Toe Walking and Autism: Cross-Sectional Study on Presentation Patterns and Correlation with Autism Severity

Background: According to the literature, about twenty per cent of individuals with autism walk on their tiptoes. “Toe walking” (TW) may present different functional patterns but thus far, there is no standardized clinical method of examination or assessment. Some authors describe TW as intermittent or persistent ^,   while others grade TW by history and observation (e. g. absent, present in the past, intermittently present, and persistent). Moreover, it seems that the persistence of toe walking can be related to language impairment even if systematic observations in the literature are scarce.

Objectives: The aims of this cross-sectional study are: 1) to assess the prevalence of toe walking in an ASD cohort; 2) to describe the functional patterns of presentation of TW; 3) to evaluate the relationship between TW  presentation patterns and the severity of autism with particular regard to  language delay.

Methods: The study includes sixty nine consecutive children (56 males; 13 females; mean age = 12,4 years) diagnosed with Autism according to the DSM V criteria and under observation at our institute. A therapist assessed the presence of Tiptoe behavior( TTB) during standing, walking and running using direct observation  and interview of the main caregiver living with the children. The severity of autism was established through ADOS ( 2^ndversion)  

Results: Overall: 22 children (31,88%) presented TTB. Ten children (14,49%) exhibited it while standing, walking and running (class 1), four (5,79%) only during walking and running (class 2) and eight children (11,59%) only during running (class 3). The overall ADOS mean score of all the children was 21.14 (7.93 SD). The ADOS mean score of non TTB children was 20.09 (7.66) vs a value of 23.41 (8.5 SD) in TTB children. There were no significant differences in the mean overall ADOS score of the TTB children according to the three TTB classes  24.9 (9.0 SD), class1 vs 20.25 (7.5 SD), class 2 and vs 23.13  (8.38 SD), class3. We divided the children in four groups, depending on the level of the language, according to the ADOS system: fluent language, able to produce simple sentences, able to produce single words, absence of any language( nonverbal ). 44.6% per cent of non TTB children and 72.7% of TTB children were nonverbal ( p<0.05). However, language delay severity was not correlated to the severity of TTB.

Conclusions: TTB frequently manifests itself in individuals with Autism. It may occur in three mutually exclusive modalities, which include what is  commonly defined toe walking. The presence of TTB is  not correlated to autism severity but rather to language delay.