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. 2024 Jul 31;18(1):221–233. doi: 10.1007/s40617-024-00971-9

A Caregiver Survey on Medical and Behavior Analytic Treatments for Idiopathic Toe Walking

Christina Sheppard 1, David Wilder 1,✉
PMCID: PMC11904036  PMID: 40092348

Abstract

Toe walking, which is defined as walking with a bilateral toe-to-toe gait, is common among children with intellectual and developmental disabilities and can result in a number of medical problems. Both medical and behavioral treatments for toe walking have been evaluated. In the current study, we surveyed caregivers of individuals who engage in toe walking about their use of various medical and behavioral treatments. Results suggest that the use of medical treatments is more common, and most respondents reported that they were unaware that behavioral treatment of toe walking is an option. Most respondents reported that the hypothesized function of toe walking by their child is automatic positive reinforcement, although more than half attributed toe-walking to a disorder (e.g., autism spectrum disorder), a physical cause (e.g., tight muscles), or reported they did not know why their child engaged in toe walking. Surgery and increased response effort via weighted boots were the medical and behavioral treatments, respectively, perceived to be most effective in treating toe walking. To assist the behavior analytic community in managing toe-walking cases, we also provide some specific recommendations for practitioners, including a description of the advantages and disadvantages of behavioral treatments for toe walking and a decision tree for behavior analysts unfamiliar with the literature on this topic.

Keywords: Toe walking, Intellectual and developmental disabilities, Behavioral interventions, Medical interventions

Toe walking, or walking with a bilateral toe-to-toe gait, which results in failure to make heel contact with the ground, is most common in early childhood (Sala et al., 1999). Between 2% and 5% of children under 5 years of age engage in consistent toe walking (Engström & Tedroff, 2018). In some cases, toe walking may be caused by muscle or spinal abnormalities, but most often, the specific cause is undetermined. When the cause is unknown, the condition is called idiopathic toe walking (ITW; Sala et al., 1999).

ITW is more common among children with intellectual and developmental disabilities and, in particular, autism spectrum disorder (ASD; Barrow et al., 2011). Barrow et al. (2011) found that approximately 20% of a cohort of 954 children engaged in toe walking and noted a 10% greater prevalence of toe walking in participants diagnosed with ASD relative to children without an ASD diagnosis. Other studies, however, have estimated the prevalence of toe walking to be as high as 41% among children with ASD and related disabilities (Engström & Tedroff, 2018). ITW is also exhibited by children with cerebral palsy and neuropathy. In fact, among children who engaged in ITW and were referred to a neurology clinic by orthopedic physicians, 37% had cerebral palsy, and 16% had peripheral neuropathy (Haynes et al., 2018).

Although short-term ITW may not be harmful and thus not warrant intervention, long-term ITW may lead to a number of medical problems, including tightening or shortening of the ankle or calf muscles; abnormal gait and posture; foot and ankle deformities; foot pain and joint stiffness, fatigue, and bunions. In addition, long-term ITW can lead to decreased physical activity levels, which can result in additional health problems later in life (Engström & Tedroff, 2018).

Interventions for ITW include both medical and behavioral treatments. Medical treatments include surgery (Hemo, 2006), serial casting (Fox et al., 2006), Botulinum Toxin A (BTX-A; Sätilä et al., 2016), and orthoses (Herrin & Geil, 2016). Surgery often involves lengthening the Achilles tendon and is the most invasive and expensive treatment for ITW (Leyden et al., 2019). Unfortunately, many people with ASD who receive surgery for ITW resume toe walking within 2 years of the procedure (Leyden et al., 2019). Serial casting involves placing a patient’s lower legs and feet in a series of plaster or fiberglass casts to continually stretch the muscles surrounding the ankle to prevent toe walking. Although it can be effective in the short term, ITW often returns (van Bemmel et al., 2014).

BTX-A is a protein that causes temporary muscle paralysis at the injection site. Sätilä et al. (2016) found that BTX-A was effective in treating ITW among all participants in their study, although the majority of participants who received standard treatment (i.e., stretching and night splints) also stopped toe walking. Orthoses are plastic devices that cover the foot or ankle to prevent ITW. Herrin and Geil (2016) found that orthoses were effective, but like other treatments, ITW often returned when they were removed.

Relative to medical treatment, fewer behavior-analytic treatment studies on ITW exist (Hodges et al., 2023). Behavioral interventions for ITW have included the use of increased response effort (Hobbs et al., 1980), a wristband to indicate when reinforcement for appropriate walking is available (Hodges et al., 2018), the delivery of conditioned reinforcement (Marcus et al., 2010; Persicke et al., 2014), overcorrection (Barrett & Linn., 1981), and shoe insole surface modification (Wilder et al., 2022).

