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TREATMENT OF IDIOPATHIC TOE-WALKING IN A CHILD WITH AUTISM AND

DATA COLLECTION OF MOVEMENTS THROUGH CAREME APP: HOW NEW
TECHNOLOGIES CAN HELP IN THE TREATMENT OF PROBLEM BEH....

Conference Paper · November 2021

DOI: 10.21125/iceri.2021.1835

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 TREATMENT OF IDIOPATHIC TOE-WALKING IN A CHILD WITH
AUTISM AND DATA COLLECTION OF MOVEMENTS THROUGH
CAREME APP: HOW NEW TECHNOLOGIES CAN HELP IN THE
TREATMENT OF PROBLEM BEHAVIORS
S. Vita1, A. Rega2, A. Mennitto3, L. Iovino3
1
AIAS Cicciano (ITALY)
2
Federico II (ITALY)
3
Neapolisanit srl (ITALY)

Abstract
Toe walking (TW) is an idiopathic behavior present in many individuals with disabilities, particularly with
autism (occurring in approximately 19% of children diagnosed with ASD). This behavior can also be
considered a stereotypy (as it presents repetition over time) and has a serious impact on people's lives
for physical (shortening of the tendons) and social reasons (stigma regarding the eccentricity of the
behavior). The etiology and nature of TW is heterogeneous and presents differences between individual
and individual. However, there are recurring patterns that, if recognized, can help in the treatment and
work of reducing TW. The aim of this study is to evaluate the reduction of toe walking in a child with
ASD through sound stimulation (using GaitSpot Auditory Squeakers) and the use of the CareMe
hardware device (a set of devices connected to a processor that manages the analysis of movements
and heartbeat) for data collection and monitoring of the various phases of TW reduction.
Keywords: Toe Walking, New Tech, Autism, ASD, Problem Behavior, ABA.

1 INTRODUCTION
A large number of children with neurobiological disorders have motor performance problems that have
significant adverse effects on their ability to participate fully in daily home, school and play activities [1].
These children have a neurodevelopmental disorder more commonly known as developmental
coordination disorder (toe walking - TW) [1] which results in tiptoe walking. In children it is recognized
as a tiptoe gait pattern in the absence of any known cause [2]. Specifically, the fine movement in
question takes shape in the act of walking on tiptoe and strongly influences the progression of involution
in speech disorders and autism spectrum disorders (ASD) (toe walking present in 20% of cases) [2]. In
the specific case of autism, the symptom is associated with the hyper or hyposensitivity that children
show in this condition but also with a markedly stereotyped behavior in the sensory-motor response [2]
that leads automaticity in the motor act.
Automaticity, which is characterized by being a fluent behavior modeled on contingency with a low
cognitive cost [3]. Walking is a behavior that is first learned, then practiced and finally automated with
the walker no longer aware of selecting, using and reacting to specific environmental stimuli. It is
plausible that the child with ASD has rooted tiptoe walking in his walking habits. An intervention
procedure used for the problem of automaticity is that of habit reversal (HR). It is a multicomponential
treatment [4] based on the creation of a conflict response to non-adaptive, automated behavior or which
brings negative physical effects, such as tiks [5]. Human beings are not always aware of the resources
they have and this is the prerequisite for their use. Generally, the treatment consists of 4 phases: 1)
Awareness; 2) The formation of a competitive response; 3) General procedures; 4) Motivational
procedures.
To better understand the association between persistent walking and sensory and motor variables and
in response to this need, innovative technological tools are presented based on the use of sensors
(applied both to the sole of the shoes and to the sides) that strengthen the relationship and the
association between tactical sensory stimuli obtain a significant reduction of walking pauses on tiptoe in
adult subjects with multiple disabilities and obtaining significant results also in autistic children [6].
However, in the literature there are also low tech tools whose use has brought evident results [7]. An
example is the use of Gaispot Auditory Squeakers system which is based on a procedure that uses
auditory prompts (squeaks) which act as a gentle push to gradually reduce the frequency of the TW and
bring it back to a normal "from heel to toe [7]. In the work conducted by Bradley and Gray [7], sessions
of 10 minutes were carried out by applying sensors on the heels of the feet of the shoes that emitted a
squeak that was subsequently reinforced when the weight of the foot reached the heel. Procedure
utilized was Habit reversal (HR) with DRI. In the second phase the session time period was extended
while in the third the Gaitspot sounds were faded and in the fourth phase training for generalization and
maintenance of gait improvements were conducted. The procedure produces significant improvements
in patients albeit to varying degrees depending on the subject.
On the other hand, there has also been a rapid improvement of wearable high technologic tools in recent
years [2]. It can represent a concrete solution to TW since, it exploits the ability of bipedal humanoid
robots [8] to train the child with autism by providing him with different positions, training his walking
through the process of imitation. It was also found that this system is also useful for learning the signs
and the expressiveness factor. It would appear that in many cases the child with autism spectrum
syndrome would prefer robotic interaction to human interaction [8].
Today, despite all these advances on the part of rehabilitation, psychology, neuropsychology and
engineering, and while trying to have an integrated approach, there is no robust literature of applied
studies concerning the phenomenon of TW [8]. Perhaps because this factor of ASD has not had the
right relevance up to now. It is necessary to create a clear conceptual model and a comprehensive
behavioral approach starting from the clear definition of the ASD. TW, like other behavioral loops, have
all too often been defined as simple stereotyped motor movements [9]. The challenge of new
technologies in the rehabilitation field must necessarily be that of first building a clearer and more holistic
conceptual model of the symptoms and, subsequently, implementing therapies to give the right relief
and correct even the apparently more superficial aspects of the ASD syndrome.
The aim of this paper is, by replicating the application of HR with DRI on a child with TW as in work of
Bradley and Gray [7], the reduction of problem behavior (TW) in addition to monitoring and data
collection via the CareMe device.

