Ask the Expert: The Wilbarger Protocol for Sensory Defensiveness
Autism Asperger's Digest magazine Sept-Oct 2004 issue
Ask the Experts
The Wilbarger Protocol for Sensory Defensiveness
By Ellen Yack, B.Sc., M.Ed., O.T., Shirley Sutton, B.Sc., O.T. &
Paula Aquilla, B.Sc., O.T.
Q: My 5 year-old daughter was recently evaluated for sensory processing
difficulties. One of the treatments being suggested is the 'brushing
technique.' What can you tell me about it?
The Wilbarger Protocol (Wilbarger, 1991) is a specific, professionally
guided treatment regime designed to reduce sensory defensiveness.
The Wilbarger Protocol has its origins in sensory integration theory,
and it has evolved through clinical use. It involves deep-touch
pressure throughout the day. Patricia Wilbarger, M.Ed., OTR, FAOTA,
an internationally recognized expert who specializes in the assessment
and treatment of sensory defensiveness, developed this technique.
Ms. Wilbarger offers training courses where professionals can learn
how to administer her technique and has produced videotapes, audiotapes,
and other publications. At these courses, she also shares strategies
for integrating the protocol into intervention plans and training
parents, teachers, and other caregivers.
There currently is a lack of documented research to substantiate
this technique. However, the protocol has been used by many occupational
therapists who have noted positive results with a variety of populations.
Many parents of children with autism have reported that their children
have responded positively to this technique, including reduction
in sensory defensiveness, as well as improved behavior and interaction.
Many adults with autism have also reported reduction in sensory
defensiveness, decreased anxiety, and increased comfort in the environment
through the use of this technique. We have observed significant
behavioral changes in many of our clients following the introduction
of the Wilbarger Protocol.
The Wilbarger Protocol represents one of those difficulties in
clinical practice where positive results are observed in treatment
regimes that have not yet been fully validated by scientific research.
However, because of the strength of anecdotal reporting and our
own observations, we feel we would be doing a disservice if we did
not advise our clients about this technique. When we discuss this
option with our clients, we review why it is being recommended and
provide them with information on sensory defensiveness. We also
inform them about the absence of research in this area, and we make
it clear that it is their decision if they want to include the technique
in their treatment regimes.
An occupational therapist who has been trained to use the technique,
and who knows sensory integration theory, needs to teach and supervise
the Wilbarger Protocol. This statement cannot be emphasized enough.
If the technique is carried out with-out proper instruction, it
could be uncomfortable for the child and may lead to undesired results.
The first step of the Wilbarger Protocol involves providing deep
pressure to the skin on the arms, back, and legs through the use
of a special surgical brush. Many people mistakenly call this technique
"brushing" because a surgical brush is used. The term
"brushing" does not adequately reflect the amount of pressure
that is exerted against the skin with the movement of the brush.
A more appropriate analogy would be that it is like giving someone
a deep massage using a surgical brush. The use of the brush in a
slow and methodical manner provides consistent deep-pressure input
to a wide area of the skin surface on the body. Ms. Wilbarger has
found and has recommended a specific surgical brush to be most effective.
The face and stomach are never brushed.
Following the "massage" stage, the child receives gentle
compressions to the shoulders, elbows, wrists/fingers, hips, knees/ankles,
and sternum. These compressions provide substantial proprioceptive
input. Ms. Wilbarger feels that it is critical that joint compressions
follow the use of the surgical brush, and if there is no time to
complete both steps, then compressions should not be administered.
The complete routine should only take about three minutes. This
technique can be incorporated into a sensory diet schedule. The
procedure is initially repeated every ninety minutes. After a period
of time, the frequency is reduced. Eventually the procedure can
be stopped, but gains can be maintained. Some children immediately
enjoy this input, and others resist the first few sessions. You
may distract the child by singing or offering a mouth or fidget
Some children really like the administration of this protocol and
will seek out the brush and bring it to their parents, teachers,
or caregivers. Other children tolerate it with little reaction,
and occasionally a child is resistive. If the child continues to
resist, and you see negative changes, you must reconsider the use
of the technique and contact the supervising therapist. This has
rarely occurred in our practice.
A sensory diet is a planned and scheduled activity program designed
to meet a child's specific sensory needs. Wilbarger and Wilbarger
(1991) developed the approach to provide the "just right"
combination of sensory input to achieve and maintain optimal levels
of arousal and performance in the nervous system. The ability to
appropriately orient and respond to sensations can be enhanced by
a proper sensory diet. A sensory diet also helps reduce protective
or sensory defensive responses that can negatively affect social
contact and interaction.
There are certain types of sensory activities that are similar
to eating a "main course" and are very powerful and satisfying.
These activities provide movement, deep-touch pressure, and heavy
work. They are the powerhouses of any sensory diet, as they have
the most significant and long-lasting impact on the nervous system
(Wilbarger, 1995; Hanschu, 1997.)
There are other types of activities that may be beneficial, but
their impact is not as great. These "sensory snacks,"
or "mood makers," are activities that last a shorter period
of time and generally include mouth, auditory, visual, or smell
A sensory diet is not simply indiscriminately adding more sensory
stimulation into the child's day. Additional stimulation can sometimes
intensify negative responses. The most successful sensory diets
include activities where the child is an active participant. Every
child has unique sensory needs, and his sensory diet must be customized
for individual needs and responses.
This material was adapted from Chapter 5, "Strategies for Managing
Challenging Behaviors" that appears in the authors' book, Building
Bridges Through Sensory Integration.
Ellen Yack has practiced occupational therapy since 1979 and is
currently the Director of Ellen Yack & Associates Pediatric
Occupational Therapy, a private agency providing occupational therapy
services to children, adolescents, and their families in Toronto.
Her areas of expertise include sensory integration, autism, and
Shirley Sutton has worked as an occupational therapist for children
with special needs for more than 25 years. She currently has a private
practice in Collingwood, Ontario, and also works with Children's
Therapy Services of OSMH in Early Intervention.
Paula Aquilla is an occupational therapist who has worked with adults
and children in clinical, educational, home and community-based
settings. She was the founding executive director of Giant Steps
in Toronto, and directs Aquilla Pediatric Occupational Therapy,
also in Toronto, serving families with children who have special
Reprinted with permission from the Sept-Oct 2004 issue of the Autism
Asperger's Digest, a 52-page bimonthly magazine devoted to autism
spectrum disorders. For more info, visit www.autismdigest.com or
call Future Horizons at 800.489.0727.