Hobbs et al. (1980) used a pair of heavy boots to increase the effort associated with ITW. The procedure was effective, but only when the researchers combined it with differential reinforcement of other behavior (DRO). Hodges et al. (2018) used a multiple schedule to indicate when reinforcement for walking appropriately was available for a young boy with ASD. The boy wore a wristband, in the presence of which appropriate walking was praised and ITW was reprimanded. Once ITW was reduced to acceptable levels, the researchers increased the duration of wearing the wristband. The researchers also had the participant wear the wristband in the community and had the participant’s mother implement the procedure. The wristband was effective, and follow-up data were encouraging.

Marcus et al. (2010) used Gaitspot Auditory Squeakers to treat ITW exhibited by three children. The sound of the squeakers was first paired with preferred items, and an appropriate step produced the squeaker sound and a preferred item on a fixed or variable ratio reinforcement schedule. The procedure was effective for all three participants, but long-term follow-up data were not provided. Persicke et al. (2014) used a modified TAGTeach procedure in which they paired a clicking sound with access to preferred edible items so that the sound functioned as a conditioned reinforcer. They then delivered the clicking sound contingent upon appropriate steps. This procedure was effective in reducing ITW. Barrett and Linn (1981) evaluated positive practice overcorrection to treat ITW exhibited by a 9-year-old boy with a moderate intellectual disability. The overcorrection procedure required the participant to tap his toes for 30 consecutive s while the experimenter held the participant’s heels to the floor. The procedure was effective, and the researchers incorporated some physical therapy techniques as well. In a recent study, Wilder et al. (2022) lined two participants’ shoes with a surface that inhibited toe walking. The procedure was effective in reducing ITW to low levels. In general, very little follow-up data on ITW have been collected in behavioral treatment studies, so the long-term effects of these treatments are unknown.

Despite the existing data on ITW, information on caregiver use of and experience with behavior analytic treatments for ITW is scant. That is, no information on caregivers' experiences with various behavioral treatments and their perceived effectiveness exists. Because more medical than behavioral intervention studies on ITW have been published and many of the behavior analytic studies included only one or a few participants (Hodges et al., 2023), some healthcare providers might assume that the only viable treatment options for ITW are medical, and therefore suggest these interventions when consulting with caregivers. The purpose of this study is to gather information on caregiver use of and experience with medical and behavioral interventions for ITW. In particular, we want to learn the percentage of caregivers who have used medical versus behavioral interventions for ITW, and of those who have used these interventions, the percentage of caregivers who report that the intervention was effective. We are also interested in caregivers’ perceived function of their children’s ITW. Of course, we recognize that parent (and clinician) perception of ITW function may not represent actual function, but causal explanations may influence intervention choice and acceptability (e.g., feedback-based interventions may be less acceptable for ITW perceived to be maintained by automatic negative reinforcement). Finally, given that ITW can lead to an array of health complications, ITW is relatively common in populations with whom behavior analysts typically work, and behavior analysts have the tools to effectively treat some cases of ITW, the larger purpose of this research is to provide a guide to the management of ITW cases for behavior analytic practitioners.

Method

Participants

Participants were caregivers of individuals who engaged in ITW. Most (85%) were parents, others were primary caregivers, therapists, or teachers of the individual who engaged in ITW, and most (87%) knew the individual since birth. Ethnicities of participants included white (70%), Asian (8%), Hispanic or Latinx (7%), Black or African American (5%), American Indian or Alaskan Native (2%), and multiple ethnicities (8%). Most participants (78%) reported no family history of ITW.

Participants responded to an anonymous survey distributed through social media platforms (e.g., Facebook) via an anonymous link to the host site. The title of the survey was “Toe-Walking Survey.” We distributed the survey to social media pages of those living both in and outside the United States. We targeted pages that emphasized ASD, developmental disabilities, cerebral palsy, neuropathy, and education. The number of individuals who accessed the survey is unknown. One hundred thirty-four individuals responded to the anonymous link, completed the survey, and were included in the analysis. We excluded respondents who completed only a portion of the survey.

Instrumentation and Survey Structure

We developed the survey using an online survey creation, distribution, and analysis platform (i.e., SurveyMonkey). The survey took approximately 10 min to complete, and all participants were exposed to the purpose, time expectancy, and informed consent form prior to beginning the survey. The system was arranged such that it prevented participants from completing the survey more than once. The survey consisted of 25 questions (see Table 1) on the participant's (i.e., respondent) background, the child engaging in ITW background, that child’s medical and psychiatric history, ITW history, and assessment and treatment history for ITW. Scale anchors for questions ranged from dichotomous (e.g., Yes/No) to a 3-point Likert scale (e.g., Mild/Moderate/Severe). We also included some open-ended and multiple-choice style questions. For example, participants could select having been exposed to any combination of both medical (e.g., surgery) and behavioral (e.g., auditory feedback) interventions. For clarity and consistency, we embedded (i.e., included parenthetically) brief descriptions of these medical and behavioral interventions in the relevant questions.

