Journal of Pediatric Psychology, Vol. 25, No. 4, 2000, pp. 279-284
© 2000 Society of Pediatric Psychology
Brief Report: Psychological Symptoms in Healthy Female Siblings of Adolescents With and Without Chronic Conditions
1 Albert Einstein College of Medicine, 2 Helen Hayes Hospital
All correspondence should be sent to Ellen Johnson Silver, Department of Pediatrics, Albert Einstein College of Medicine, Jack & Pearl Resnick Campus, 1300 Morris Park Avenue, NR 7S-15, Bronx, New York 10461. E-mail: ejsilver{at}aecom.yu.edu .
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Abstract |
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Objective: To examine the psychological impact of having a sibling with a chronic condition on healthy adolescent females and to explore the potential moderating role of birth order on this relationship.
Method: We compared selected Brief Symptom Index subscales (anxiety, depression, interpersonal sensitivity, hostility) and global severity scores (GSI) in two groups of healthy, inner-city female adolescents matched for sibling age, gender, birth order, and age spacing: 34 sisters of males and females ages 13-19 years with chronic health conditions (ILLSIBS) and 34 sisters of males and females in the same age range without conditions (WELLSIBS).
Results: ILLSIBS generally had more symptoms than WELLSIBS. MANOVA yielded significant three-way interactions of sibling illness status, birth order, and gender for the anxiety, hostility, and GSI. A similar pattern was nonsignificant for the two other subscales. Among younger sisters in general and among older sisters of males only, ILLSIBS had higher scores; however, ILLSIBS who were older sisters of females did not differ significantly in symptom levels from the comparable group of WELLSIBS.
Conclusions: Psychological symptoms in sisters of inner-city, male and female adolescents are related to sibling health status. However, the combination of sibling gender and birth order may modify this relationship and should be considered when evaluating psychological risk or designing interventions.
Key words: adolescents; chronic illness; psychological distress; siblings.
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Introduction |
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The development of physically healthy siblings in a family can be influenced both positively and negatively by the experiences of living with a brother or sister who has an illness or disability. Although prosocial behaviors, such as tolerance, insight, and compassion, may be heightened in children whose siblings have chronic conditions (Horwitz & Kazak, 1990
;
Leonard, 1991), higher rates of
aggression and maladaptive interpersonal interactions also have been reported
in these children (Breslau & Pabrucki,
1987; Cadman, Boyle, &
Offord, 1988; Lobato, Barbour,
Hall, & Miller, 1987). However, research on the psychological
impact of having a brother or sister with a health condition has been sparse,
and its few findings have been inconsistent
(Stoneman & Brody, 1993;
Thompson & Gustafson,
1996; Williams,
1997). Although there appears to be an elevated risk of distress
for this group, it is clear that many healthy siblings adjust quite well. In
addition, many factors may influence the level of distress they report. For
example, study results have tended to vary depending on the birth order and
gender make-up of the sibling dyads examined
(Howe, 1993;
Williams, 1997). This is not
surprising given that roles and role symmetry are important components of the
sibling relationship and may be related to these factors
(Stoneman & Brody, 1993).
Some specific evidence suggests that girls whose younger siblings have chronic
conditions are more likely to experience internalizing problems such as
depression and anxiety (Lobato, Faust,
& Spirito, 1988). Male siblings, especially those who are
younger than the affected child, are thought to be at risk for aggression
(Howe, 1993). However,
variables such as sibling gender and birth order typically have not been
investigated together in well-controlled studies
(Howe, 1993). The purpose of this analysis was to extend the current body of knowledge about the adjustment of healthy adolescent girls whose siblings have chronic conditions. The decision to include only sisters was both theoretical and practical. As noted, in some studies, boys have been found to display different reactions from girls to having siblings with health conditions, particularly in terms of aggressivity. There also were more female patients available for screening at the medical center. Enrolling boys would have required an increased sample size and more time to identify and interview participants, both of which were beyond the resources available to the investigators. Thus, we restricted the investigation to sisters. Our goals were to (1) compare levels of psychological symptoms in healthy adolescent girls whose sisters or brothers either did or did not have chronic conditions, and (2) explore the potential moderating role of birth order on the relationship between psychological symptoms and sibling health status. Based on the literature, we posited that sisters of adolescents with chronic conditions would have more symptoms than sisters of adolescents without conditions, and that birth order and sibling illness status would interact so that symptoms would predominate in older sisters of adolescents with conditions.
