Written by:

Courtney Keleher, MEd, BCBA1, Kristina Gasiewski, MOTR/L, MEd, BCBA2, Mary Jane Weiss, PhD, BCBA-D1, 2

1Endicott College 2Melmark

Description:

Autism Treatments SummaryIn the 1970s, Dr. A. Jean Ayres developed sensory integration (SI) theory, which is based on the idea that atypical sensory processing requires therapeutic exposure to sensations that can change the brain’s ability to integrate perception across the senses, thus improving behavior and learning (Roley et al., 2007, Moore et al., 2015). In particular, this approach asserts that symptoms of avoidance are due to an individual’s oversensitivity to sensory input becoming over-reactive, overwhelmed, and hyper-reactive to touch (i.e. tactile defensiveness). In other words, an individual may be trying to get away from the sensation. On the other hand, sensory seeking behaviors may also be observed. These behaviors are theorized to be due to the individual’s need for more input or under-reacting to the sensory sensation, resulting in the individual seeking out situations to receive input (Roley et al., 2007; Devlin et al., 2011).

The Wilbarger brushing protocol, as it is typically referred to, evolved from SI theory. Developed by occupational therapist (OT) Patricia Wilbarger, it was originally named the Wilbarger Deep Pressure and Proprioceptive Technique (DPPT) and Oral Tactile Technique (OTT) because of the specific techniques it involves (Hatlestad, 2018). While academic research studies on brushing do not describe the procedures in detail, there is a consensus among nonacademic articles that the DDPT portion of the protocol involves brushing, joint compressions, and a sensory diet for patients displaying tactile defensiveness, whereas the OTT portion is used with patients displaying oral defensiveness. For the brushing technique, a surgical scrub brush is used to apply pressure to the patient’s hands, arms, back, legs, and feet using three steady swipes for each body part. The amount of pressure to be applied should be such that the brush bristles bend, but back and forth motions are to be avoided. Additionally, the brush should not scratch, tickle, or itch the patient. The literature states that brushing can be done over the clothes, although therapists who utilize this technique express that this is less effective than direct contact with the skin, and it should never be applied on the stomach. Once brushing is complete, joint compressions are administered by delivering ten presses in rapid succession to each of the major extremities. The entire process of brushing and joint compressions should take no longer than 3-5 minutes. Access to a sensory diet consisting of various sensory activities said to keep the body’s neurological system appropriately aroused is then provided. According to the brushing protocol, the entire sequence of brushing, joint compressions, and sensory diet activities must be repeated every 90 minutes to two hours by a trained interventionist (Hatlestad, 2018; Wilbarger Deep Pressure Protocol, 2013). This manualized procedure is intended to improve a child’s ability to gradually tolerate tactile sensations (Bodison & Parham, 2018). In addition, many sensory integration theorists endorse SBI and brushing as effective in reducing interfering behaviors claimed to be associated with tactile defensiveness (Benson et al., 2011).

While the non-academic literature calls for appropriate training by a competent OT for anyone administering the DPPT, it is unclear how an OT becomes qualified to train others and what the training entails (Hatlestad, 2018; Wilbarger Deep Pressure Protocol, 2013). Patients are discouraged from self-administering brushing and joint compressions “unless they are old enough and competent to be trained to do it with the specific technique and protocol” (Wilbarger Deep Pressure Protocol, 2013, p. 1). However, the literature does not specify the age and competency requirements for someone to administer DPPT to themselves.

Research Summary:

Interventions based on SI theory are frequently used by OTs when working with autistic patients, and the method has been used for many years. In a survey of 72 OTs nearly 30 years ago, 99% reported SI treatment as the most common technique they use in therapy sessions with 2–12-year-old children with ASD (Watling et al.,1999). Despite the historical popularity of SI/SBIs for treating individuals with autism, a review of the literature illustrates that little to no scientific evidence of the effectiveness of the Wilbarger brushing protocol on symptoms of ASD exists (Heflin & Simpson,1998). Moreover, a search of a library database for articles in peer-reviewed journals published between 1994-2024 yielded eight studies addressing the impact of the Wilbarger protocol on improving behaviors in autistic individuals. In three of the studies, the brushing protocol was found to have no significant effect on reducing challenging behaviors including stereotypy (Davis et al., 2010; Moore et al., 2015), aggression, and self-injury (Devlin et al., 2011). A fourth study showed that brushing was not effective at increasing on-task behavior (Bonggat & Hall, 2010).

