Research in Autism Spectrum Disorders 5 (2011) 10531058

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

The effects of a brushing procedure on stereotypical behavior

Tonya N. Davis a,*, Shannon Durand a, Jeffrey M. Chan b
a
b

Baylor University, United States

Northern Illinois University, United States

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 23 November 2010
Accepted 29 November 2010
Available online 30 December 2010

In this study we analyzed the effects of a brushing protocol on stereotyped behavior of a

young boy with autism. First, a functional analysis was conducted which showed that the
participants stereotypy was maintained by automatic reinforcement. Next, the Wilbarger
Protocol, a brushing intervention, was implemented. An ABA design was implemented in
which the participant was observed during four phases: (a) baseline, prior to the
administration of the brushing protocol; (b) week 3 of implementation of the brushing
protocol; (c) week 5 of implementation; and (d) 6 months after the discontinuation of the
brushing protocol. Findings suggest that the brushing protocol had no marked affect on
levels of stereotypy.
2010 Elsevier Ltd. All rights reserved.

Keywords:
Stereotypy
Sensory integration
Body brushing
Wilbarger Protocol
Autism
Developmental disabilities

The presence of restricted and stereotyped behavior is a core characteristic of individuals with autism (American
Psychiatric Association, 2000). Stereotyped behaviors are repetitive behaviors that serve no apparent adaptive purpose
(Baumeister & Forehand, 1973; Bodsh et al., 1995; Lee, Odom, & Loftin, 2007). Stereotypy may be the most debilitating of
the core characteristics of autism because it often encompasses a signicant portion of an individuals behavioral repertoire,
leaving little room for appropriate and adaptive behaviors. Stereotyped behaviors interfere with vital activities including
learning, skill acquisition, social interactions, and typical toy play (Conroy, Asmus, Sellers, & Ladwig, 2005; Epstein, Doke,
Sajwaj, Sorrel, & Rimmer, 1974; Matson & Dempsey, 2008; Matson, Hamilton, et al., 1997; Matson, Kieley, & Bamburg, 1997;
Morrison & Rosales-Ruis, 1997; Rapp & Vollmer, 2005; Wolery, Kirk, & Gast, 1985). Moreover, the display of stereotyped
behaviors is stigmatizing and therefore results in social isolation (Dunlap, Dyer, & Koegel, 1983; Jones, Wint, & Ellis, 1990;
Koegel & Covert, 1972). With the multitude of problems resulting from the display of stereotyped behaviors, it is imperative
that successful and efcient treatments are identied.
Treatment of any challenging behavior begins with identication of the contingencies maintaining the behavior;
however, functional assessment of stereotypy often concludes that the behaviors are automatically reinforced. It is likely
that stereotyped behaviors often produce visual, tactile, vestibular, or other desirable sensory stimulation that serves as
reinforcement (Cunningham & Schriebman, 2008; Rapp, Vollmer, Peter, Dozier, & Cotnoir, 2004; Lang et al., 2010). In fact,
stereotypy is so frequently maintained by automatic reinforcement, that the term self-stimulatory behavior is often used
interchangeably with the term stereotypy (Cunningham & Schriebman, 2008).
Perhaps due to the potential relationship between stereotypy and sensory stimulation, sensory integration therapy is
often implemented with children with autism. Sensory integration was identied as the third most commonly implemented
treatment among parents of children with autism: 38% of parents reported as currently receiving sensory integration

* Corresponding author at: Baylor University, One Bear Place #97031, Waco, TX 76798-3701, United States. Tel.: +1 254 710 6166; fax: +1 254 710 3265.
E-mail address: Tonya_Davis@baylor.edu (T.N. Davis).
1750-9467/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2010.11.011