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Method |
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Recruitment Procedures
Two equal-sized groups of healthy female adolescents were recruited: 34 were older or younger sisters of adolescent boys and girls with chronic conditions (ILLSIBS) and 34 were older or younger sisters of adolescent boys and girls without chronic conditions (WELLSIBS). Each participant and her "index" sibling was from 13 to 19 years old. To identify potential participants, a doctoral student in health psychology (M.J.F.) approached male and female patients 13 to 19 years old attending the adolescent and pediatric general and subspecialty clinics or hospitalized in the adolescent inpatient unit at a large, urban, university-affiliated medical center. They were asked to complete a brief screening interview to determine if they or a family member might be eligible for a study looking at the lives of adolescents receiving health care at the medical center. The interview asked for some basic demographic information (e.g., age, gender, grade) and about any ongoing health problems or medical conditions they had themselves. Additional questions asking about persons residing in the household were used to determine if they lived with an adolescent sibling who met the study criteria.
Of 150 adolescents approached, 135 (90%) agreed to be screened and to have an eligible family member contacted (when the person approached for screening was under age 18, both their own assent and parental consent were obtained). This screening procedure yielded 91 sibling dyads who potentially qualified for the study, but two eligible sisters declined to participate; all but two pairs were identified from outpatient sources. The eligible dyads then were stratified by sibling illness status, gender, birth order, and age spacing (more or less than 2 years apart) to assure that the WELLSIBS and ILLSIBS groups were frequency matched by these characteristics. There were 68 healthy girls who completed the survey after signed consent/assent forms from the participant and/or her parent (as appropriate) were received; 90% were interviewed by telephone. Participants were paid $10.00. The study protocol was approved by the Institutional Review Board.
Sample Characteristics
The sociodemographic characteristics of the 68 participating girls
reflected the inner-city patient population served at the medical center. Most
were of minority ethnic backgrounds (Hispanic, 63%; Black, 19%) and from
families of low to moderate socioeconomic status (68% received Medicaid and/or
public assistance). The average household size was five persons. Less than a
third of the dyads (29%) lived with two biological parents, and more than half
(53%) lived with their mother only; the remainder lived in other family types
such as with mother and stepfather, father only, or the maternal grandmother.
The mean age of participants was 16.3 years. Older sisters (mean = 16.8,
SD = 1.8, range = 14-19) and younger sisters (mean = 15.9,
SD = 2.0; range = 13-19) had mean ages about 1 year apart. ILLSIBS
and WELLSIBS groups did not differ significantly in any characteristic. The
sisters and brothers of ILLSIBS had various types of chronic conditions that
included but were not limited to: asthma (n = 5), arthritis
(n = 4), diabetes (n = 3), cancer (n = 2), epilepsy
(n = 2), sickle cell disease (n = 2), thyroid (n =
2) and cardiac disorders (n = 2). In the WELLSIBS group, neither the
participant, her index sibling, nor any other sibling in the household had a
chronic health condition.
Measures
Information on age, gender, and illness status, as well as family
structure, was assessed in the screening interview. The participant
questionnaire provided data on ethnic background, socioeconomic status, and
psychological distress. We used the Brief Symptom Inventory (BSI,
Derogatis, 1993), a
well-validated and reliable 53-item self-report scale that may be used with
respondents as young as 13 years. Higher subscale scores indicate more
symptoms. Raw scores also may be converted to standardized T scores, with
values of 63 or greater considered a positive clinical diagnosis. The BSI
assesses nine dimensions of psychopathology, but we selected only the anxiety,
depression, hostility, and interpersonal sensitivity subscales for these
analyses. These dimensions seemed appropriate because they reflect
internalizing symptoms that were found to be problematic for sisters of
siblings with chronic illness in other studies, and they were likely to have
some variation in the sample. The other BSI subscales assess more severe
clinical syndromes such as psychoticism and paranoid ideation, which have not
been found to relate to sibling illness. The Global Severity Index (GSI) was
used to measure overall symptom levels.
