The Prevalence and Clinical Significance of Toe Walking in Autism Spectrum Disorder: A Cross-Sectional Study in an Italian Pediatric Sample.

This study looked at toe walking in nearly 300 children with autism compared to children without autism. Toe walking was much more common in autistic children (27% vs 6%). Importantly, it only occurred in children with the highest support needs (Level 3 autism) and was linked to sleep problems and constipation. This suggests toe walking might be a sign of more complex autism presentations that affect multiple body systems.

This cross-sectional study examined toe walking (TW) prevalence in 289 Italian children with autism spectrum disorder (ASD) compared to 289 typically developing controls. Results showed TW was significantly more common in the ASD group (27.3% vs 5.5%). Within the autism group, TW was exclusively found in children with Level 3 (requiring very substantial support) severity (50.5% prevalence), with no cases in Levels 1 or 2. TW was associated with greater sleep disturbances, and all Level 3 children experienced constipation.

The findings suggest TW may serve as a marker of neurodevelopmental severity and reflects broader gut-brain axis dysfunction in autism.

Clinicians should routinely assess for toe walking in autism evaluations, particularly as a potential marker of Level 3 severity. When toe walking is present, comprehensive evaluation of sleep disturbances and gastrointestinal symptoms is warranted, suggesting a multisystemic approach to autism assessment and intervention planning.

Single cross-sectional design limits causal inferences. Study limited to Italian pediatric population may affect generalizability. No longitudinal follow-up to assess persistence or changes in toe walking patterns over time.

: Toe walking (TW) is frequently observed in children with Autism Spectrum Disorder (ASD), yet its clinical significance and association with comorbid conditions remain poorly understood. This study aimed to examine the prevalence of TW in a large Italian cohort of children with ASD and to explore its association with ASD severity, sleep disturbances, feeding behaviors, and gastrointestinal symptoms.: A total of 289 children with ASD and 289 typically developing controls (TDC), matched for age and sex, were evaluated in a multicentric observational study. TW was assessed during neurodevelopmental evaluations. Sleep quality was assessed using the Sleep Disturbance Scale for Children (SDSC), feeding behaviors via the Brief Autism Mealtime Behavior Inventory (BAMBI), and gastrointestinal symptoms through clinical reporting.

Statistical analyses included Chi-square tests, Mann-Whitney U tests, Spearman correlations, and logistic regressions.: TW was significantly more prevalent in the ASD group (27.3%) than in TDC (5.5%,< 0.0001). Within the ASD group, TW occurred in 50.5% of children with Level 3 severity but was absent in Levels 1 and 2 (< 0.0001). Males exhibited TW more frequently than females. Children with TW had higher SDSC scores (ρ = 0.33,< 0.0001), though no subscale independently predicted TW.

Constipation was reported in 100% of children with Level 3 ASD and was strongly correlated with SDSC total scores (ρ = 0.58,< 0.0001). The Disorders of Arousal (DA) subscale emerged as an independent predictor of constipation (β = 0.184,= 0.019).: TW in ASD appears to be a marker of greater neurodevelopmental severity and is associated with sleep disturbances and gastrointestinal dysfunction. These findings support the hypothesis that TW may reflect broader dysfunctions involving the gut-brain axis, sensory processing, and motor control. The routine clinical assessment of TW should include the evaluation of sleep and somatic symptoms to better understand the multisystemic nature of ASD phenotypes.