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Grandma wants to stop tiptoe walking in grandaughter who has autism

Perspective and guidance on this common autism-related behavior, from a pediatrician and a physical therapist in the Autism Speaks ATN

“How can I stop my granddaughter [who has autism] from constantly walking on tip toes?”

Today’s “Got Questions?” answer is by neurodevelopmental pediatrician Kristin Sohl and physical therapist Jan McElroy, of the University of Missouri Thompson Center for Autism and Neurodevelopmental Disorders. The Thompson Center is one of 14 sites in the Autism Speaks Autism Treatment Network.

Editor’s note: The following information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.

At our clinic, we frequently see toe walking or walking on the ball of the foot in children who have autism. Like you, a parent or other family member is often first to notice and become concerned.

Many typically developing toddlers go through a short stage of toe walking interspersed with more typical walking patterns. But toe walking that persists beyond the “first learning to walk” phase is considerably more common among children with autism than among the general population.

When habitual toe walking persists for more than 6 months, it’s important to bring it to the attention of your child’s doctor or a pediatric physical therapist.

The importance of a skilled evaluation
As the reasons for toe walking differ child to child, it’s important to get a thorough evaluation of your child’s manner of walking (gait) and large muscle abilities (gross motor development) as part of a comprehensive physical evaluation.

This is typically done by a pediatric physical therapist – ideally someone skilled in working with children who have autism.

Common causes include:

* Sensory issues. This can include discomfort or anxiety in response to the feel of certain surfaces on the bottom of the child’s feet.

* Tight calf muscles and shortened heel (Achilles) tendons. The tight muscle and/or shortened tendon can prevent the heel from touching the ground. So instead of walking flat footed, the child walks on his or her toes. Calf muscle tightness often occurs with autism. Sometimes it’s related to cerebral palsy, another condition that can co-occur with autism.

* Hyper-reactive calf muscles. In this case, fast movements such as walking cause the calf muscle to spasm, or shorten, at the wrong time. To avoid the uncomfortable spasm, the child may begin to stay up on his or her toes.

* Hyper-extended back posture (“sway-back”). This posture shifts the child’s weight forward onto the toes. We commonly see this in children with low muscle tone, or muscle weakness.

Once an expert has identified the underlying cause or causes, a physical therapist can design an effective intervention.

Interventions
In each of the situations above, the physical therapist will develop a personalized program to address the issues and help the child develop a healthier manner of walking

These interventions can include:

* Exercises for muscle strengthening and coordination. For example, we might ask the child to practice walking on her heels with his or her toes off the floor and/or to stand on a tippy surface to practice keeping her balance

* Activities to decrease hypersensitivity and ease sensory issues. We’ve seen instances where this was as simple as finding socks without irritating seams. Other times, the sensory issues were far more complex. We strongly urge professional help with such issues, because it can be easy to worsen the problem if the approach doesn’t fit the child’s challenges.

* Muscle stretching or application of casts to lengthen tight or short calf muscles. 

* Postural exercises and supports to improve body alignment.

* If the above measures are not sufficient, an orthopedic doctor may propose orthotics or braces for the lower legs, ankles and feet. Another medical intervention involves Botox injections to relax the calf muscles. As a last resort, a child may need surgery to lengthen the heel tendons.

As you can see, there’s no single approach that works for all children who toe walk. It’s crucial to match the intervention to the specific cause for each child.

As we mentioned earlier, pediatric physical therapists can be particularly helpful in assessing the cause or causes of toe walking and developing an intervention program appropriate for your grandchild.

Meanwhile, no limitations to activity
If possible, we recommend seeing a therapist skilled in working with children who have autism. One place to find such specialists is at an autism clinic such as those in the Autism Speaks Autism Treatment Network. You can find the ATN center nearest you here. Even if you live distant from such a center, the staff may able to help you find a specialist in your area.

In general, children who toe walk have no limitations on their ability to engage in physical activity. Toe walking does not need to keep children from gym class or other forms of play.

Sometimes, a lack of understanding on the part of other children can lead to teasing. We recommend reassuring the child with autism with the reminder that every child does things a little differently. If the bullying worsens or becomes a serious issue, it’s important to involve teachers and school counselors in efforts to address and stop the hurtful behavior.

We hope this information proves helpful. Please let us know how your granddaughter and your family are doing with a comment below or by writing us again at gotquestions@autismspeaks.org.

Editor’s note: For more information, also see Toe Walking, on the website of Toronto’s Hospital for Sick Children, another member center of the Autism Speaks ATN.

* Learn more about the Autism Speaks Autism Treatment Network here.
* Find the ATN center nearest you 
here.
* Explore our archive of ATN expert-advice blogs and news stories 
here.

The Autism Speaks blog features opinions from people throughout the autism community. Each blog represents the point of view of the author and does not necessarily reflect Autism Speaks' beliefs or point of view.