Treatment of idiopathic toe-walking in children with autism using GaitSpot Auditory Speakers and simplified habit reversal Ann Marcus a , Brigit Sinnott a , Stephen Bradley a , Ian Grey b, * a St. Catherine’s Association, Co. Wicklow, Ireland b Royal College of Surgeons in Ireland - Bahrain, PO Box 15503, Buisateen, Bahrain 1. Idiopathic toe-walking Idiopathic toe-walking (ITW) is a diagnosis of exclusion given when a child presents with a bilateral toe-to-toe gait when physical or neurological disorders have been ruled out (Babb & Carlson, 2008). Although considered part of the normal gait spectrum in early development, toe-walking is considered abnormal when persisting past the age of two. However, for individuals with Autistic Spectrum Disorder (ASD), it may become established and persist long past the age where it can be considered part of normal development (Heilbroner & Castanada, 2006). Though prevalence rates of ITW have not been firmly established, recent estimates suggest a rate of occurrence of approximately 20% in individuals with ASD (Ming, Brimacombe, & Wagner, 2007). The consequences of ITW can include a shortened Achilles tendon and ankle equinus (tightening or shortening of the muscles when there is less than 10–208 ankle joint dorsiflexion during walking; Sobel, Caselli, & Velez, 1997). Persistent engagement in toe-walking may also lead to the development of an abnormal gait pattern as adults and possibly postural problems (Pendharkar, Daniel, & Begg, 2008). As a result, intervention is recommended prior to the development of these and other physical problems. However, physical interventions such as physiotherapy or the use of casts appear not to have any lasting positive effect on ITW (Eastwood, Menelaus, Dickens, Broughton, & Cole, 2000; Hirsch & Wagner, 2004). Research in Autism Spectrum Disorders 4 (2010) 260–267 ARTICLE INFO Article history: Received 11 September 2009 Accepted 17 September 2009 Keywords: Idiopathic toe-walking Autism Treatment Applied behaviour analysis ABSTRACT This study aimed to examine the effectiveness of a simplified habit reversal procedure (SHR) using differential reinforcement of incompatible behaviour (DRI) and a stimulus prompt (GaitSpot Auditory Squeakers) to reduce the frequency of idiopathic toe-walking (ITW) and increase the frequency of correct heel-to-toe-walking in three children with autism. The study involved a delayed multiple baseline changing criterion design across individuals. Firstly, a baseline phase was conducted to determine the number of intervals where ITW occurred. Secondly, the GaitSpot Auditory Squeakers were paired with reinforcers. Thirdly, children wore GaitSpot squeakers over the heels of their feet under their shoes for a small number of 10 min sessions and when weight was placed on their heel, a squeak was emitted which was subsequently reinforced. Fourthly, the length of time the children wore the GaitSpot Auditory Squeakers was extended. Finally, the GaitSpot Auditory Squeakers were faded out and tests for generalisation and maintenance of heel-to-toe walking were conducted. The intervention produced substantial reductions in ITW across all participants though degree of reduction differed. The role of SHR and additional modifications for the treatment of ITW are discussed. ß 2009 Elsevier Ltd. All rights reserved. * Corresponding author. E-mail address: igrey@rcsi-mub.com (I. Grey). Contents lists available at ScienceDirect Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp 1750-9467/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2009.09.012