Running head: WILBARGER PROTOCOL

Pediatric Qualitative Research Review: Analysis of Adherence to the Wilbarger Protocol

Marissa Stendel
Touro University Nevada

WILBARGER PROTOCOL

2
Introduction

During the development of my research question I felt it was in my best interest to pursue
something I had learned in my fieldwork experience but also something that I was interested in
learning more about. My ideation of the Wilbarger Protocol came to fruition when my fieldwork
educator demonstrated the intervention on one of her clients. I was able to witness the
administration and education of this protocol along with her client and family during the first
week of my fieldwork. Three weeks later, we revisited the same client within their home and
asked the mother if she had followed through with the protocol. She explained that she had and
that she saw a difference. My FE and I definitely agreed and were able to see an advance in the
clients sensory modulation. The client was now allowing more HOH without resistance and was
even picking up different textured foods which he had never done before!
This simple yet demanding protocol caught my attention from the beginning and thus led
to my research question, how does parental adherence effect home treatment usage of the
Wilbarger Protocol for children with sensory defensiveness? I will now discuss this research
question based on the article, Integration and Application of a Home Treatment Program: A
Study of Parents and Occupational Therapists.
Research Question
How does parental adherence effect home treatment usage of the Wilbarger Protocol for
children with sensory defensiveness?
APA Reference
Segal, R., & Beyer, C. (2006). Integration and application of a home treatment program: A study
of parents and occupational therapists. American Journal of Occupational
Therapy, 60(5), 500-510.

WILBARGER PROTOCOL

How does this study relate to your research question?

Home treatment programs introduced by occupational therapists can help families make
adaptations for their child through the use of activity during their daily life. This study describes
parental adherence to home treatment programs, specifically the Wilbarger Protocol which
correlates with sensory defensiveness (Segal & Bayer, 2006). The Wilbarger Protocol is
specifically geared towards treatment of sensory defensiveness by using brushing techniques and
joint compressions as a modulation toward sensory exploration (Wilbarger & Wilbarger, 1991;
2004).
Purpose of Study
The purpose of this study was to find what facilitates and hinders parental adherence to
the Wilbarger Protocol in the view of parents and occupational therapists. Parents were asked a
series of open ended questions related to the facilitation and occupational therapists were asked
what strategies were used to promote the adherence of the brushing and compression protocol
(Segal & Bayer, 2006).
Research Questions
The Wilbarger Protocol has three components: caregivers education on the program, the
childs sensory diet, and the brushing and compression aspect. The program expects that
brushing and compression to be administered every 90-120 minutes, or every two hours, for
children two months to 12 years of age (Wilbarger & Wilbarger, 1991; 2004).
Questions from the researchers particularly within this article pertain to the Wilbarger
Protocol intervention strategies and were a guide to the analysis of the study. Segal and Bayer
(2006), looked at: What do parents do to integrate the brushing and compression into their daily

WILBARGER PROTOCOL

lives? What were successful and failed attempts at integration? What are the parental perceptions
of what facilitated or hindered the success of the attempts? What are occupational therapists
perceptions of facilitators and hindrances to the success of the parental adherence to the brushing
and compression program? What are the strategies used by occupational therapists to encourage
parental adherence to the program?
Study Design
The study was conducted under an exploratory qualitative design where parents of the
children using the protocol and occupational therapists were interviewed in-depth to understand
the experiences of the program (Segal & Bayer, 2006).
Theoretical Perspective
The theoretical background used for this study was the ecocultural theory of family
accommodation (Bernheimer, Gallimore, & Kaufman, 1993; Gallimore, Wisner, Kaufman, &
Bernheimer, 1989). This theory describes the family accommodations taken by families in
response to social, cultural, and material environments for the purpose of constructing
sustainable niches for children. These niches then become what are seen as family routines and
occupations (Segal & Bayer, 2006). Overall the theory intertwined with the current research at
hand implies that integration of interventions into a familys routine requires that there be a fit
between the family and the familys ecocultural niche.
Participant Recruitment
Participants for this study were recruited from private occupational therapy clinics using
flyers and presentations to the clinic staff (Segal & Bayer, 2006).
Participant Total

WILBARGER PROTOCOL

The total number of participants was six parents and eight occupational therapists (Segal
& Bayer, 2006).
Participant Descriptions
Of the six parents, there were five mothers and one father. Five of the six families were
dual parent families and one was a single parent family which was a single mother and child.
Although only the parents were used for the study itself, some demographics of the children were
provided: all children were boys and ranged from four to seven years of age who received
occupational therapy services. Occupational therapists were described as working within the
large and small urban areas and had 4-12 years of experience. All therapists learned of the
Wilbarger approach in academic programs and were trained at a conference, workshop, or at the
Wilbargers clinic (Segal & Bayer, 2006).
Researcher- Participant Relationship
There were no major relationships between the researcher and participants however, the
researchers were responsible for in depth interviews on one or two different days with both the
parents and the occupational therapists. The two main contributors along with Parul Dhankhar
were elected to interview the parents and occupational therapists (Segal & Bayer, 2006).
What are the sources for data?
The sources used for this particular study were done so by way of open ended
interviewing of participants (Segal & Bayer, 2006). From the analysis of transcribed verbatim
answers the authors constructed themes. From there they used constant comparison method
along with open coding to develop categories (Segal & Bayer, 2006).
How are the findings reported?