Table 1.

Survey Questions

1) What is your relation to the person who toe walks?
      a) Parent Primary Caregiver Therapist
      b) Self-report
      c) other (Please specify)
2) How long have you known the person who toe walks?
      a) Weeks
      b) Months Years
      c) Entire duration of person's life
3) Approximately how much time in hours do you spend with the person who toe walks per day? (Open ended)
4) What was the sex of the person who toe walks at birth?
      a) Male
      b) Female
      c) Other
5) What is the age of the person who toe walks in years? (Open ended)
6) Was the person who toe walks diagnosed with any of the following (Please check all that apply)?
      a) Autism Spectrum Disorder
      b) Cerebral Palsy
      c) Neuropathy
      d) Arthritis
      e) Other (Please Specify)
7) Is the person who toe walks currently receiving any therapy services?
      a) Yes (Please specify reason for referral)
      b) No
8) Have others (e.g., teachers, therapists, relatives, friends) expressed concern about the person’s toe-walking?
      a) Yes
      b) No
9) How would you rate the severity of this person’s toe-walking?
      a) Mild (Not Currently Causing Social or Medical Problems)
      b) Moderate (Causing Some Social or Medical Problems)
      c) Severe (Causing More than One Social or Medical Problem)
10) Is this person currently experiencing any complications from toe-walking (e.g., affected ankles/ joints/ tendons, motor difficulties)?
      a) Yes
      b) No
11) What percentage of this person's steps per day tend to be toe-walking? (Sliding scale)
12) Why do you think this person walks on their toes? (Open-ended)
13) Would you describe this person's toe-walking as sensory-seeking (e.g., seems to enjoy the sensation of being on toes/actively seeks novel surfaces to press feet) or sensory-avoiding (e.g., seems to dislike and avoid the sensation of various surfaces on feet)?
      a) Sensory-seeking
      b) Sensory-avoiding
14) Has this person ever visited any of the following professionals for evaluation or treatment of toe-walking (Please check all that apply)?
      a) Pediatrician
      b) Occupational Therapist
      c) Physical Therapist
      d) Behavior Analyst
      e) Other (Please specify)
      f) None of the above
15) Has this person ever received or is this person currently receiving any medical interventions for toe-walking?
      a) Yes
      b) No
16) Has this person ever received or is this person currently receiving any of the following medical interventions for toe-walking?
      a) Serial casting
      b) Surgery
      c) Botulinum Toxin A (Botox injections)
      d) Ankle Foot Orthoses (AFOs) (lower limb brace used to improve gait)
      e) Stretching recommended by a professional (e.g., Occupational Therapist, Physical Therapist, Physician)
      f) Other (Please specify)
17) If applicable, what is your perceived effectiveness of the medical intervention?
      a) Excellent
      b) Good
      c) Poor
      d) N/A
18) If applicable, have the treatment results of the medical intervention(s) maintained?
      a) Yes
      b) No
      c) N/A
19) If applicable, what is your primary reason for not pursuing medical intervention?
      a) Cost
      b) Did not know it was an option Using "watch and wait" Other (Please specify)
      c) N/A
20) Has this person ever received or is your child currently receiving any behavioral interventions for toe-walking?
      a) Yes
      b) No
21) Has this person ever received or is this person currently receiving any of the following behavioral interventions for toe-walking?
      a) Heavy-weighted boots (increased effort to walk)
      b) Delivering preferred item/ snack contingent on appropriate steps (reinforcement-based procedure for appropriate steps)
      c) Required to perform the appropriate form of the behavior (flat-footed step) multiple times following an episode of toe-walking (contingent upon toe walking)
      d) Verbal reprimand (for steps with toe-walking)
      e) Gaitspot Auditory Squeakers (squeakers attached to bottom of heel that provide auditory feedback/ make a sound for each appropriate heel
      f) Shoe inserts
      g) Other (Please specify)
22) If applicable, what is your perceived effectiveness of the behavioral intervention?
      a) Excellent
      b) Good
      c) Poor
      d) N/A
23) If applicable, have the treatment results of the behavioral intervention(s) maintained?
      a) Yes
      b) No
      c) N/A
24) If applicable, were there any complications from the behavioral intervention(s)?
      a) Yes (Please specify)
      b) No
      c) N/A
25) If applicable, what is your primary reason for not pursuing medical intervention?
      a) Cost
      b) Did not know it was an option
      c) Using "watch and wait"
      d) Other (Please specify)
      e) N/A
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Procedure

We distributed anonymous links to participants via social media platforms. The post caption and flyer included the link, introduction to the survey, definition of ITW, benefits to participation, and contact information for the authors. If participants clicked the link, they were taken to SurveyMonkey, where they were presented with the informed consent form prior to answering the survey questions. Approximately 1 month following the initial post, a reminder was posted to prompt potential participants to complete the survey. Participants could complete the survey between July 20, 2022, and December 19, 2022. The survey platform only recorded completed responses for the postsurvey analysis.