1054

T.N. Davis et al. / Research in Autism Spectrum Disorders 5 (2011) 10531058

therapy, while another 33% reported receiving sensory integration therapy in the past (Green et al., 2006). According to
sensory integration theory, stereotypic behaviors characteristic of individuals with autism are interpreted as an attempt to
seek preferred sensory stimuli and avoid aversive sensory stimuli in order to create homeostasis within the central nervous
system (Hein & Simpson, 1998).
One particular sensory integration technique with much popularity is the Wilbarger Protocol. The Wilbarger Protocol is
rooted in sensory integration theory, which was originated by Ayers in the 1960s (Wilbarger, 1995). The protocol involves
rmly brushing an individual on the arms, hands, back, legs, and feet with a soft surgical brush. The brushing is typically
followed by gentle joint compressions to the shoulders, elbows, wrists, hips, knees, ankles, ngers, and feet (Wilbarger &
Wilbarger, 1991). The brushing protocol is recommended for children ages 212 years and is to be implemented every 90
120 min (Wilbarger & Wilbarger, 1991). However, Wilbarger and Wilbarger (2004) urge consumers to receive specialized
training as the procedure cannot be conveyed adequately in written form (p. 337); in other words, hands-on training is
required to master the technique.
The original purpose of the Wilbarger Protocol was to treat sensory defensiveness, dened as the overreaction and
avoidance of a sensation from any sensory modality (Wilbarger & Wilbarger, 1991, 2004). However, the protocol has
targeted a variety of skills and behaviors including stereotypy, self-injury, language skills, cognition, distractibility, excessive
physical activity, and coping strategies (David, 1990; Frick, 1989; Moore & Henry, 2002; Reisman, 1993). The Wilbarger
Protocol has also been implemented across a variety of disorders and disabilities, including autism, intellectual disability,
developmental delays, attention decit hyperactivity disorder, cerebral palsy, dementia, mania, depression, and anxiety
(Champagne & Stromberg, 2004; David, 1990; Frick, 1989; Moore & Henry, 2002; Reisman, 1993; Snyder-Stonebraker, 2001;
Stratton & Gailfus, 1998).
The brushing protocol is widely used by occupational therapists today. Over 15,000 health care professionals have
received the specialized Wilbarger Protocol training and more than 20,000 therapeutic brushes are ordered each year
(Kimball et al., 2007). In a survey conducted by Sudore (2001), it was reported that 78% of occupational therapists use the
Wilbarger Protocol but only 2.6% of respondents reported a concern regarding the lack of evidence supporting the
effectiveness of the protocol.
Although the Wilbarger Protocol may be a popular treatment option for individuals with autism, there is little evidence to
support its effectiveness (Hein & Simpson, 1998). The few studies that have examined the effects of brushing suffer from
methodological aws. First, evidence in support of the brushing protocol consists of clinical reports and case studies without
an experimental design (Frick, 1989; Kimball et al., 2007; Reisman, 1993; Moore & Henry, 2002; Snyder-Stonebraker, 2001;
Stratton & Gailfus, 1998). Second, many studies utilized the protocol as a single component of a multi-component treatment
program, making it impossible to determine the effectiveness of the brushing protocol alone (e.g., Frick, 1989; Moore &
Henry, 2002; Reisman, 1993). For example, Frick (1989) implemented the brushing protocol in addition to twice weekly
therapy sessions of proprioceptive activities and linear vestibular stimulation with a young boy with autism. In a literature
synthesis of the Wilbarger Protocol, Foss, Swinth, McGruder, and Tomlin (2003) concluded that published and objective
evidence supporting the brushing protocol is scant (p. 4).
The purpose of this study was to examine the effects of a brushing protocol on the stereotyped behavior of a young boy
with autism. The intervention was applied in the participants home by his mother and one-to-one therapist, both of whom
received hands-on training in the protocol. The level of the participants stereotyped, self-stimulatory behavior was
measured before, during, and after the implementation of the brushing treatment.
1. Method
1.1. Participant and target behavior
Aiden, a 4-year-old Caucasian male, participated in the study. Aiden was from a two-parent home and he had two siblings.
Aiden was professionally diagnosed with autism at the age of 2 years. Aiden did not attend school, but received
approximately 40 h of one-to-one in-home behavioral therapy per week. Aiden was nonverbal and communicated using
gestures to request preferred objects. According to therapist and parent report, Aiden engaged in high levels of stereotypical
behavior. Three specic topographies of stereotypy were identied via direct observation, including hand apping, nger
icking, and body rocking. Hand apping was dened as moving one or both hands in an up and down movement at least
6 in. from the top to the bottom of the swing. Finger icking was dened as striking an object with one or more ngers
without utilizing the object in its intended manner. Body rocking was dened as repeatedly swinging his torso left to right or
front to back with a swing of at least 6 in. to either side.
1.2. Setting
Data collection during all portions of the study (functional analysis and intervention) occurred in Aidens bedroom, which
was utilized regularly during in-home therapy. The bedroom was not altered in any way. Aidens bedroom included a bed
and several toys that were neatly stored away. In this setting, the bedroom door was closed; therefore, Aidens mother and
siblings were not in sight, but Aiden was intermittently able to hear their voices from the other rooms. Aidens mother
and siblings were home during all sessions.

