Few studies have examined the risks, resources, and adaptation of siblings of children with SED and their caregivers; however, existing research (Aguilar et al. 2001
; Kilmer et al. 2008
) has underscored the degree to which they, and the family system, may be impacted by the challenges experienced by the youth with diagnoses. Indeed, these siblings are believed to be at-risk not only because they are exposed to many of the same adversities as the identified child who is receiving services, but because they also have a brother or sister with SED and are influenced by that child’s impact on the family (e.g., such as contributing to decreased parental attention or increased family strain and distress) (Huang et al. 2005
; Kilmer et al. 2008
). Reinforcing that belief, many of their parents report a need for supports and/or mental health services for the siblings (and themselves). Nevertheless, with so much attention focused on the identified child, these other children may “slip through the cracks” of the system. Consistent with that notion, although significant research has focused on SOCs and the functioning of system-identified youth (see Holden and Brannan 2002
), their siblings and other family members have received scant attention in the literature as well as actual practice.
In the first systematic examination of siblings in the context of SOCs, Kilmer et al. (2008)
assessed siblings in the context of two SOC sites in North Carolina and found that they (a) had been exposed to extremely high levels of adversity and (b) evidenced substantial variability in behavioral and emotional strengths and social-emotional adjustment. Although many siblings exhibited significant strengths and positive adjustment, a substantial proportion displayed levels of competencies or problem behaviors suggestive of having an emotional or behavioral disorder. In fact, although the siblings as a group evidenced more positive scores on multiple indicators of strengths, resources, and adjustment than their system-identified brothers or sisters, a meaningful proportion of the siblings exhibited higher levels of maladjustment/problem behaviors (and fewer competencies) than many targets. More fine-grained analyses revealed that, even within families, a significant minority of siblings received scores equal to or worse than their own target brothers and sisters on the study’s key adjustment measures. As Kilmer and colleagues concluded, “While this pattern may be partly attributable to the benefits of treatments received by target SOC children, it reinforces the critical importance of adopting a plan for services that seeks to meet the needs of the entire
family, including the siblings” (p. 7).
A just-completed study by the present authors sought to replicate and extend the work of Kilmer et al. (2008)
, using parent and teacher-completed indicators of adjustment and in-depth caregiver measures capturing developmental history, qualities of the family and caregiving environment, caregiver resources, and a range of other contextual variables. In this new study, families had at least one child with SED and at least one 5- to 10-year-old sibling who did not have a history of receiving mental health services. The discussion here will focus on the stress exposure, strain, and adjustment of the siblings and their caregivers in this more geographically and socioeconomically diverse sample than that described by Kilmer et al. (2008)
Using a multidimensional Life Events Checklist (Kilmer et al. 1998
), including several major, chronic stressors, caregivers indicated that siblings experienced an average of 9.65 stressors (SD
= 5.69). Given that several studies of risk and resilience (e.g., Cowen et al. 1992
; Wyman et al. 1999
) have used exposure to ≥ 4 stressors on this same measure as a criterion for “highly stressed”, this finding indicates high stress exposure and underscores the level of risk experienced by the youngsters within participating families. Of the measure’s five factors, the factor with the most items, Family Turmoil
, also captured the most endorsed items (M
= 4.79, SD
= 2.65), followed by Poverty
= 1.37, SD
= 1.42), Family Illness/Injury
= 1.30, SD
= 1.27), Unsafe/Violent Neighborhood
= .85, SD
= 1.10), and Family Separation/Social Services
= .57, SD
= .86). Several specific stressors were experienced by at least half of the siblings: family members have serious arguments (72%); child upset by family arguments (72%); serious emotional problems in family (63%); family member away from home a lot (58%); and our family had serious financial problems (52%).
These findings are consistent with what caregivers have reported in the longitudinal national evaluation of SOC. While that effort assesses a smaller number of specific risks, results have consistently indicated that youth and families enrolled in SOCs are exposed to substantial adversity. For example, in a sample of 1,238 families participating in SOC initiatives across 28 sites, 71.0% of youth had a biological parent with major depression; 63.0% had a biological family member with a drug or alcohol problem; 48.3% had been exposed to domestic violence; 36.8% had lived with someone who had been convicted of a crime; 23.2% had been physically abused; and 15.5% had been sexually abused (US Department of Health and Human Services 2008
). Notably, many of these stressful life events and circumstances reflect adversities that affect the entire family system and its members, not just the system-identified child.