Significant flaws in research methodology were present in the remaining four studies, which compromised the ability to conclude that there is a cause-and-effect relationship between brushing and outcomes of the intervention. Three articles were case studies, one of which simply described anecdotal information provided by the participant’s parents about his functioning before, during, and after brushing treatment (Stagnitti et al.,1999). The other two case studies relied on pre- and post-intervention parent survey data and did not include direct measurements of participants’ behavior (Bestbier & Williams, 2017; Benson et al., 2011). The fourth study and one additional from the prior three did not isolate brushing in the intervention, but rather included it as part of a treatment package along with other techniques, such as massage and squeezing (Bestbier & Williams, 2017; Case-Smith & Bryan, 1999). It is therefore impossible to know if the brushing alone may have been responsible for any treatment effects. Lastly, none of these four studies included measures of treatment integrity, which is necessary to instill confidence that the intervention was conducted as intended and is therefore responsible for resulting outcomes.

These findings are echoed in a literature review article by Weeks et al. (2012). This review identified and evaluated studies that addressed the Wilbarger protocol, three of which were already discussed above (Davis et al., 2010; Benson et al., 2011; & Stagnitti et al., 1999). In evaluating the results of these studies, combined with a fourth (Kimball et al., 2007), their review concluded that “a lack of high quality evidence currently exists to support or refute the use of the Wilbarger protocol with children.” This was due to the studies’ weaknesses such as small sample sizes, low rigor in research methods, and a lack of treatment fidelity measures (Weeks et al., 2012, p. 79).

Recommendations:

In a published policy statement, the American Academy of Pediatrics (AAP, 2012) urged physicians to: (1) inform families that the effectiveness of “sensory-based therapies for childhood developmental and behavioral problems” is scarce and inconclusive and (2) to recommend that caution should be exercised when considering these treatments (p. 1188). Furthermore, the policy statement advises physicians to educate their patients on how to evaluate interventions for their effectiveness and to keep them time-limited while monitoring their treatment effects (AAP, 2012).

While more research regarding the specific effects of the Wilbarger brushing protocol on sensory-seeking behaviors in autism may be warranted, the studies that exist so far indicate that this procedure is ineffective. Furthermore, since the potential for harmful effects has not been ruled out, the Wilbarger brushing protocol should be approached with extreme caution.

Sensory processing difficulties are common among people with autism and often require attention in treatment. Importantly, a number of interventions can be used to assist autistic individuals in managing sensory challenges. Many behavioral interventions can be used in this context (i.e. antecedent strategies, stimulus discrimination, differential reinforcement). Given the above findings, it is recommended that parents of children with ASD do not pursue the Wilbarger brushing protocol to treat sensory-related problem behaviors. Time and resources would be better spent on evidenced-based interventions, which have shown to be far more effective in treating these symptoms. Given the fact that treatment decisions must be made with sensitivity to efficiency, the allocation of time and hope to brushing is not supported at this time.

References

Selected Scientific Studies

Benson, J. D., Beeman, E., Smitsky, D. & Provident, I. (2011). The Deep Pressure and Proprioceptive Technique (DPPT) versus nonspecific child-guided bushing: A case study. Journal of Occupational Therapy, Schools, & Early Intervention, 4(3-4), 204-214. https://doi.org/10.1080/19411243.2011.629536

Bestbier, L., & Williams, T. I. (2017). The immediate effects of deep pressure on young people with autism and severe intellectual difficulties: Demonstrating individual differences. Occupational Therapy International, 2017, 1-7. https://doi.org/10.1155/2017/7534972

Bonggat, P. W., & Hall, L. J. (2010). Evaluation of the effects of sensory integration-based intervention by a preschool special education teacher. Education and Training in Autism and Developmental Disabilities, 45, 294–302. http://www.jstor.org/stable/23879813

Case-Smith, J., & Bryan, T. (1999). The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. American Journal of Occupational Therapy, 53(5), 489-497. https://doi.org/10.5014/ajot.53.5.489