2 METHODOLOGY

2.1 Participant
A girl aged 8 years with a diagnosis of autism and ITW participated in the study. The child attended ABA
therapy in a rehabilitation center in Italy (Aias Onlus). She did in past some treatments about toe-walking
but this was not successful.
Results of a brief functional assessment indicated that toe-walking did not appear to be associated with
any particular stimulus event, such as setting, time of day, particular footwear or activities.

2.2 Setting
The girl attended a rehabilitation center specializing in ABA treatment 5 times a week for two hours a
day. The sessions were recorded with a camera in the girl's therapy room. During the across settings
generalization phase (last phase) the shots were conducted in the hallway and at home.

2.3 Response Measurements and IOA

Toe-walking was defined as walk on tiptoes for at least two steps without the heel ever touching the
ground. Considering that the child's behavior could only occur when she was walking, special training
sessions were conducted within the therapy alternating with treatment moments as per clinical-
rehabilitation planning. Toe-walking behaviour was scored as the percentage of time the child engaged
in the behaviour using partial interval recording—10 s intervals in 5 min sessions across baseline and
intervention conditions recorded as percentage of toe-walking (partial interval recording). Percentages
were calculated by dividing the number of occurrences of behaviour by total number of opportunities
and multiplying by 100.

2.4 Materials
A video recorder (GoPro 7) was used to record the behaviour. A set of GaitSpot Auditory Squeakers
were used. The GaitSpot features one squeaker, one heel loop and an adjustable hook and loop strap
that adjusts to fit most toddlers to children’s shoes sizes. When placed on the foot in a heel-strike position
the squeakers provide auditory feedback when the individual engages in appropriate heel-to-toe gait.
Two were used (one for each foot). Each GaitSpot was placed over the sock of each foot and then the
shoe was placed on each foot. The GateSpot were removed as soon as the procedure stopped.
CareMe hardware (Fig 1) consists of: an M5Stick-C based on Esp 32 processor, mounted on an elastic
ankle strap tied to the right ankle (Fig. 2). The device firmware has been programmed with the help of
Arduino IDE.

Figure 1. CareMe hardware

Figure 2. Elastic ankle strap tied to the right ankle.

2.5 Experimental design

The study used a AB design with changing criteria. There were five treatment phases following baseline.

