Behavioral health challenges continue to be a pervasive issue that impacts children and their families. According to the 2022-2023 National Survey of Children’s Health, over 25% of children aged 3-17 were reported to have mental, emotional, developmental or behavioral problems. Commonly diagnosed conditions in children include Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Autism Spectrum Disorder (ASD). Other internalizing conditions, including anxiety and depression, can also be present in addition to behavioral disorders. These disorders are often characterized by significant challenges that impact individuals and families.
Siblings of individuals with disabilities may be at increased risk for poorer adjustment compared to their peers. For example, siblings of children diagnosed with ADHD tend to have an increased number of mental health challenges compared to typically developing peers who have typically developing siblings (Orm & Fjermestad, 2021). Children with siblings diagnosed with ASD have also been shown to have poorer adjustment outcomes compared to children with typically developing siblings (Meyer, Ingersoll, & Hambrick, 2011). Although there are studies that document negative outcomes, there is research to suggest that there are positive impacts on siblings and sibling relationships when one individual has been diagnosed with a behavioral health condition, especially when there is social support in place (Ferraioli & Harris, 2009; Shivers et al., 2019). Several factors may contribute to future outcomes for these siblings, including the severity of symptoms related to the disorder, sibling coping strategies, amount of social support the individuals and family receives, parental mental health, and level of family communication (Kirchhofer et al., 2022). Fortunately, there are support strategies and interventions to positively impact siblings and their adjustment.
Skills to Bolster
For siblings, increasing skills is critical in supporting their own emotional and behavioral adjustment. Skills to promote independence and involvement within the family can be beneficial; however, it is important to not overwhelm siblings with responsibilities and give them tasks that could put them in a parental role. Capitalizing on a sibling’s strengths and interests can be a great way to acknowledge their contributions and unique attributes while also allowing them to feel more involved in family activities. Providing siblings with opportunities to feel a sense of control in their every day lives may be of benefit, particularly when situations arise during which they may have limited control. An example of this could include giving choices and soliciting their input whenever possible throughout the day.
Siblings may also benefit from developing certain social-emotional (SEL) skills to increase their ability to cope with difficulties that may arise. Specific SEL skills that can be fostered include teaching how to ask for help and support when needed and learning to express their emotions in helpful ways. This can be done through individual counseling or support groups for siblings of individuals with disabilities. Caregivers can also facilitate opportunities for open communication so that siblings can ask questions and express their feelings. Additionally, siblings may benefit from the development of their own action plan for when behaviors escalate in the home. If there are aggressive or challenging behaviors, it would be wise to provide siblings with a plan for how to respond and remove themselves from the situation for safety.
Psychoeducation and Sharing Information
The unpredictability of the family situation and environment, with associated factors such as a sense of control and access to information, has also been found to affect sibling risk (Incledon et al., 2015). Younger children may interpret a sibling’s challenging externalizing behavior as “not liking me” or their sibling being upset with them, further negatively impacting their relationship or creating stress for the unaffected child. For these reasons, it is increasingly necessary not only for parents but also for siblings of individuals with behavioral challenges to receive psychoeducation and information about diagnoses, outcomes, and necessary support. Providing accurate and developmentally appropriate information about their sibling’s diagnosis can help them better understand the behavior and needs. The information that is provided promotes continued transparency and communication about potential changes to the home environment and the needs and requirements of family members, including the siblings themselves.
Due to the potential of significantly different needs and strengths between siblings, there may be situations during which consequences, activities, parental attention, or support may be unevenly provided in these situations. Providing explanation or insight into the sibling, discussing these situations in advance, and outlining contingencies is key in order to promote understanding and acceptance of unavoidable differences which may exist. Understanding and acceptance through discussion can potentially stave off feelings of resentment, anger, and isolation, which may occur as a result of the focus being shifted to a higher needs child. Other potential effects of sharing this information may include empowerment stemming from the knowledge of what is needed to support their sibling and what potential role they can play.
Providing Dedicated Time and Attention
As a result of the increased needs of the individual who presents with challenging behavior, the parent may be less available to the sibling. Considering this, there is an increased need to provide consistent times of dedicated attention and engagement between the parent and that individual. These times can be scheduled or spontaneous; however, it may benefit both the higher needs sibling and the lower needs sibling to have these times scheduled. A predetermined dedicated time adds to the predictability and consistency of the family schedule and expectations. This also ensures that those times are less likely to be missed or moved due to a schedule that may already be filled with therapies and appointments.