WILBARGER PROTOCOL

The interviews for this study were conducted over one to two interviews with 45-90
minutes being the average time taken. The interviews were transcribed verbatim by a
professional transcriber (Segal & Bayer, 2006). The findings were reported by first data analysis
and second data analysis. Together these constructed the major themes of the article which
include, hindrances or facilitators to the integration of brushing and compression into the
familys daily life and, the strategies that therapists use to support parental adherence to the home
treatment program (Segal & Bayer, 2006).
What are the findings?
As mentioned above, the two major categories are: hindrances or facilitators to the
integration of brushing and compression into the familys daily life and, the strategies that
therapists use to support parental adherence to the home treatment program (Segal & Bayer,
2006). The home treatment program category is further subdivided into three categories: the
childrens responses to the intervention, the parents perceived efficacy of the program and the
family daily schedule. Occupational therapists interviews had subcategories as well which
discussed the training for the parents, working with the familys schedule and education provided
to increase adherence (Segal & Bayer, 2006).
With themes and categories in place the researchers found subcategories to further
analyze. Hindrances and facilitators to integration was further broken down into childrens
responses to brushing, perceived efficacy, and families daily schedules.
Parents consistently reported that the childrens response to the brushing was critical to
the use of the program therefore making it a condition for following the protocol (Segal & Bayer,
2006). The perceived efficacy of the protocol was found only to be positive when parental

WILBARGER PROTOCOL

observation of the effects of the protocol were immediate. One parent discussed the short and
long term differences but noted that only short effects seemed to last (Segal & Bayer, 2006).
Lastly, the families daily schedules played a major role in adherence to the program. Managing
to integrate the protocol into their daily lives every two hours was difficult for most. The
frequency varied across all parents from two times a day to every two hours as requested (Segal
& Bayer, 2006).
The strategies used by occupational therapists was further analyzed for education, daily
routine program suggestions, providing charts, and merely asking to implement the program for
two weeks (Segal & Bayer, 2006). Education for the Wilbarger Protocol was demonstrated by
physical example but also providing the parents with a deeper understanding of SI, what sensory
deficits are and how they can effect daily life for a child (Segal & Bayer, 2006). Therapists also
helped families to integrate the protocol into activities such as dressing in the morning and
undressing at night. Some provided the families with charts much like checklists for parents to
use for implementation (Segal & Bayer, 2006). Lastly, asking the families to try this program
was considered a subcategory. One therapist from the study explained that she asked the family
to give the protocol a try for two weeks so she could compare a list of concrete behaviors to a list
of behaviors after the two weeks was over. If this did not work, then they would try something
new (Segal & Bayer, 2006).
Overall the findings of this study indicate that there are three major issues for parents in
adhering to such a program: childrens response to the brushing, the perceived efficacy of the
intervention, and how to implement the rigorous routine into their daily schedule (Segal &
Bayer, 2006). Occupational therapists reported that finding activities within the program can be

WILBARGER PROTOCOL

challenging for parents and that parental knowledge of the overall sensory spectrum can have an
effect on the usage (Segal & Bayer, 2006).
Current Findings and Previous Research
Past studies from Hinojosa (1990), Hinojosa and Anderson (1991), and Law and King
(1993) focused on studies similar to this focusing on families with children with cerebral palsy.
These studies found that a lack of time and support, can hinder adherence to at home treatment
programs as well as roles of parents and values and priorities. Much like this study, Hinojosa
(1990) found that mothers of children with cerebral palsy would not adhere to at home treatment
programs if they felt that their child was uncomfortable or in pain. Lastly, Hinojosa (1990) and
Hinojosa and Anderson (1991) found that interventions need to be embedded in naturally
occurring activities and occupations at home.
Clinical Implications
This studys findings suggest that occupational therapists who would like to use the
Wilbarger Protocol with their clients need to inquire about childrens responses to the brushing
and compression program at home and about parental expectations before beginning (Segal &
Bayer, 2006). It is important to note that not every family hold occupational therapy to be
particularly important and that other issues identified in the ecocultural theory of family
accommodations should be taken into consideration. (Segal & Bayer, 2006).
Limitations
The author does not explicitly identify any limitations for the study however, I am able to
identify some myself. The study was qualitative but only consisted of six parents and eight
occupational therapists. The demographics of the children is also limited to only male children

