Udzella, N., Kovalic, K., Hirst, H., & Luiselli, J. K. (2024). Establishing tolerance for orthotics casting in a child with autism spectrum disorder and idiopathic toe walking. Clinical Case Studies, 23(6), 446–456. https://doi.org/10.1177/15346501241273341

Reviewed by: Frank Cicero, PhD, BCBA, Seton Hall University

 

Why research this topic?

Procedures to teach specific skills for individuals with autism

Children with autism and other developmental disabilities often have difficulty tolerating necessary medical and assistive-care treatment procedures (Allen & Kupzyk, 2016; Abdel-Jalil et al., 2024). In an effort to avoid and escape unpreferred medical procedures, children will sometimes engage in dangerous problem behavior (e.g., aggression, self injury, elopement, etc.), which makes administering treatments unsafe to the child as well as to the medical practitioner performing the procedure. The result is that medical and assistive-care procedures are often not initiated or completed as they should be, potentially leading to preventable health risks. If a procedure is absolutely necessary, problem behavior may result in the decision to administer the procedure using sedation or physical restraint as a safety measure (Camoin et al., 2018). This increases the intrusiveness and risk of harm for even relatively minor medical procedures (e.g., dental cleanings, blood pressure monitoring, etc.).

The current case study describes an intervention for an autistic child with idiopathic toe walking (ITW). ITW is diagnosed when an individual walks with a toe-to-toe gate (toe walking) in the absence of physical and neurological disorders beyond the age of two (Marcus et al., 2010). ITW in the autistic population is diagnosed in about 9% to 20% of individuals (Leyden et al., 2019; Barrow et al., 2011). Although seeming like a minor thing, prolonged ITW can result in many physical issues including ankle sprains, pain, shortening of the Achilles tendon and ankle equinus, abnormal gait patterns, postural problems, change in the bone alignment of the ankle and foot, poor balance, and frequent falling (Udzella et al., 2024; Marcus et al., 2010). Given these long and short term health and safety issues associated with ITW, treatment from an early age is recommended (Udzella et al., 2024).

When it comes to the treatment of medical procedure avoidance in persons with developmental disabilities, a literature review by Kupzyk and Allen (2019) revealed two primary forms of evidence-based practice; graduated exposure and positive/negative reinforcement. In graduated exposure (used in 81% of reviewed studies), an unpreferred activity is gradually introduced to the individual in systematic steps arranged by preference from least avoidance to most avoidance producing. The key to treatment is to work up the hierarchy of steps without provoking avoidant behavior. In positive/negative reinforcement procedures (used in 72% of reviewed studies) individuals would earn either verbal praise or a short break from the activity contingent on tolerance of the activity in the absence of avoidance behavior. Interventions combining graduated exposure and reinforcement have been shown to increase tolerance for doctor’s examinations (Cavalari et al., 2013), dental appointments (Conyers et al., 2004), and blood draws (Grider et al., 2012).

What did the researchers do?

Udzella et al., (2024) is a recently published case study where a child with ITW was treated for avoidance behavior associated with casting of medically necessary orthotic devices. The participant was a 10-year-old boy (pseudonym: Karl) with autism spectrum disorder, Attention Deficit Hyperactivity Disorder (ADHD), and speech-language impairment. He lived at home with his parents and attended a specialized day school. To help correct his ambulation, Karl wore specialized Supra Malleolar Orthoses (SMOs), however he was in need of a new pair of SMOs. SMOs are custom made braces molded out of thin, flexible plastic that support the inner foot and ankle of children with issues including toe walking, flat feet, and overly high arches. They are worn by younger children in order to correct movement issues thereby preventing future issues with walking, balance, and other physical issues associated with the feet and ankles (Rebound Orthotics and Prosthetics, Inc., 2025). Developing a new pair of SMOs involved making molds of his ankles and feet through casting performed by an orthopedist. Unfortunately, Karl’s avoidance behavior  (failing to keep his legs in select positions, physically resisting, etc.) when faced with casting prevented the orthopedist from  going through with the procedure on several occasions.

In an effort to treat his avoidance behavior, so that the casting procedure could be performed, the researchers created an interdisciplinary treatment team to design and implement an intervention consisting of graduated exposure and reinforcement. The team consisted of a behavior analyst, a physical therapist, four instructors, and consultation with an orthopedist. The goal of the intervention was to help Karl become comfortable with the orthopedist making castings of both ankles and feet. This was achieved by maintaining pleasant and supportive sessions, gradually exposing Karl to the casting process—which he had previously avoided—and positively reinforcing the steps during which he demonstrated non-avoidant behavior.

The first step of treatment was to develop a 21-step task analysis (listing of steps) involved in the activity of ankle/foot casting. The steps were ordered from first to last in the process. Then, baseline data on avoidance were collected by putting Karl through a simulation of the entire task analysis. Graduate exposure treatment sessions were conducted by trained classroom therapists, one or more times per day with an average of five times per week. Sessions started with Karl being given preferred objects to play with or preferred edibles. He was able to keep these objects throughout the treatment session. Therapists would then expose Karl to the steps of the task analysis, in order, delivering verbal praise and a break upon each completed step where Karl didn’t exhibit avoidance behavior. The instructor never forced Karl to move to a step once avoidance behavior was displayed. Instead, Karl was given a brief break and then the session was re-initiated once avoidance behavior was not displayed. Data determined when Karl would be exposed to steps further up the task analysis hierarchy. Sessions were implemented until Karl successfully tolerated the entire casting simulation task analysis without avoidance behavior.