T.N. Davis et al. / Research in Autism Spectrum Disorders 5 (2011) 10531058

1055

1.3. Experimental design and data collection

A withdrawal design was utilized to examine the inuence of the brushing protocol on stereotypy (Kennedy, 2005).
Specically, an ABA design was implemented in which data were collected on stereotypy during baseline, before the
brushing protocol was implemented; when the brushing protocol was implemented, and after the intervention was
discontinued. Baseline data were collected for 1 week at the beginning of the study. Intervention data were collected during
the third and fth weeks of intervention; observations occurred in the early afternoon. During the intervention phase, data
collection sessions occurred immediately after a brushing session.
During both the functional analysis and treatment phases, data were collected using a 10 s partial-interval procedure
(Kennedy, 2005). The percentage of intervals in which stereotypical behavior occurred was calculated by dividing the
number of intervals with stereotypy by the total number of intervals of the observation session.
Interobserver agreement (IOA). Interobserver agreement was conducted on 33% of functional analysis sessions and 55%
of treatment sessions. Interobserver agreement was calculated using an interval-by-interval method. The number of
intervals in which both observers agreed (occurrence plus nonoccurrence) was divided by the total number of intervals
(agreements plus disagreements) and multiplied by 100 to report a percentage. Mean IOA was 97% (range 93100%) for the
FA and 96% (range 80100%) for treatment sessions.
1.4. Functional analysis
A functional analysis was conducted in a manner similar to that described by Iwata, Dorsey, Slifer, Bauman, and Richman
(1982/1994). The FA consisted of ve assessment conditions: (a) attention, (b) demand, (c) tangible, (d) play, and (e) alone.
Each condition lasted 5 min. A multielement design was utilized to demonstrate experimental control (Kennedy, 2005). The
sequence of FA conditions was counterbalanced prior to the assessment.
Attention. During the attention condition, the participant was instructed to sit quietly or play while the implementer
engaged in work. Contingent upon target behavior, the implementer provided attention for 10 s in the form of disapproving
statements such as, Dont do that, and redirection, such as, Play quietly, please. This condition was used to determine the
possibility of positive social reinforcement as the maintaining consequence of stereotypy.
Demand. During the demand condition, an academic task that was difcult for the participant to complete independently
was presented. These tasks were selected by his in-home therapist and included academic activities such as motor imitation
and puzzle completion. Both the implementer and the participant sat at a table, and the implementer gave a verbal
instruction to begin the task. A three-step prompting procedure consisting of (a) verbal, (b) verbal + model, and (c)
verbal + physical was implemented. Successful completion of small steps towards task completion was praised. Contingent
upon target challenging behavior, the implementer removed the task and turned away from the participant. The
implementer remained turned away from the participant for 10 s after the absence of target behavior. This condition
assessed the possibility of negative reinforcement as the maintaining consequence of the target behavior.
Tangible. During the tangible condition, both the implementer and participant sat at a table. The participant was
provided non-contingent access to a highly preferred toy (as identied via therapist interview) for 10 s. The toy was then
removed and, contingent upon the occurrence of stereotypy, it was returned to the participant for 10 s. No other attention or
eye contact was provided. This condition assessed the possibility of positive reinforcement in the form of tangibles
maintaining the target challenging behaviors.
Play. During the play condition, the implementer remained in close proximity with the participant and preferred toys
were within reach of the participant. The participant was allowed to play with toys and move around the room; no
educational tasks or materials were presented. Non-contingent social praise and physical contact were presented every 10 s
and challenging behavior was ignored. This condition was included as a control in that it was considered an enhanced
environment.
Alone. During the alone condition, Aiden was placed in his room alone. Toys and any other source of stimulation were
removed or stored away. The implementer remained in the doorway with the door slightly open or outside a window in
order to collect data. At certain angles, Aiden may have been able to see the implementer, but he never responded in a way
that would suggest that he did (e.g., making eye contact, pointing, etc.). The purpose of this condition was to determine if
sensory stimulation was the main reinforcer for stereotypy, which would be more likely to occur in an impoverished
environment.
1.5. Procedures
Aiden was exposed to two experimental phases: baseline and brushing. During observation sessions of each phase, Aiden
engaged in various ne motor activities, including stringing beads, completing puzzles, and picking up cotton balls with
tweezers. Each activity was recommended by Aidens occupational therapist as part of this occupational therapy plan. A
three-step prompting consisting of (a) verbal, (b) verbal + model, and (c) verbal + physical was implemented to help Aiden
complete the ne motor tasks. Verbal praise was given for on-task behavior. All instances of stereotyped behavior were
ignored. Each session was 15 min in duration.
Baseline. During the baseline phase, no brushing was provided to Aiden.