Prioritizing the Care of the Caregiver
A parent or guardian who is experiencing significant levels of depressive symptoms, potentially as a result of caring for an individual with severe and persistent behavioral challenges, may be less effective in balancing the demands of multiple individuals with different developmental needs and may be less adept at providing both necessary emotional support and effective discipline. Further emphasizing the need for self-care, research suggests that a depressed caregiver may model less adaptive coping styles that are then adopted by their typically developing children (Meyer, Ingersoll, & Hambrick, 2011). Caregiver support can range from individual or family-based mental health services, respite care, or dedicated time engaged in various self-care tasks. Ensuring that caregiver needs are met calls for specific and dedicated services, time, or activities which provide rest, validation, or other types of support.
Connecting with Resources and Next Steps
Ongoing monitoring, assessing level of understanding, and continued connection with resources as the sibling moves through the lifespan is essential. Reassurances with regard to support that they may need or what is being provided to their sibling may be accomplished by multiple methods, including individual or family-based therapies or support sessions. When considering individual needs, research has suggested that beginning with treatments or support groups that include the entire family may be more effective for these siblings than individual treatments that do not address the characteristics and needs of the entire family (Meyer, Ingersoll, & Hambrick, 2011).
Many statewide or diagnosis-based organizations offer resources and support group opportunities for siblings to engage with community members who may help further their understanding, develop coping skills, and practice interaction strategies. To continue enhancing rapport and connections between siblings, many community agencies and organizations create opportunities for engagement surrounding mutual interests, host activities or events that allow for the sibling bond to be strengthened, and reinforce positive interactions.
In addition to strengthening bonds within the family network, siblings may require careful monitoring of their status or involvement in a social support network. Lower levels of social support are associated with more negative psychosocial adjustment among siblings of children with neurodevelopmental disorders (Kirchhofer et al., 2022). To further exemplify what is required, Cobb (1976) indicated that feeling loved, valued, and belonging to a group of some kind were among the key features of individuals who felt well supported by their social network.
While it may be more evident that an individual displaying challenging behavior requires intensive support, their sibling may be overlooked in terms of immediate needs or underlying concerns. The functioning of one family member often has collateral effects on the dynamics of the household as a whole. From schedule alteration and the need for additional therapeutic support to periods of turmoil, conflict, and distress, the ripple effects from maintaining the needs of one sibling will inherently impact the other. From childhood to adulthood, the needs of an individual impacted by a higher needs sibling will vary and potentially require different levels of support and education. Community, social support, and therapeutic involvement encompass valuable resources for families and siblings of those who may display challenges with regard to externalizing and internalizing behavior.
Bianca Coleman, PhD, NCSP, BCBA-D, LBA, is a Licensed Psychologist and Behavior Analyst, and Jeniffer Cruz, PhD, NCSP, is a Licensed Psychologist at Behavior Therapy Associates. To learn more, please visit behaviortherapyassociates.com, or call (732)-873-1212. Email inquiries can be sent to jcruz@behaviortherapyassociates.com or bcoleman@behaviortherapyassociates.com.
References
Child and Adolescent Health Measurement Initiative. (2023). 2022-2023 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health. Supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved [March 9, 2025], from [https://www.childhealthdata.org].
Ferraioli, S.J. & Harris, S.L., (2009) The Impact of Autism on Siblings, Social Work in Mental Health, 8:1, 41-53, DOI: 10.1080/15332980902932409.
Iannuzzi, D., Fell, L., Luberto, C. et al. Challenges and Growth: Lived Experience of Adolescents and Young Adults (AYA) with a Sibling with ASD. J Autism Dev Disord 52, 2430–2437 (2022). https://doi.org/10.1007/s10803-021-05135-0.
Incledon E, Williams L, Hazell T, Heard TR, Flowers A, Hiscock H. A review of factors associated with mental health in siblings of children with chronic illness. Journal of Child Health Care. 2013;19(2):182-194. doi:10.1177/1367493513503584.
Kirchhofer, S. M., Orm, S., Haukeland, Y. B., Fredriksen, T., Wakefield, C. E., & Fjermestad, K. W. (2022). A systematic review of social support for siblings of children with neurodevelopmental disorders. Research in developmental disabilities, 126, 104234. https://doi.org/10.1016/j.ridd.2022.104234.
Meyer, K., Ingersoll, B., & Hambrick, D. (2011). Factors influencing adjustment in siblings of children with autism spectrum disorders. Research in Autism Spectrum Disorders, 5(4), 1413–1420. https://doi.org/10.1016/2fj.rasd.2011.01.027.
Orm, S., & Fjermestad, K. (2021). A scoping review of psychosocial adjustment in siblings of children with attention-deficit/hyperactivity disorder. Advances in Neurodevelopmental Disorders, 5(4), 381–395. https://doi.org/10.1007/s41252-021-00222-w.
Shivers, C. M. (2019). Empathy and perceptions of their brother or sister among adolescent siblings of individuals with and without autism spectrum disorder. Research in Developmental Disabilities, 92, 103451. https://doi.org/10.1016/j.ridd.2019.103451.
