Toe walking can occur in individuals without ASD. It becomes a concern when combined with other autism-related behaviors.

Q: Can adults with autism also exhibit toe-walking behavior?

A: While some adults with autism may exhibit distinctive walking styles, such as toe-walking, it’s essential to recognize that this is not a universal characteristic. The way individuals with autism walk can differ based on various factors, making it unique to each person.

Q: When should you worry about toe walking?

A: Discuss with your doctor if your child walks on their toes after age 2. Schedule an appointment sooner if your child also has tight leg muscles or struggles with muscle coordination.

Q: What are the long-term effects of toe walking?

A: Walking on toes can lead to issues like tight ankles and poor balance, causing frequent falls. Additionally, bad posture may result in muscle imbalances, affecting hip and core strength.

Q: Can toe walking in autism be corrected?

A: Yes, toe walking in autism can often be corrected with appropriate interventions, such as physical therapy and behavioral strategies. Early detection and intervention can be especially helpful in addressing this behavior.

References:

Toe walking in children (walking on tip toes)
https://www.oxfordhealth.nhs.uk/podiatry/wp-content/uploads/2013/12/Toe-walking-in-children.pdf

Autism and toe-walking: Are they related? Trends and treatment patterns between 2005 and 2016
https://journals.sagepub.com/doi/10.1302/1863-2548.13.180160

Biomechanical Characteristics of the Typically Developing Toddler Gait: A Narrative Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8946917/

Central Auditory and Vestibular Dysfunction Are Key Features of Autism Spectrum Disorder
https://www.frontiersin.org/articles/10.3389/fnint.2021.743561/full

Autism and toe-walking: Are they related? Trends and treatment patterns between 2005 and 2016
https://journals.sagepub.com/doi/10.1302/1863-2548.13.180160

Prevalence of motor impairment in autism spectrum disorders
https://www.brainanddevelopment.com/article/S0387-7604(07)00089-7/fulltext

Persistent Toe Walking in Autism
https://journals.sagepub.com/doi/10.1177/0883073810385344

Brief Report: An Evaluation of TAGteach Components to Decrease Toe-Walking in a 4-Year-Old Child with Autism
https://link.springer.com/article/10.1007/s10803-013-1934-4

Teaching complex behaviors with acoustic guidance
https://journals.indexcopernicus.com/api/file/viewByFileId/582792.pdf

Brief Report: An Evaluation of TAGteach Components to Decrease Toe-Walking in a 4-Year-Old Child with Autism
https://www.researchgate.net/publication/256452090_Brief_Report_An_Evaluation_of_TAGteach_Components_to_Decrease_Toe-Walking_in_a_4-Year-Old_Child_with_Autism

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