Response Measurement, Data Analysis, and Intercoder Agreement

We calculated the percentage of respondents who selected each answer to each question. We did this by dividing the number of respondents selecting the answer by the total number of respondents who were presented with the question. We exported the responses of all participants from SurveyMonkey as a spreadsheet to allow for comparisons and detailed analyses. For question 12 (an open-ended question), we coded responses according to the definitions in Table 2. The second author independently coded 25% of all responses to determine intercoder agreement. Code categories were not mutually exclusive (i.e., one response could be categorized according to multiple codes and therefore counted more than once). We calculated exact item-by-item agreement by dividing the number of responses with full agreement (i.e., both authors scored the same codes and the same number of codes) by the total number of responses. The arithmetic mean agreement was 95% (range: 90%–100%). Discrepancies were resolved by discussing each response with a disagreement to clarify the reason each author scored the item the way they did; after this process, mean agreement was 100%.

Table 2.

Respondents' Hypotheses Regarding Reasons for Child's Toe-walking

Code Operational Definition %
Unknown Any response in which the respondent stated that they did not know why the client engaged in toe-walking (e.g., "don't know") 20
Habit Any response in which the respondent stated that the client engaged in toe-walking because it was a repeated behavior that was difficult to stop 18
Attributed to disorder or Physical cause Any response in which the respondent stated that the client engaged in toe-walking due to a psychiatric diagnosis (e.g., autism) or due to a physicalor structural cause (e.g., tight muscles/ tendons) 31
Sensory seeking or avoiding Any response in which the respondent stated that the client engaged in toe-walking due to sensory input/ seeking/ issues, because it feelsgood/ comfortable, or to avoid a sensation 31
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Results

All respondents reported that their child engaged in ITW for 10 min or more each day. Most respondents rated their child’s toe walking as moderate (54 of 134 or 40%) or severe (57 of 134 or 42%), but slightly more than 17% (23 of 134) rated their child’s toe walking as mild. Just over three-quarters of respondents (76.8%; 103 of 134) reported that a friend, teacher, or relative had expressed concern about their child’s toe walking in the previous year. Of those respondents who asked their child why they engaged in ITW (open-ended question), 52% of children said they did not know. When respondents were asked to identify the reason for their child’s ITW (open-ended question), most said that their child’s toe walking occurred due to either a disorder or physical cause (31%) or due to sensory seeking or sensory avoidance (31%; see Table 2). Fifty-nine percent (80 of 134) of respondents reported that they believed the purpose of their child’s toe walking was to “produce pleasant stimulation,” whereas 40% (54 of 134) of respondents reported that they believed the purpose of their child’s toe walking was to “avoid unpleasant stimulation.” We further analyzed these data by diagnosis; the majority of respondents whose child had a diagnosis of ASD (24 of 39 or 63%) indicated a sensory-seeking (i.e., automatic positive reinforcement) function, whereas the majority of respondents whose child had a diagnosis of cerebral palsy (5 of 7 or 83%) and neuropathy (100%) indicated a sensory-avoiding (i.e., automatic negative reinforcement) function. More than 61% (83 of 134) of respondents reported consulting a pediatrician about their child’s toe walking, whereas only 11% (15 of 134) reported consulting a behavior analyst.

Fifty-two percent (70 of 134) of respondents reported that their child had received medical treatment for ITW (see Fig. 1). Of those respondents who reported that their child had received a medical intervention, 65% reported that their child received daily stretching as a treatment, 42% reported that their child had received orthoses as a treatment, 24% reported that their child had received serial casting as a treatment, 9% reported that their child had received surgery as a treatment, and 6% reported that their child had received BTX-A as a treatment. Forty percent of respondents who reported using a medical treatment said that the medical treatment was effective over time (i.e., reduced ITW by at least some). When asked to rate the effectiveness of medical interventions that they had experienced, respondents rated surgery as the most effective, although it was rated as producing excellent effects by fewer than half of respondents who answered this question, whereas ankle-foot orthoses were rated least effective (see upper panel of Table 3).

Fig. 1.