1056

T.N. Davis et al. / Research in Autism Spectrum Disorders 5 (2011) 10531058

Intervention. Aidens occupational therapist provided his mother with hands-on training to implement the protocol.
Aidens mother, in turn, provided the in-home behavioral therapist with training. Aiden was brushed with a soft surgical
brush approximately seven times per day, evenly spaced among his waking hours. The brush was specically recommended
by the occupational therapist as being the correct brush for the Wilbarger protocol. Aiden was predominantly brushed by his
mother, but the in-home therapist provided brushing when his mother was unavailable. During the brushing protocol, Aiden
was systematically brushed using rm pressure on his arms, hands, back, legs, and feet. He was brushed with long strokes
until the entire skin surface was brushed at least once. This typically resulted in 310 brushes per body part, depending on
the skin surface area.
Return to baseline. The nal phase of the study was a return to baseline. This phase occurred 6 months after the
completion of the brushing protocol to ensure that no carry-over effects of brushing would affect Aidens stereotypy. During
this 6-month interval, no brushing protocol was provided to Aiden. The second baseline phase was identical to the initial
baseline phase.
2. Results
Fig. 1 displays the results of the functional analysis. Visual analysis concludes that Aidens engages in stereotypy in
relatively high levels across conditions. Stereotypy was most frequent in the tangible condition (M = 81%; range = 60100%).
However, stereotypy was also frequent in the alone condition (M = 56%; range = 4763%). While visual analysis may
conclude that Aidens stereotypy is maintained by access to tangibles, only nger icking increased during the tangible
condition. As identied in previous observations, Aidens nger icking increased when he had small toys available, as the he
was most likely to ick small, hand-held objects with his ngers. Therefore, the presence of small objects in the tangible
condition appeared to cause an increase in nger icking. Specically, nger icking increased dramatically when Aiden was
provided access to the preferred tangible; however, it decreased once the tangible was removed. In other words, it did not
appear that Aiden utilized nger icking to gain access to a tangible, instead, another target behavior, such as body rocking,
was displayed, after which he received access to a tangible, then at this time, nger icking increased. This suggests that the
presence of tangibles may have served as a motivating operation for nger icking. The elevated nger icking across
conditions and the high levels of stereotypy in the alone condition, suggests that Aidens stereotypy may be maintained by
access to automatic reinforcers, such as sensory stimulation.
The results of the brushing protocol are presented in Fig. 2. During the baseline condition, stereotypy ranged 1654% of
intervals (M = 40%). During the third week of intervention, stereotypical behavior occurred at an average of 52% of intervals
(range = 4163%). During the fth week of intervention, Aidens stereotypy slightly increased again to a mean of 55% of
intervals (range = 3769%). Finally, 8 months after the completion of the brushing protocol, Aidens mean stereotypy
decreased (M = 28%, range = 1742%). Overlapping data points exist among each of the phases of this study, and there is not a
marked and consistent distinction among brushing and non-brushing phases. The results of this data suggest that brushing
did not have an effect on Aidens stereotypical behaviors.
3. Discussion