What did the researchers find?

In baseline, Karl was not able to complete any of the task analysis steps without engaging in avoidance behavior. The first round of intervention lasted for approximately seven months (96 sessions) and resulted in Karl being able to tolerate 87.5% of casting steps without avoidance behavior. After the 96th session, the researchers did an assessment of the remaining steps and reconstructed the task analysis. After an additional two months of treatment (41 sessions) Karl mastered the task analysis with 100% success. After mastery with the researchers, Karl completed an assessment with a casting simulation administered by an orthopedist. He was able to perform 100% of steps without avoidance behavior and was ready for actual casting. Soon after the treatment was completed, Karl was able to sit for a casting and have his new SMOs made. Using a gradual procedure, within two months, he was able to wear his new SMOs consistently throughout the day. As a measure of social validity, instructors were administered a survey post treatment and all agreed that the procedures were beneficial.

What are the strengths and limitations of the study?

This case study is a good example of how a behaviorally-based treatment package, consisting of empirically supported strategies (graduated exposure and reinforcement), can be used to treat avoidance behavior that was preventing necessary treatment of ITW in a child with autism.Although the treatment was highly beneficial to the participant, the authors self identified several limitations that should be considered. First, the single case study design does not have any comparison to a control condition or to any other treatment phase, therefore the relationship between the gradual exposure/reinforcement intervention and the results cannot be firmly established. Another limitation is that interobserver agreement data were not collected. Therefore, the reliability and accuracy of the data technically cannot be confirmed. It is also important to note that the intervention took over nine months from baseline to completion. Given the consistency and dedication that is needed to run an intervention over a nine month persio of time, replication of the treatment in other settings may be difficult.

What do the results mean?

Udzella et al. (2024) is a good example of how avoidance behavior for a medical procedure can be treated in a child with autism through the use of the evidence-based practices of graduated exposure and reinforcement. Although this has been done for other medically related procedures, this is the first published case in which the intervention package was used specifically for ankle/foot casting, which is a necessary procedure for children with pervasive ITW.

 

References 

Abdel‐Jalil, A., Baldwin, J. N., & Leaf, J. B. (2024). Exposure‐based treatments for fear and reactivity to medical procedures: A systematic review of the literature with implications for research and practice. Behavioral Interventions, 39(3). https://doi.org/10.1002/bin.2010

Allen, K. D., & Kupzyk, S. (2016). Compliance with medical routines. In J. K. Luiselli (Ed.), Behavioral health promotion and intervention in intellectual and developmental disabilities (pp. 21–42). Springer.

Barrow, W. J., Jaworski, M., & Accardo, P. (2011). Persistent toe walking in autism. Journal of Child Neurology, 26(5), 619–621. https://doi.org/10.1177/0883073810385344

Camoin, A., Dany, L., Tardieu, C., Ruquet, M., & Le Coz, P. (2018). Ethical issues and dentists’ practices with children with intellectual disability: A qualitative inquiry into a local French health network. Disability and Health Journal, 11(3), 412–419. https://doi.org/10.1016/j.dhjo.2018.01.001

Cavalari, R., DuBard, M., Luiselli, J. K., & Birtwell, K. (2013). Teaching an adolescent with autism and intellectual disability to tolerate routine medical examination: Effects of a behavioral compliance training package. Clinical Practice in Pediatric Psychology, 1(2), 121–128. https://doi.org/10.1037/cpp0000013

Conyers, C., Miltenberger, R. G., Peterson, B., Gubin, A., Jurgens, M., Selders, A., Dickinson, J., & Barenz, R. (2004). An evaluation of in vivo desensitization and video modeling to increase compliance with dental procedures in persons with mental retardation. Journal of Applied Behavior Analysis, 37(2), 233–238. https://doi.org/10.1901/jaba.2004.37-233

Grider, B., Luiselli, J. K., & Turcotte-Shamski, W. (2012). Graduated exposure, positive reinforcement, and stimulus distraction in a compliance-with-blood-draw intervention for an adult with autism. Clinical Case Studies, 11(3), 253–260. https://doi.org/10.1177/1534650112448921

Leyden, J., Fung, L., & Frick, S. (2019). Autism and toe-walking: Are they related? Trends and treatment patterns between 2005 and 2016. Journal of Children’s Orthopaedics, 13(4), 340-345.

Marcus, A., Sinnott, B., Bradley, S., & Grey, I. (2010). Treatment of idiopathic toe-walking in children with autism using GaitSpot auditory speakers and simplified habit reversal. Research in Autism Spectrum Disorders, 4(2), 260-267.

Rebound Orthotics & Prosthetics Inc. (2025). Supra Malleolar Orthoses (SMO). https://www.reboundoandp.com/supra-malleolar-orthoses-smo

Udzella, N., Kovalic, K., Hirst, H., & Luiselli, J. K. (2024). Establishing tolerance for orthotics casting in a child with autism spectrum disorder and idiopathic toe walking. Clinical Case Studies, 23(6), 446–456. https://doi.org/10.1177/15346501241273341

 

Reference for this article:

Cicero, F. (2025). Research synopsis: Establishing tolerance for orthotics casting in a child with autism spectrum disorder and idiopathic toe walking. Science in Autism Treatment, 22(9).

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