In the new sibling study, direct comparisons between siblings and “target” children with SED demonstrate that, as a group, siblings evidence more strengths and resources, less symptomatology, and, overall, more positive adjustment than their brothers and sisters who have already been identified as having SED. These substantial group differences in adjustment are not unexpected; however, they do not capture fully the proportion of siblings exhibiting difficulties. Consistent with the findings reported by Kilmer et al. (2008)
, there is considerable variability in sibling adjustment, with some seemingly doing quite well, and a substantial percentage of siblings evidencing difficulties similar to those experienced by children identified with SED and receiving services. For example, on the Behavioral and Emotional Rating Scale (BERS-2; Epstein 2004
), which yields Strength Quotients and standardized subscale scores that can be classified into one of seven levels (ranging from very poor to very superior), 40.4% of siblings had Strength Quotients indicating above average to very superior levels of personal strengths and very low probabilities of having an emotional or behavioral disorder, and 27.2% had Strength Quotients in below average to poor categories, reflecting borderline or lower personal strength levels and high probabilities of having an emotional or behavioral disorder (Epstein 2004
). In the normative sample, roughly 23% obtained scores in each of these ranges (Epstein 2004
); this is notable because these siblings had been judged to not meet criteria for SED nor require mental health services, yet they evidenced similar probabilities of disorder to a diverse sample of youngsters, including some with diagnoses. Using Conners’ Parent Rating Scales-Revised (CPRS-R: short version) norms, a notable percentage of siblings evidenced difficulties – i.e., roughly 19% of siblings’ Oppositional scores fell in the Moderately to Markedly Atypical range, indicating significant problems (Conners 2001
), and 16% of siblings’ ADHD Index scores fell in that range, compared to only 5% (or less) for the normative sample on these scales. These findings, from validated, norm-based measures, reinforce the importance of attending to the needs of siblings. Not surprisingly, in light of the diverse presentations in the sibling sample, caregivers endorsed a range of needs for these siblings, reporting a need for school-based services for the siblings (e.g., counseling/therapy, speech/ language therapy, tutoring and remedial reading work, special education services) as well as services outside of school (e.g., counseling/therapy, psychotropic medication).
Caregivers also report noteworthy levels of strain, challenge, and difficulty. As one case in point, on the Brief Symptom Inventory (BSI-18), 22% had BSI-Depression scores and 32.4% had BSI-General Severity Index scores above clinical cutoffs (Derogatis 2001
). They also reported multiple service needs for themselves (e.g., counseling/ therapy, respite care, drug/alcohol counseling, parenting education and skills training) or their family (e.g., family therapy).
Thus, while limited research has focused on these siblings, on the basis of existing data, a notable proportion of siblings and caregivers of youth with SED appear to have significant mental health needs. Even more significantly, many of these siblings are not receiving needed mental health services or supports. Although many do not currently display diagnosable adjustment problems, the adversity experienced by these siblings and their families warrants discussion. Although children vary in their responses to adversity, exposure to multiple, chronic stressors can increase substantially the probability of maladjustment (Luthar and Cicchetti 2000
). Nevertheless, many of the stressors experienced (e.g., poverty, neighborhood violence, parental unemployment) by these children and families are not traditionally addressed by “mental health” service systems, despite findings that addressing such factors as parental employment and family poverty can have a significant impact on the functioning of children with mental health problems (see, e.g., Costello et al. 2003
Moreover, the recognizable levels of difficulty experienced by meaningful percentages of the children and caregivers imply that the system at-large should be attentive to their needs and potential vulnerability. The levels of self-reported maternal distress and depressive symptomatology bear particular mention, given that a substantial evidence base documents the risk of maternal depression and/or other internalizing concerns on child adaptation and functioning (e.g., Goodman and Gotlib 1999
; Rishel et al. 2006
), and research suggests that, as caregivers struggle with their own symptoms, they have difficulty meeting the challenges of caring for a child with significant mental health challenges (e.g., Swartz et al. 2008
). In light of findings that improved maternal functioning may relate to improved child functioning (e.g., Swartz et al. 2008
) and, more specifically, that reductions in maternal depression mediated improvements in children’s externalizing and internalizing behavior (after accounting for the potential role of positive parenting; Shaw et al. 2009
), planning teams would do well to assess and address maternal strain and mental health concerns.
While many of those with diagnosable disorder(s) can receive help through existing funding streams if they have adequate health insurance, it is clear that many family members of children with SED are likely to experience very high levels of stress and could benefit from preventive and/or supportive services focusing on the entire family. As the research examining siblings demonstrates, many youth who do not meet standards for SED may very well require services and supports, and proactive, early intervention could reduce the likelihood that those at risk subsequently require more extensive and expensive assistance (see Farmer and Farmer 2001