Percent of Intervals with Stereotypy

In the current study, a standardized treatment protocol for application of brushing, known as the Wilbarger Protocol, was
administered to a child with autism. The goal of the intervention was to decrease the level of stereotypy displayed by the
child, which was hypothesized to serve an automatic reinforcing function based on the data from a functional analysis. The
brushing protocol was implemented daily by the childs mother and one-to-one therapist. The participants level of
stereotypy did not decrease during the brushing phases of the study, and analysis suggests that a slightly elevated level of
challenging
behavior occurred during the daily brushing phases.
[()TD$FIG]
100
80
60

Alone
Attention

40

Demand
Tangible

20

Play

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Session
Fig. 1. Aidens functional analysis results.

[()TD$FIG]

T.N. Davis et al. / Research in Autism Spectrum Disorders 5 (2011) 10531058

Percent of Intervals with Stereotypy

100

Week 3
of Brushing

Baseline

Week 5
of Brushing

1057

Baseline

80

60

40

20

0
1

11

13

15

17

19

Session
Fig. 2. Results of stereotypy conducted during (a) baseline, (b) week three of receiving the brushing protocol, (c) week ve of receiving the brushing protocol,
and (d) a return to baseline.

The rationale behind use of brushing techniques is to provide a sensory diet for students with autism. The mechanism
behind the sensory diet is exposure to elevated levels of sensory input, which in turn satises the childs need for extra
sensory stimulation. With this need satised, it is expected that individuals will engage in lower levels of self-stimulatory
behavior. The introduction of the Wilbarger brushing protocol did not lead to any notable decrease in the level of stereotyped
behavior displayed by the participant during the 6 weeks of intervention. There are two possible explanations for this. First, it
is possible that the frequent brushing of the participant did not provide enough sensory stimulation to override the
participants desire to engage in stereotypy during non-brushing situations.
Second, it may be the case that the type of sensory input provided by brushing (i.e., tactile) was not consistent with the
type of sensory input typically achieved through Aidens stereotypy (i.e., visual and/or vestibular for hand apping,
vestibular for body rocking). As the brushing did not satisfy Aidens primary mode of automatic reinforcement, his levels of
stereotypy did not decrease upon introduction of the intervention.
The slightly elevated levels of stereotypy and the upward trend observed during the two phases of intervention remain
unexplained. The regularly timed schedule in which the brushing was implemented could possibly have provided reinforcement
on a xed interval schedule. Such reinforcement could have provided the student with extra consequences (beyond automatic
reinforcement) for stereotypy. Another possibility is that brushing acted to increase the reinforcing properties of self-stimulatory
behavior, thus increasing its levels during observation. Previous research has shown that providing limited exposure to preferred
items, activities, or situations can increase the occurrence of behavior (Ayllon & Azrin, 1968; Roantree & Kennedy, 2006). By
providing access to a reinforcing situation (i.e., brushing) that provided the same reinforcement as stereotypy (i.e., automatic
reinforcement), Aidens use of stereotypy increased in the short-term. The application of the Wilbarger Protocol in the current
study did not attenuate the level of stereotypy in the participant with autism. The practical implications of these results suggest
that if parents, teachers, or therapists seek to use antecedent interventions to decrease stereotypy, the reinforcing properties of
stereotypy should be decreased. One method of doing so is allowing children to engage in stereotypy to the point of satiation,
which has been shown to decrease levels of stereotypy in free play situations (Lang et al., 2010).
There are some limitations to the current study. First, a replication of the brushing intervention following the second
baseline condition would have been ideal, but Aidens parents did not wish to reinstate the brushing protocol due to the lack
of positive effects. Second, treatment delity data were not collected on implementation of the Wilbarger Protocol. The
extent to which Aidens mother and therapist accurately provided the brushing intervention according to the protocol
cannot be determined. Future studies should address these shortcomings and examine the effectiveness of the Wilbarger
Protocol in decreasing stereotypy as well as the effects it may have on functional, social, or academic behaviors.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric
Association.
Ayllon, T., & Azrin, N. H. (1968). Reinforcer sampling: A technique for increasing the behavior of mental patients. Journal of Applied Behavior Analysis, 1, 1320.
Baumeister, A. A., & Forehand, R. (1973). Stereotyped acts. In Ellis, N. R. (Ed.). International Review of Research in Mental Retardation (Vol. 6, pp. 5596).New York:
Academic Press