Fig. 1

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Percentage of respondents reporting use of medical and behavioral treatments for toe walking (BTX-A= Botulinum Toxin A; DRA = Differential Reinforcement of Alternative Behavior, DRI = Differential Reinforcement of Incompatible Behavior; DRO = Differential Reinforcement of Other Behavior). Note: The upper panel depicts the percentage of respondents who have used medical and behavioral treatments for toe walking. The middle and lower panels depict the percentage of respondents reporting use of each type of medical and behavioral treatment, respectively, of those who reported use of a medical or behavioral treatment

Table 3.

Perceived Treatment Effectiveness (Poor, Good, Excellent)

Treatment % Poor % Good % Excellent
Medical
Serial casting 27.78 (n= 10) 44.44 (n= 16) 27.78 (n= 10)
Surgery 16.67 (n= 2) 16.67 (n= 2) 41.67 (n= 5)
Botulinum Toxin A (Botox injections) 30 (n= 3) 50 (n= 5) 20 (n= 2)
Ankle Foot Orthoses (AFOs) (lower limb brace used to improve gait) 46.43 (n= 26) 37.5 (n= 21) 16.07 (n= 9)
Stretching recommended by a professional (e.g., Occupational Therapist, Physical Therapist, Physician) 41.46 (n= 34) 46.34 (n= 38) 12.2 (n= 10)
Behavioral
Heavy-weighted boots 31.82 (n= 7) 36.36 (n= 8) 31.82 (n= 7)
Delivering preferred item/ snack contingent on appropriate steps (reinforcement-based procedure for appropriate steps) 44 (n= 11) 32 (n= 8) 24 (n= 6)
Required to perform the appropriate form of the behavior (flat-footed step) multiple times following an episode of toe-walking (contingent overcorrection) 44.83 (n= 13) 44.83 (n= 13) 10.34 (n= 3)
Verbal reprimand (for steps with toe-walking) 56.16 (n= 41) 31.51 (n= 23) 12.33 (n= 9)
Gaitspot Auditory SqueakersTM (squeakers attached to bottom of heel that provide auditory feedback/ make a sound for each appropriate heel-to-ground step) 18.18 (n= 2) 72.73 (n= 8) 9.09 (n= 1)
TAGTeachTM (auditory feedback/ click delivered by another person for appropriate steps) 25 (n= 1) 25 (n= 1) 0 (n= 0)
Textured shoe inserts 43.75 (n= 7) 50 (n= 8) 6.25 (n= 1)
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Thirteen percent (18 of 134) of respondents reported that their child had received a behavioral treatment for ITW. Of those respondents who reported that their child had received a behavioral treatment, 56% of respondents reported that their child received a verbal reprimand as a treatment, 20% of respondents reported that their child had received overcorrection as a treatment, 13% of respondents reported that their child had received differential reinforcement of alternative (DRA),incompatible (DRI), or other (DRO) behavior as a treatment, 13% of respondents reported that they had received a treatment involving modifying their child’s shoe insoles, 12% of respondents reported that their child had received heavy boots or shoes (to increase response effort) as a treatment, and 10% reported that their child had received some form of conditioned reinforcement / auditory feedback as a treatment. Thirty-six percent of respondents who reported using a behavioral treatment said that the behavioral treatment was effective over time. When asked to rate the effectiveness of behavioral interventions they had experienced, respondents rated heavy-weighted boots as the most effective, although they were rated as producing excellent effects by fewer than one third of respondents who answered this question, whereas reprimands were rated least effective (see lower panel of Table 3). When those respondents who said they had not tried a behavioral treatment were asked why they had not tried one, 55% said they did not know it was an option / had not been informed of behavioral treatments for ITW.

Finally, respondents reported that when their child is instructed to stop toe walking, some children (59%) do temporarily stop (i.e., for a few minutes or steps). Other respondents said that when their child is asked to stop ITW, their child continues toe walking and engages in an emotional response such as crying (22%) or stops toe walking but continues to walk with an abnormal gait or posture (8%).

Discussion

Persistent ITW can result in acute and long-term health problems and is relatively common in children with ASD. In the current study, we surveyed caregivers of children who exhibit ITW about their use of and experience with both medical and behavior-analytic treatments. More than half of respondents reported trying a medical intervention for their child’s ITW, but only 13% of respondents reported trying a behavioral treatment. These data suggest that health-care professionals are largely recommending medical interventions instead of behavioral interventions, despite the invasive and expensive nature of many medical treatments for ITW (e.g., surgery, orthoses, BTX-A).