Data Analyses
To examine the first hypothesis, we used ANOVAs to compare mean BSI scores
of ILLSIBS and WELLSIBS. We also examined the proportions of each group having
subscale scores above the clinical cut-off (T score 
63). To test the
second hypothesis, three-way MANOVA was conducted with the five BSI scores
entered simultaneously as the dependent variables and sibling illness status,
birth order, and gender entered as independent factors. We were particularly
interested in determining whether there was a significant illness status
x birth order interaction effect in this analysis. As noted, we expected
a combined effect of these two variables such that older ILLSIBS would have
significantly higher scores than other groups. Sibling gender had no
hypothesized main or interaction effect but was included in the MANOVA as an
additional control variable. All data were analyzed using SPSS/PC+, Version
5.0 (Norusis, 1992).
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Results |
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ILLSIBS had comparatively higher mean BSI scores than WELLSIBS across the scales (Table I). Differences in means were statistically significant for the GSI, F(1, 66) = 5.0, p <.05, and for two of the four subscales: anxiety, F(1, 66) = 4.8, p <.05, and interpersonal sensitivity, F(1, 66) = 4.6, p <.05. Differences in the proportions of ILLSIBS and WELLSIBS above the clinical cut-off were significant only for interpersonal sensitivity (24% vs. 6%;
2(1) = 4.22, p <.05).
Differences between ILLSIBS and WELLSIBS did not reach significance at 
=.05 for anxiety (21% vs. 9%), depression (24% vs. 9%), hostility (29% vs.
21%), or GSI (27% vs. 9%).
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Three-way MANOVA confirmed the main effects of sibling illness status on mean BSI scores. As expected, there were no simple main effects for either sibling gender or birth order in this analysis. We also failed to detect either the significant illness status x birth order interaction we had hypothesized or any other two-way interaction among these variables. However, the analysis revealed significant three-way interactions indicating a combined effect of illness status, birth order, and sibling gender for three BSI scores: anxiety, F(1, 60) = 4.0, p <.05; hostility, F(1, 60) = 7.0, p <.05; and GSI, F(1, 60) = 4.3, p <.05.
As the mean scores in Table II show, younger sisters followed the pattern reported above, in which ILLSIBS generally had higher symptom levels than WELLSIBS, although the difference between the groups reached statistical significance only for the GSI score; F(1, 30) = 4.3; p <.05. Among older sisters, however, differences between the groups diverged according to the gender of the index sibling. That is, differences between WELLSIBS and ILLSIBS who were older sisters of males were significant for four of the five scales we examined: anxiety, F(1, 14) = 4.8, p <.05; hostility, F(1, 14) = 9.7, p <.01; interpersonal sensitivity, F(1, 14) = 6.5, p <.05; and GSI, F(1, 14) = 8.9, p <.01. In contrast, WELLSIBS and ILLSIBS who were older sisters of females did not differ significantly on any subscale.
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Discussion |
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The first hypothesis, that healthy adolescent sisters of 13- to 19-year-old males and females with chronic conditions would have more symptoms of psychological distress than sisters of demographically similar adolescents without chronic conditions, generally was confirmed. Although differences between the groups were significant only for overall symptom severity, anxiety, and interpersonal sensitivity, the nonsignificant differences for depression and hostility scores were directionally consistent with our stated hypothesis. Moreover, the effect sizes ascertained were about.40-.50, which suggests that there may be moderate differences between the groups; differences this size would be significant at
=.05 and power =.80 if
we doubled the sample size (Cohen,
1977). More sisters of siblings with conditions had scores above
the clinical cut-offs, but these comparisons failed to achieve statistical
significance because of the small sample size. Still, 21% to 24% of the
ILLSIBS had scores suggesting a likely positive diagnosis (i.e., T scores
63) for anxiety, depression, and interpersonal sensitivity compared with 9% or
less of WELLSIBS on the same subscales. The second hypothesis, which suggested that an interaction between illness status and birth order would result in higher symptom scores among older sisters of adolescents with chronic conditions compared with all other groups, was not supported. Instead, there was an interesting three-way interaction of sibling illness status, birth order, and gender relating to anxiety, hostility, and overall symptom levels in this sample. An identical but nonsignificant pattern emerged for the depression and interpersonal sensitivity subscales. Thus, in contrast to our stated expectations, sibling gender was an important moderating factor, and older sisters of females with chronic conditions appeared to be comparatively less vulnerable to some types of psychopathology than other sisters of adolescents with conditions.