Davis, T., Durand, S., & Chan, J. (2010). The effects of a brushing procedure on stereotypical behavior. Research in Autism Spectrum Disorders, 5, 1053-1058. https://doi.org/10.1016/j.rasd.2010.11.011

Devlin, S., Healy, O., Leader, G., & Hughes, B. (2011). Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. Journal of Autism and Developmental Disorders, 41(10), 1303-1320. https://doi.org/10.1007/s10803-010-1149-x

Moore, K. M., Cividini-Motta, C., Clark, K. M., & Ahearn, W. H. (2015). Sensory integration as a treatment for automatically maintained stereotypy. Behavioral Interventions, 30, 95–111. https://doi.org/10.1002/bin.1405

Stagnitti, K., Raison, P., & Ryan, P. (1999). Sensory defensiveness syndrome: A paediatric perspective and case study. Australian Occupational Therapy Journal, 46(4), 175–187. https://doi.org/10.1046/j.1440-1630.1999.00197.x

Systematic Reviews of Scientific Studies

Weeks, S., Boshoff, K., & Stewart, H. (2012). Systematic review of the effectiveness of the Wilbarger Protocol with children. Pediatric Health, Medicine and Therapeutics, 3, 79. https://doi.org/10.2147/PHMT.S37173

Position Statements

American Academy of Pediatrics (2012). Sensory integration therapies for children with developmental and behavior disorders. Pediatrics, 129(6), 1186-1189. https://doi.org/10.1542/peds.2012-0876

Additional Resources

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425596

Bodison, S. C., & Parham, L. D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: A systematic review. The American Journal of Occupational Therapy, 72(1), 7201190040p1–7201190040p11. https://doi.org/10.5014/ajot.2018.029413

Cunningham, A. B. & Schreibman, L. (2008). Stereotypy in autism: The importance of function. Research in Autism Spectrum Disorders, 2(3), 469-479.https://doi.org/10.1016/j.rasd.2007.09.006

Gourley, L., Wind., C, Henninger, E. M., & Chinitz, S. (2013). Sensory processing difficulties, behavioral problems, and parental stress in a clinical population of young children. Journal of Child & Family Studies, 22(7), 912-921. https://doi.org/10.1007/s10826-012-9650-9

Hatlestad, B. (2018, October 25). The Wilbarger Protocol. Augustana Digital Commons.
https://core.ac.uk/reader/234817301

Heflin, L. J., & Simpson, R. L. (1998). Interventions for children and youth with autism: Prudent choices in a world of exaggerated and empty promises. Part 1.Intervention and treatment option review. Focus on Autism and Other Developmental Disabilities, 13, 194–211. https://doi.org/10.1177/108835769801300401

Kimball, J. G., Lynch, K. M., Stewart, K. C., Williams, N. E., Thomas, M. A., & Atwood, K. D. (2007). Using salivary cortisol to measure the effects of a Wilbarger protocol-based procedure on sympathetic arousal: A pilot study. American Journal of Occupational Therapy, 61(4), 406–413.https://doi.org/10.5014/ajot.61.4.406

McCormick, C., Hepburn, S., Young, G. S., & Rogers, S. J. (2016). Sensory symptoms in children with autism spectrum disorder, other developmental disorders and typical development: A longitudinal study. Autism, 20(5), 572-579. https://doi.org/10.1177/1362361315599755

Roley, R. S. & Mailloux, Z. & Miller-Kuhaneck, H. & Glennon, T. (2007). Understanding Ayres Sensory Integration®. OT Practice, 12, 7.

Watling, R., Deitz, J., Kanny, E. M., & McLaughlin, J. F. (1999). Current practice of occupational therapy for children with autism. American Journal of Occupational Therapy, 53, 498-505. https://doi.org/10.5014/ajot.53.5.498

Wilbarger Deep Pressure Protocol. (2013, September). TheraKids. https://www.therakids.org/media/pdf/Newsletter_Wilbarger_Deep_Pressure_Protocol.pdf

Citation for this article:

Keleher, C., Gasiewski, K., & Weiss, M. J. (2024). A treatment summary: The Wilbarger Brushing Protocol. Science in Autism Treatment, 21(9).

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