2.6 Procedure
Before starting, informed consent was given to the girl's parents for data collection and video recording.
TOE WALKING PROCEDURE
The procedure integrates the SHR or the inversion of a simplified habitual behavior, using the differential
reinforcement for incompatible behavior (DRI) and a stimulus prompt (GaitSpot Auditory Squeakers) to
reduce the frequency of idiopathic walking (ITW) and increase the frequency of correct walking (heel
toe). The reinforcements used were chosen after an indirect assessment of the preferences. Were used:
chips, Plasticine, tickle.

2.7 Phase A Baseline intervention

5 minutes for 3 consecutive days with the gatespots on the feet.
Baseline every day for CareMe: 1 minute for each session the child will have to keep the palms of the
feet on the ground without lifting them or walking.

2.8 GaitSpot sound conditioning (Reinforcement pairing)

Place a GateSpot on the work table and let it ring at variable intervals (average 2 min) for a total interval
of 5 min. Associate specific Reinforcements (identified through indirect Assessment) to the sound. After
two sessions from FR1 to FR2 and finally FR3 (six sessions in total) we switched to Phase C.

2.9 Phase B simplified habit reversal with DRI and use of GaitSpots
The treatment sessions should initially last 5min (alternate 10 minutes of activity with 5 minutes of
walking). When the GaitSpots are placed under the foot, were give child a physical prompt accompanied
by a "feet down" voice prompt. Fade out the physical prompt gradually while keeping only the voice
prompt. After 3 sessions also fade voice prompt.
Reinforcement Scheme: Every 3 sounds (FR3,) reinforce the "feet down" behavior with specific SR
followed by "good keep your feet down" praise.
Acquisition criterion: 0 occurrences of the "toe walking" behavior for two consecutive 5-minute sessions.

2.10 Phase C simplified habit reversal with DRI with no verbal prompt and
schedule thinning
At the beginning of each session, do not provide any prompts. Reinforce every 3 sounds (FR5) for 5
minutes treatment. After 3 sessions on FR5 switch to a Variable Reinforcement (VR3).
Acquisition criterion: 0 occurrences of the "toe walking" behavior for two consecutive 5-minute sessions.

2.11 Phase D: lengthen the duration of the procedure

Use the GateSpots for the duration of the therapy. Switch to VR10 reinforcement scheme. Every 5 praise
deliver specific SR.
Acquisition criterion: 0 occurrences of the "toe walking" behavior for two consecutive 5-minute sessions.

2.12 Phase E: generalization in other contexts and other people

The GateSpots were used in various phases of the day (different time slots were chosen where the child
was inserted in various contexts). Do not instruct the child but provide variable interval reinforcement
(VR10).
Acquisition criterion: 0 occurrences of the "toe walking" behavior for two consecutive 5-minute sessions.

2.13 Phase F: Fading Gatespot

The GateSpots were used in various phases of the day (different time slots were chosen where the child
was inserted in various contexts). Do not instruct the child but provide variable interval reinforcement
(VR10).
Acquisition criterion: 0 occurrences of the "toe walking" behavior for two consecutive 5-minute sessions.
3 RESULTS
The results (Figure 3) show a significant reduction in toe walking behavior across the various sessions.
The criterion for the last phase (fading the GaitSpot) was not reached as it was no longer possible to
record the sessions due to lack of the child from the center and delivery times. As shown by the graph,
the passage of each phase has always resulted in an increase in TW, as the child was very affected by
the thinking of the reinforcement scheme. Furthermore, during phase C, a sudden increase in TW can
be noted due to the interruption of treatment for a week due to the summer closure of the center.
Furthermore, in each phase after an initial settling phase (with a high TW percentage), the reduction in
behavior is visibly sudden.

Figure 3. Percentage of intervals with toe-walking behaviour present

3.1 CareMe registration

From the graphs (Figure 4) of the data collected, it can be deduced that in the sensor mounted on the
ankle, the most influential oscillation is the yaw. In tiptoe walking, it has a behavior that follows an
increasing straight line with few peaks, while in a walk where the heel touches the ground, the peaks
are of a great number, with a much greater variety of values over time, being the latter a much more
dynamic movement than the former which is a more stationary movement.

–– roll
–– pitch
–– yaw

Figure 4. CareMe registration in July

 Figure 5. CareMe registration in September

Figure 6. CareMe overlapping

Black Strips in Y-Axis in Fig. 4, 5 and 6 are the values assumed by the measurements taken by the
sensor, which overlap in the graph making them not legible.