It is interesting that the perceived effectiveness of behavioral treatments by caregivers was similar to medical treatments. That is, about 40% of respondents who reported that they tried a medical treatment perceived the treatment as effective, whereas about 36% of respondents who reported that they tried a behavioral treatment perceived the treatment as effective. Of course, the perceived effectiveness of an intervention is different from the actual effectiveness. The data from this survey should be interpreted cautiously because the actual effectiveness of any behavioral treatment must be formally evaluated at the individual level; much more research on the actual effectiveness of behavioral (and medical) treatments for ITW is needed.

Recommendations for Practitioners

One reason that few respondents reported using behavioral treatments may be that many caregivers and health-care professionals are unaware of their utility in treating ITW. Indeed, when asked why they had not tried a behavioral treatment, more than half of survey respondents said they were unaware that these treatments are an option for ITW. To acquaint caregivers and non-behavior-analytic practitioners with a behavior-analytic approach to managing ITW and to better familiarize behavior analysts who may be unaccustomed to treating ITW, we have included a decision tree for ITW treatment selection (see Fig. 2). It is intended for use by behavior analytic practitioners who have experience with functional assessment and function-based treatment. Though we provide specific applications from behavior analytic ITW studies, typical assessment and intervention considerations apply (Axelrod et al., 1993). These include obtaining appropriate medical clearance, selecting appropriate measurement systems (LeBlanc et al., 2016), determining relevant prerequisite skills of clients, assessing the sufficiency of resources (i.e., finances and time), taking client preferences into account, utilizing least restrictive procedures as a first course of action, and communicating effectively when collaborating with other professionals. We should also note that the behavioral treatment recommendations are organized around the child’s listener repertoire. We provide this very general guide to treatment selection based on the current literature and our own experience with the most effective and efficient approaches. We designed this as a rough guide to the general management of ITW cases and emphasize that individual cases may require more nuanced assessment and intervention selection considerations.

Fig. 2.

Fig. 2

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Decision Tree for Behavior Analysts Managing ITW Cases

Consider Age, Medical Clearance, and Interdisciplinary Collaboration

First, when providing recommendations to caregivers, practitioners should consider the age of the client. Toe walking is not considered developmentally inappropriate for a child who is under 2 years old. For such clients, “watching and waiting” (Engström & Tedroff, 2018) to determine whether gait normalizes is appropriate. For children older than 2 years, practitioners should recommend a pre-intervention medical evaluation. If the medical evaluation is unremarkable (i.e., there is no apparent medical cause), practitioners might proceed with a behavior-analytic approach. If medical treatment is warranted, with caregiver consent, the behavior analytic practitioner can offer to discuss collaboration with the medical health professional to determine whether supplementing with behavioral intervention would be beneficial. Through such efforts, individual behavior analysts can educate other healthcare professionals about behavioral assessment and treatment of ITW. An interdisciplinary team for ITW may consist of professionals such as a physical therapist, pediatrician, orthopedist, neurologist, occupational therapist, and podiatrist.

Consider Function

The first step in the behavioral approach is to conduct a screening to confirm that ITW is maintained by automatic reinforcement (Querim et al., 2013). The few existing studies in which a functional analysis of ITW has been conducted (Wilder et al., 2020; Wilder et al., 2022) have all shown maintenance via automatic reinforcement. However, unlike many other topographies of challenging behavior maintained by automatic reinforcement, common behavior analytic interventions may not be a good fit for ITW. For example, the first line intervention for automatically maintained challenging behavior is noncontingent access to competing items (Rooker et al., 2018). However, noncontingent access to competing items may be less likely to be effective for ITW. Although no research has formally examined this intervention for ITW, the reinforcer for ITW is likely a pleasant sensation produced in the ankle, toes, or calf muscles (or avoidance of an unpleasant sensation in one of these body parts). Items that produce the same type of stimulation produced by this sensation may be difficult to identify, although this is also true for other topographies of challenging behavior maintained by automatic reinforcement. Further, items that successfully compete with this sensation may not necessarily have to match the stimulation produced by ITW. Nevertheless, the topography of ITW (only occurs when the individual is mobile) may make access to competing items less practical, because individuals would need to carry competing items as they walk. Another common intervention for automatically maintained challenging behavior, blocking or physically preventing the occurrence of the behavior (Saini et al., 2016), may also be difficult to implement for ITW. That is, it is impractical for a therapist to physically intervene to prevent steps on toes before or as a step is taken. Orthoses prevent steps on toes, but this involves a medical device, as opposed to a person, preventing ITW. It is interesting that in the current survey, many caregivers speculated that their child engaged in ITW to reduce or avoid an unpleasant sensation (i.e., automatic negative reinforcement). Behavior analytic researchers should develop methods of distinguishing between ITW maintained by automatic positive reinforcement versus automatic negative reinforcement, as treatment of ITW should differ based on this. That is, treatment for ITW maintained by automatic negative reinforcement should consist of reduction or (ideally) removal of the aversive sensation experienced by the client via medical intervention. Of course, ITW may not always be maintained by automatic reinforcement (although no data have demonstrated a social function to date). In cases of ITW maintained by social reinforcement, identification of the specific source of reinforcement is the first step. Once identified, providing the maintaining reinforcer for heel-to-toe steps or noncontingently, along with withholding the functional reinforcer for ITW, is advised.