WILBARGER PROTOCOL

between 4-7 years of age. Perhaps, a mixture of gender and wider array of ages could be better
for implications and results.
Implications for Future Research
The authors describe how future research could be used as a tool to help therapists
identify the type of change expected from the intervention and help facilitate that knowledge to
parents to encourage the usage of the program as well as the overall establishment of the efficacy
of the Wilbarger Protocol (Segal & Bayer, 2006).
Biases
The authors of the study did not discuss the biases within the study however, I was able
to identify a few. The occupational therapists all received different modes of training in the
Wilbarger Protocol therefore there is a discrepancy in how parents are being educated on the
program. There is no written description of how to perform the protocol because actual training
is required to master the program therefore, how can the efficacy of the program be truly
measured? Also, sensory diet was not discussed in the program even though it is a main
component of the Wilbarger Protocol. There could also be bias because one of the authors was a
parent and described how she believed it would be next to impossible to adhere to such a
rigorous program therefore leading to some preconceived notions of the plan of study. Lastly,
one of the parent participants was an occupational therapist implementing the program with her
son. This could lead to some bias in the results because of previous educational perceived
efficacy.
Participation Selection and Credibility
There was not rationale for participants explained however, the parents are most likely
credible because recruitment for the program took place within occupational therapy clinics.

WILBARGER PROTOCOL

10
Trustworthiness

Data was collected from multiple clinics with a number of occupational therapists. The
therapists did not work in the clinics that the parents were recruited from. This could lead to
some inadequacy in education and development of client rapport. The parents that were recruited
may have had better rapport with therapists within the clinic they were attending and therefore
may have been more apt to follow such a routine if there was a strong bond between therapist
and child.
Analysis of Themes
I believe that the themes presented are consistent with the data presented. The article
described very much in detail the responses from the parents and how they felt about the
protocol. Most all parents had similar responses to each question which supported the themes.
The conclusions are consistent as well however, I feel that better conclusions could have been
made with a gender difference or a larger age difference in child participants because a child that
is three years old may act very differently than a seven year old.
Flexibility in Data Collection Process
I believe that the researchers were flexible in both sets of questions given to the parents
and occupational therapists. The parents adherence was asked in many ways looking at
education, integration, and implementation. Occupational therapists were asked many of the
same ideas and were given the chance to explain how it is difficult for both parties. The data
seemed to be legitimate and analyzed well for themes, categories, and subcategories.
How would you use this article as a therapist?
I might use this article as a means to be hesitant on who I would prescribe this protocol
too. For instance, different cultures may have different feelings about touching one another. It

WILBARGER PROTOCOL

11

was interesting to see how many negative response there were to the protocol but also positive!
For example, parents did not feel that implementing this program was doable every two hours
which could be perceived as negative however, many believed that their children liked the
brushing and joint compressions thus leading to the question, if the child enjoys the brushing
why would one not try to implement it as much as possible? This article did support my thoughts
as an OTS about how difficult it might be to use this method however, it did help me to think
about activities that could be done with the child to better implement the program as prescribed
by Wilbarger.
Article Support for Occupation
This article supports occupation in the field of occupation therapy by trying to
demonstrate how an intervention could promote sensory modulation and lessen the effects of
sensory defensiveness. Through the study, we can see that implementation is difficult however
using it in the context of occupation within different activities can be helpful when completing an
at home treatment program.

WILBARGER PROTOCOL

12
References

Bernheimer, L. P., Gallimore, R., & Kaufman, S. Z. (1993). Clinical child assessment in a family
context: A four-group typology of family experiences with young children with
developmental delays. Journal of Early Intervention, 17(3), 253269.
Bernheimer, L. P., & Keogh, B. K. (1995). Weaving interventions into the fabric of everyday life:
An approach to family assessment. Topics in Early Childhood Special Education, 15,
415419.
Hinojosa, J. (1990). How mothers of preschool children with cerebral palsy perceive
occupational and physical therapists and their influence on family life. Occupational
Therapy Journal of Research, 10, 144162.
Hinojosa, J., & Anderson, J. (1991). Mothers perceptions of home treatment programs for their
preschool children with cerebral palsy. American Journal of Occupational Therapy, 45,
273279.
Law, M., & King, G. (1993). Parent compliance with therapeutic interventions for children with
cerebral palsy. Developmental Medicine & Child Neurology, 35, 983990.
Segal, R., & Beyer, C. (2006). Integration and application of a home treatment program: A study
of parents and occupational therapists. American Journal of Occupational
Therapy, 60(5), 500-510.
Wilbarger, P., & Wilbarger, J. (1991). Sensory defensiveness in children aged 212: An
intervention guide for parents and other caregivers. Denver, CO: Avanti Educational
Programs.

WILBARGER PROTOCOL

13

Wilbarger, J., & Wilbarger, P. (2004). The Wilbarger approach to tricking sensory defensiveness.
In A. C. Bundy, S. J. Lane, & E. A. Murray (Eds.), Sensory integration: Theory and
practice (2nd ed., pp. 335338). Philadelphia: F. A. Davis.