4 CONCLUSIONS
Toe walking is a problematic behavior present in various neurodevelopmental disorders and, if not
corrected in time, can lead to a number of serious problems. Although in the literature there are not
many interventions dedicated to the reduction of TW, in recent years there has been a significant
increase in interest in this problem and in the technological tools useful for its study and reduction. The
possibility of using wearable devices capable of collecting data and, through specific algorithms, finding
patterns of behavior common to various individuals who share the same pathological profile, has allowed
the opening of new therapeutic and research scenarios. CareMe, thanks to its monitoring and matching
system of the collected data, can be a useful tool for the reduction of various problem behaviors present
in various psychopathological profiles.
The next studies will therefore have to be conducted by comparing the same problematic behaviors in
more individuals and using other physiological parameters through other tools (eg galvanic skin
response) in order to identify any antecedents that can trigger the problem behavior and therefore
prevent its presence in the environment.
CareMe Allows daily use (even in the school setting) of a tool usually linked to rehabilitation, marking
and subsequently mitigating a series of problem behaviors that hinder the learning of new skills.

5 LIMITATION
The study did not include the generalization phase outside the center (home, school) and as the fading
phase has not been completed, the results may not be maintained. The procedure should also be tested
on other individuals with TW to test its effectiveness on other individuals. Furthermore, as already
written, the CareMe hardware should be tested on a large behavioral sample to allow the algorithm to
search for stable patterns of behavior.
 REFERENCES
[1] Helene J Polatajko , Noemi Cantin, (2005). “Developmental Coordination Disorder (Dyspraxia): An
Overview of the State of the Art”, National Library of Medicine, DOI
https://doi.org/10.1016/j.spen.2005.12.007
[2] Mennito, Carretti & Iovino (2019). Wearable devices to help children with autism overcome toe
walking, PSYCHOBIT, Neapolisanit S.R.L. Rehabilitation Center, Ottaviano, Italy 2 Italian National
Research Council, Rome, Italy,CEUR-WS.org/vol 2524/paper 25.pdf
[3] Clarke, Bray, Kehle and Truscott, (2001), “A School-Based Intervention Designed to Reduce the
Frequency of Tics in Children with Tourette's Syndrome”, School psychology Review, Vol 30, Iussue
1, DOI https://doi.org/10.1080/02796015.2001.12086097
[4] Caselli, M. A., Rzonca, E. C., & Lue, B. Y. (1988). “Habitual toe-walking: Evaluating and approach
to treatment. Clinical Podiatry and Medical Surgery”, 5, 547–559 PMID: 3293753
[5] Cushings, Adams, & Rincover, (1983). “Research on the Education of Autistic Children”, Elsevier,
in Progress in Behaviour Modification, vol 14, pp 1-48, https://doi.org/10.1016/B978-0-12-535614-
5.500060
[6] Giulio E Lancioni et. al. (2013). “Technology-based programs to improve walking behavior of
persons with multiple disabilities: two single-case studies” ,in: Disability and Rehabilitation: Assistive
Technology, Vol 8, Issue 1, pp 92-98, doi.org/10.3109/17483107.2012.678030
[7] Stephen Bradley, Ian Grey (2010). “Treatment of Idiopatic toe-walking in children with autism using
Gaispot Auditory Speakers and simplified habit reversal”, Elsevier, in: Researched in Autism
Spectrum Disorder, Vol 4, Issue 2, pp 260- 267, DOI doi.org/10.1016/j.rasd.2009.09.012
[8] PJ Accardo , W. Barrow 2014, “ “Toe Walking in Autism: Further Observations” Journal of Child
Neurology, doi.org/10.1177%2F0883073814521298
[9] Raqisha Banul et.al. (2017). “A rehabilitation method for developing a biped humanoid robot for
training autistic children”, ISSN: 1314-3395
[10] R. Nappo, M. Iorio, and F. Somma, “ASTRAS: a software for the assessment and training of
executive functions in children,” in Proceedings of the Second Symposium of Psychology-Based
Technologies, 2020, pp. 1–10.

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