1058

T.N. Davis et al. / Research in Autism Spectrum Disorders 5 (2011) 10531058

Bodsh, J. W., Crawford, T. W., Powell, S. B., Parker, D. E., Golden, R. N., & Lewis, M. H. (1995). Compulsions in adults with mental retardation: Prevalence,
phenomenology, and comorbidity with stereotypy and self injury. American Journal of Mental Retardation, 100, 183192.
Champagne, T., & Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion and restraint. Journal of
Psychosocial Nursing, 42(9), 3544.
Conroy, M. A., Asmus, J. M., Sellers, J. A., & Ladwig, C. N. (2005). The use of an antecedent-based intervention to decrease stereotypic behavior in a general education
classroom: A case study. Focus on Autism and Other Developmental Disabilities, 20, 223230.
Cunningham, A. B., & Schriebman, L. (2008). Stereotypy in autism: The importance of function. Research in Autism Spectrum Disorder, 2, 469479.
David, S. (1990). A case study of sensory affective disorder in adult psychiatry. Sensory Integration Special Interest Section Newsletter, 13(4), 14.
Dunlap, G., Dyer, K., & Koegel, R. L. (1983). Autistic self stimulation and interval duration. American Journal on Mental Deciency, 84, 194202.
Epstein, L. A., Doke, L. A., Sajwaj, T. E., Sorrel, S., & Rimmer, B. (1974). Generality and side effects of overcorrection. Journal of Applied Behavior Analysis, 7, 385390.
Foss, A., Swinth, Y., McGruder, J., & Tomlin, G. (2003). Sensory modulation dysfunction and the Wilbarger Protocol: An evidence review. OT Practice, 8(12), CE-1
CE-8 (Suppl).
Frick, S. (1989). Sensory defensiveness: A case study. Sensory Integration Special Interest Section Newsletter, 12(2), 78.
Green, V. A., Pituch, K. A., Itchon, J., Choi, A., OReilly, M., & Sigafoos, J. (2006). Internet survey of treatments used by parents of children with autism. Research in
Developmental Disabilities, 27, 7084.
Hein, 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, 194211.
Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1982/1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27,
197209.
Jones, R. S. P., Wint, D., & Ellis, N. C. (1990). The social effects of stereotyped behavior. Journal of Mental Deciency Research, 34, 261268.
Kennedy, C. H. (2005). Single-case design for educational research. Boston: Allyn & Bacon.
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. The American Journal of Occupational Therapy, 61, 406413.
Koegel, R. L., & Covert, A. (1972). The relationship of self stimulation to learning in autistic children. Journal of Applied Behavior Analysis, 5, 381387.
Lang, R., OReilly, M., Sigafoos, J., Machalicek, W., Rispoli, M., Lancioni, G. E., et al. (2010). The effects of an abolishing operation intervention component on play
skills, challenging behavior, and stereotypy. Behavior Modication, 34, 267289.
Lee, S., Odom, S., & Loftin, R. (2007). Social engagement with peers and stereotypic behavior of children with autism. Journal of Positive Behavior Interventions, 9,
6779.
