About a year ago, I posted a TikTok video of my 18-month-old daughter toe-walking. For the record, every toddler (for the most part) will experiment with tiptoeing. If it is infrequent and they’re under the age of 3, there’s no need to worry.

Shortly after the video posted, multiple comments came along the lines of “You need to get her checked. She might have autism.” Side note: she doesn’t.

Although I know their concerns were well-intended, their rationale seemed ill-informed. While frequent toe-walking may be a sign of developmental issues, other delays or difficulties must be present to determine such a diagnosis. But if you Google toe-walking, autism is in the top 3 search suggestions. No wonder parents get nervous when their kid starts walking on their tiptoes.

Toe-walking is part of typical development when children are learning how to move on two feet. It indirectly strengthens their ankles and activates the calf muscles used in other gross motor movements, like jumping or running. However, toe-walking becomes an issue when it’s their go-to method of walking. This can affect their body/spatial awareness, balance, and coordination (not to mention the development of tight heel cords, muscle stiffness, and possible joint pain).

Guilty by Association

Autism spectrum disorder (aka ASD or autism) is a developmental disability characterized by communication/social difficulties as well as restricted/repetitive behaviors, interests, or activities. Although research suggests that toe-walking has a positive association with language delays, a 2019 study confirmed that children with autism toe-walk much more frequently than other kids. However, the study cannot clearly determine the reason behind the strong correlation. A few theories include:

• A dysfunctional vestibular system. Found in the inner ear, the vestibular system is responsible for sensing where we are in relation to gravity (upright, lying down, upside down, if we are moving or still, how fast we’re going and in which direction). With this information, it signals to the other sensory systems to make necessary adjustments to maintain balance, posture, and to stabilize the head and neck during movement. A recent study reveals that a majority of those with autism have some degree of auditory and vestibular issues, resulting in postural instability, impaired eye gaze, and gait dysfunction (like toe-walking).
• Tactile defensiveness. Children with ASD may process sensory information differently than their peers. For example, they may be sensitive to touch and will try to reduce the amount of contact to textures/substances by walking on their toes.
• The persistence of primitive reflexes. These are involuntary movements a baby is born with to respond to a new environment. Once integrated, they give way to voluntary motor skills. However, if certain infantile reflexes don’t go away by the age of 3, toe-walking may become the default movement accompanied by jerky and stiff movements. A 2014 study found an association between toe-walking and the presence of the tonic labyrinthine reflex (TLR), a primitive reflex that helps newborns gain muscle tone throughout their body.

With studies concluding that a high proportion of toe walkers have autism, it makes sense that parents may jump to that assumption when they notice their kiddo tiptoeing. However, autism is a complicated condition that varies from person to person. Therefore, toe walking alone is not enough to warrant an autism diagnosis. Other signs and symptoms need to be present, like:

• Speech and language difficulties
• Limited interest in engaging with others
• Displays repetitive behaviors
• Difficulties self-regulating
• Difficulties processing sensory information appropriately
• Has trouble adapting to new situations
• Restricted in interests and ideas

If other habits or behaviors in addition to tiptoeing have got you nervous, it wouldn’t hurt to talk to your pediatrician. Screening tools like the M-CHAT (Modified Checklist for Autism in Toddlers) can help verify if your child is on the typical developmental track or if a further evaluation is needed.

It’s worth noting that there is no medical test to diagnose ASD. Doctors (along with other developmental specialists) investigate the child’s developmental history and behavior through structured tests, observations, parent interviews, surveys and questionnaires. With this information, they can determine if an autism diagnosis is appropriate as well as an appropriate plan of action moving forward.

In truth, there can be a plethora of reasons why your child may be toe-walking that don’t necessarily point to an autism diagnosis. It can be as simple as your child exploring a new way of movement.

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