The potential risk factors and causal processes that influence distress may
operate differently depending on sibling birth order, gender, or their
combination. For example, traditional family roles and relationships might
lead one to expect more household responsibilities and restrictions on
personal activities among older sisters. This is particularly true for
socioeconomically disadvantaged families, who may be highly stressed even in
the absence of chronic illness. Indeed, the high scores demonstrated by older
sisters of girls without chronic conditions may relate to negative
feelings about such role-related expectations. However, older sisters of girls
with conditions may see their caretaking obligations as expected and
appropriate; thus, their symptom levels are not further elevated. Yet, when
the younger sibling is a brother, his healthy older sister exhibits more
symptoms when he has a condition, suggesting that any potential effects of
caretaking roles and expectations on psychological functioning are also
influenced by the younger sibling's gender. In younger siblings, tension and
confusion resulting from "role cross-over" may lead to
psychological difficulties (Lobato et al.,
1988). That is, younger siblings often assume more dominant roles
in interactions and take on increased caretaking responsibilities when the
older sibling has a health condition, which reflects an important shift from
normative patterns of sibling relationships
(Stoneman & Brody, 1993).
Younger siblings also may experience difficulties because children born after
the affected sibling get less attention from parents
(Howe, 1993).
Thus, differences in role strain related to perceived or actual caregiving
burdens that vary by gender and birth order could help explain our results.
This also may aid our understanding of why the literature on sibling
psychological adjustment has been so inconsistent, as most previous studies
have not segmented their samples this way. However, many additional
characteristics and processes shape typical sibling relationships, and many
other personal or family factors can promote healthy adaptation or place an
adolescent at risk when a sibling has a chronic disease or disability
(Lobato et al., 1988). For
example, birth order differences in psychological functioning might also be
reflecting developmental differences in the coping resources available to
adolescents. We also did not evaluate the mediating or moderating effects of
other previous or current life stresses, although we do know that the groups
did not differ in reported stressful life events (data available on request).
Unfortunately, the small sample size constrained our ability to find
significant differences and also made it difficult to incorporate additional
variables in the analyses.
Moreover, our participants came from a disadvantaged urban community and from minority ethnic groups. We do not know how such socioeconomic or cultural factors influence the roles that siblings assume in their families, their expectations about these roles, or their emotional reactions to them. We also included siblings of adolescents with different types of conditions, but were unable to examine the influences, if any, of individual diagnostic categories or general illness factors such as course, onset, or functional impairment. Participants also were not asked if they agreed with the health status data provided by their brothers and sisters, and it is possible that some of them did not judge their siblings to have conditions. Finally, all of our participants were female. Clearly, research with larger, more diverse samples in studies that include family constellation and illness variables in addition to other personal, cultural, and environmental characteristics would help in establishing the generalizability of our findings and in identifying factors that account for sibling differences.
In summary, our findings support the contention that despite an increased
risk, adverse effects on adolescents' psychological functioning are not
inevitable given the presence of a sibling with a chronic health condition
(Thompson & Gustafson,
1996; Williams,
1997). The specific elevations we detected suggest that distress
is more likely to be manifested as feelings of tension, depressed affect, and
self-doubt during interpersonal interactions, than as angry thoughts or
actions. This is consistent with the literature and may be related in part to
increased social isolation, but only further research will determine more
specifically both when and how adjustment may be affected in this manner.
Despite its limitations, our study adds further support to previous research,
which also found that birth order and gender may raise or lower risks
(Howe, 1993;
Williams, 1997). Thus, these
factors and this study's methodology should be considered by researchers and
by clinicians in evaluating the likelihood of psychological distress and in
planning potential mental health interventions for healthy adolescents whose
siblings have chronic conditions.
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Acknowledgments |
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Portions of this work were based on M. J. Frohlinger-Graham's doctoral dissertation, submitted to the Ferkauf Graduate School of Psychology, Yeshiva University, Department of Health Psychology, Bronx, New York, January 1996. A previous version of this article was presented at the 14th Annual Meeting of the Society for Developmental and Behavioral Pediatrics, San Francisco, California, September 30, 1996.
Received September 24, 1998; revision received January 13, 1999; accepted April 15, 1999
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