Matson, J. L., & Dempsey, T. (2008). Stereotypy in adults with autism spectrum disorders: Relationship and diagnostic delity. Journal of Developmental and
Physical Disabilities, 20, 155165.
Matson, J. L., Hamilton, M., Duncan, D., Bamburg, J., Smiroldo, B., Anderson, S., et al. (1997). Characteristics of stereotypic movement disorder and self-injurious
behavior assessed with the Diagnostic Assessment for the Severely Handicapped (DASH-II). Research in Developmental Disabilities, 18, 457469.
Matson, J. L., Kieley, S. L., & Bamburg, J. W. (1997). The effect of steretoypies on adaptive behavior as assessed with the DASH-II and Vineland adaptive behavior
scales. Research in Developmental Disabilities, 18, 471476.
Moore, K. M., & Henry, A. D. (2002). Treatment of adult psychiatric patients using the Wilbarger Protocol. Occupational Therapy in Mental Health, 18(1), 4363.
Morrison, K., & Rosales-Ruis, J. (1997). The effect of object preferences on task performance and stereotypy in a child with autism. Research in Developmental
Disabilities, 18, 127137.
Rapp, J. T., & Vollmer, T. R. (2005). Stereotypy I: A review of behavioral assessment and treatment. Research in Developmental Disabilities, 26, 527547.
Rapp, J. T., Vollmer, T. R., Peter, C., Dozier, C. L., & Cotnoir, N. M. (2004). Analysis of response allocation in individuals with multiple forms of stereotyped behavior.
Journal of Applied Behavior Analysis, 37, 481501.
Reisman, J. E. (1993). Using sensory integrative approach to treat self-injurious behavior in adults with profound mental retardation. The American Journal of
Occupational Therapy, 47, 403411.
Roantree, C. F., & Kennedy, C. H. (2006). A paradoxical effect of presession attention on stereotypy: Antecedent attention as an establishing, not an abolishing,
operation. Journal of Applied Behavior Analysis, 39, 381384.
Snyder-Stonebraker, D. (2001). The effects of a Wilbarger-based brushing protocol: A single subject study. Unpublished masters thesis. University of Puget Sound,
Tacoma, Washington.
Stratton, J., & Gailfus, D. (1998). A new approach to substance abuse treatment: Adolescents and adults with ADHD. Journal of Substance Abuse, 15(2), 8994.
Sudore, K. (2001). Tactile defensiveness and the Wilbarger brushing protocol in system management. Unpublished masters thesis. DYouville College, Buffalo, New
York.
Wilbarger, J., & Wilbarger, P. (2004). The Wilbarger approach to tricking sensory defensiveness. In A. S. Bundy, S. J. Lane, & E. A. Murray (Eds.), Sensory integration:
Theory and practice (2nd ed., pp. 335338). Philadelphia: F.A. Davis.
Wilbarger, P. (1995). The sensory diet: Activity programs based on sensory processing theory. Sensory Integration Special Interest Section Newsletter, 18(2), 14.
Wilbarger, P., & Wilbarger, J. (1991). Sensory defensiveness in children aged 212: An intervention guide for parents and other caretakers. Santa Barbara, CA: Avanti
Educational Programs.
Wolery, M., Kirk, M., & Gast, D. L. (1985). Stereotypic behavior as a reinforcer: Effects and side effects. Journal of Autism and Developmental Disorders, 15, 149161.