If automatic reinforcement is identified as the function, observations of clients walking on various surfaces (e.g., turf, tile, carpet) might be conducted (Wilder et al., 2022). If levels of ITW are lower on a specific surface, insoles with similar material might be created and inserted into the client’s shoes with consultation from an orthopedic specialist. If ITW is high across all surfaces, other treatments should be considered.

Consider Prerequisite Skills

Hirst et al. (2019) used differential reinforcement of other behavior (DRO) in the form of a token economy in which participants earned preferred items for intervals without ITW. The contingencies were specified through rules stated by the researcher, and vocal feedback on performance was provided to the participant. Such an approach might be used if clients have the appropriate listener repertoire (i.e., rules and instructions can be followed). If clients do not have this prerequisite skill, other treatments might be considered. Various forms of auditory feedback and stimulus control procedures have been found to be effective in reducing ITW. Lancioni et al. (2012) delivered a few seconds of a participant’s favorite music contingent on appropriate steps. Marcus et al. (2010) and Wilder et al. (2020) used auditory feedback for appropriate steps in the form of Gaitspot Squeakers, though Marcus et al. (2010) also combined this with simplified habit reversal. Persicke et al. (2014) used a modified TAGTeach procedure in which clicking (i.e., a conditioned auditory stimulus previously paired with the preferred edible item) was delivered contingent on appropriate steps. Likewise, Hodges et al. (2019) paired a clicking sound with a preferred tangible item. If a client is hearing-impaired, other forms of feedback (e.g., tactile, visual) might be evaluated. Hodges et al. (2018) utilized a multiple schedule indicated by a wristband. Praise was delivered contingent on appropriate steps, and reprimands were delivered contingent on ITW.

Consider Unique Variables and Combining Intervention Components

As with all behavioral interventions, data should be analyzed frequently to determine efficacy. If an intervention component is introduced and efficacy is not sufficient, or clinically significant reductions are not achieved, behavior-analytic practitioners should consider treatment packages combining various antecedent-based and reinforcement-based procedures. For example, response effort for ITW can be increased with heavy-weighted boots (Hobbs et al., 1980).

Consider Punishment-Based Procedures

As a last resort, and with the appropriate approvals, punishment-based procedures might be considered. Before implementing a punishment-based procedure, practitioners might conduct a stimulus avoidance assessment (Fisher et al., 1994; Simmons et al., 2022) to identify stimuli most likely to be effective as punishers. Various forms of punishment-based procedures might be evaluated and combined for increased efficacy. Contingent on ITW, Barrett and Linn (1981) used positive practice overcorrection (i.e., the participant had to engage in toe-tapping for 30 s along with the therapist holding the participant’s heel to the floor) with a verbal reprimand. Charlop et al. (1988) used a combination of overcorrection, a verbal reprimand, and a timeout procedure (i.e., the therapist lightly pressed on the participant’s shoulder to ensure feet were flat for a specified period). More recent studies (Wilder et al., 2020) have used a similar “hands-on-shoulder” procedure combined with the delivery of reinforcement for appropriate steps.

In our survey, caregivers indicated that a verbal reprimand was the most common form of behavioral intervention they had tried, followed by overcorrection. This is not surprising, as reprimands are relatively easy to implement. However, punishment may result in side effects such as punishment-induced aggression, escape-maintained behavior, or emotional responses (Lerman & Vorndran, 2002), and our code of ethics allows consideration of punishment-based procedures only after reinforcement-based interventions have failed. Recently published behavioral treatments for ITW that are not punishment-based and are more sophisticated (i.e., include multiple components and/or are function-based) than a reprimand (e.g., Gaitspot Squeakers, shoe insole inserts) should therefore be considered first.

If behavioral treatments still fail, medical procedures (e.g., surgery, serial casting) may need to be considered. However, if behavioral treatments are effective and results are maintained and generalized, fading procedures might be considered. Various methods have been used in the ITW literature including schedule thinning (e.g., increasing the number of appropriate steps required for reinforcement), pairing a verbal warning with a punisher so that the punisher can be faded out, and gradually and systematically reducing the volume of auditory feedback (Hodges et al., 2023). Table 4 provides an overview of advantages and limitations of behavior analytic interventions for ITW; this may be helpful to practitioners unfamiliar with this literature.

Table 4.

Advantages and Potential Limitations of Treatment Components for Idiopathic Toe-Walking

Intervention Component Description Advantages Potential Limitation Relevant Citations
Manipulation of Shoe Insoles Once the therapist has confirmed whether ITW is lower across specific surfaces, insert insole of surface with lowest ITW levels. Simple and low response effort for implementation Should consult with orthopedist Wilder et al. (2022)
Minimal training required Only applicable if ITW differs across surfaces
May not generalize to other surfaces
Increased Response Effort Use heavy-weighted boots or add weights to heels of shoes Simple and low response effort for implementation Should consult with orthopedist Hobbs et al. (1980)
Minimal training required
Rules Specify the contingencies for ITW and appropriate steps Simple and low response effort for implementation Pre-requisite of strong listener repertoire Hirst et al. (2019)
Minimal training required
Vocal Feedback Deliver vocal verbal feedback on occurrence of ITW and appropriate steps Provides clear performance expectations May be aversive if client engages in no appropriate steps and does not access praise Hirst et al. (2019)
Auditory Feedback (Gaitspot/ TAGTeach) Once Gaitspot is attached to base of heel, it produces immediate squeaking sound contingent on appropriate steps Gaitspot is simple and low response effort for implementation TAGTeach requires pre-training and may result in high levels of observer burden and high response effort for implementation.

Marcus et al. (2010);

Wilder et al. (2020);

Hodges et al. (2019)
Once the therapist has paired the TAGTeach clicker sound with a reinforcer, deliver a click contingent on appropriate steps Immediate consequence is provided for appropriate steps
Stimulus Control/Multiple Schedule Once the therapist has paired two specific stimuli with two different contingencies, use each stimulus to represent the contingency in place Relatively simple to fade Requires pre-training Hodges et al. (2018)
Clear signals representing contingencies
DRO Deliver reinforcement contingent on any behavior other than ITWnot be accessed Opportunity to reinforce appropriate behaviors If client only engages in ITW, reinforcement may Hirst et al. (2019)
Overcorrection Contingent on ITW, require the client to engage in multiple instances of the appropriate behavior Typically quick treatment effects Punishment procedures are usually more restrictive and should not be used as first-line treatments Barrett & Linn (1981); Charlop et al. (1988)
Timeout Contingent on ITW, remove access to a preferred activity Typically quick treatment effects Punishment procedures are usually more restrictive and should not be used as first-line treatments Charlop et al. (1988)
Verbal Reprimand Contingent on ITW, deliver a vocal verbal phrase such as, "No toe-walking" in a stern tone Typically immediate temporary cessation of ITW Pre-requisite of strong listener repertoire Does not teach appropriate behavior Charlop et al. (1988)
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Recommendations for Researchers and Behavior Analytic Organizations

Behavioral researchers might focus on identifying possible subtypes of ITW (similar to the way in which self-injury has been sub-typed; Hagopian et al., 2015), determining a hierarchy of least to most intrusive interventions, examining the long-term effectiveness of behavioral interventions, and evaluating effects of combined behavioral and medical treatments (Hodges et al., 2023). Behavior analytic organizations such as the Association for Behavior Analysis, International, and the Behavior Analyst Certification Board should strive to increase awareness of behavioral treatments for ITW and other problems among healthcare professionals. This can be achieved by encouraging and funding research endeavors, promoting webinars on ITW, and disseminating studies on this topic at behavior-analytic and non-behavior-analytic conferences.

Limitations

The survey we conducted is not without limitations. First, the sample from which we drew respondents was not selected at random. We sent the survey to anyone who had a child who engaged in toe walking and was willing to complete the tool. Future research on this topic should employ random selection. Second, because we wanted to increase participation, we kept the survey brief. Therefore, our questions were limited. Future research should ask additional questions to gather more information about ITW and its treatment.

Funding

This research was not funded by an outside source.

Data Availability

Additional data to support the findings of this study are available from the authors upon request.

Declarations

Ethics Approval

The authors followed all relevant ethical guidelines. The study was formally approved by the institution’s review board.

Conflicts of Interest

We (the authors) have no conflict of interest to report during the conduct of this study.

Footnotes

• Idiopathic toe walking (ITW) refers to toe walking in the absence of a known cause.

• Both medical and behavioral treatments have been shown to be effective for ITW.

• In our survey, 52% of respondents reported the use of a medical treatment for ITW, whereas 13% of respondents reported the use of a behavioral treatment.

• We provide recommendations for behavior analysts managing ITW cases, including a decision tree and some suggestions for collaborating with other professionals.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Additional data to support the findings of this study are available from the authors upon request.

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