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A Group Intervention forSiblings of Pediatric CancerPatientsMaru Barrera PhD a a , Joanna Y. Y. Chung PhD b &Carly F. Fleming MEd ca Department of Psychology and Hematology/Oncology Program , Hospital for Sick Children ,555 University Avenue, Toronto, Ontario, M5G 1X8,Canadab Department of Psychology , British Columbia'sChildren's Hospital , Vancouver, British Columbiac Hematology/Oncology Program , The Hospital forSick Children , TorontoPublished online: 25 Sep 2008.

To cite this article: Maru Barrera PhD , Joanna Y. Y. Chung PhD & Carly F. FlemingMEd (2005) A Group Intervention for Siblings of Pediatric Cancer Patients, Journal ofPsychosocial Oncology, 22:2, 21-39, DOI: 10.1300/J077v22n02_02

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A Group Intervention for Siblingsof Pediatric Cancer Patients

Maru Barrera, PhDJoanna Y. Y. Chung, PhD

Carly F. Fleming, MEd

ABSTRACT. A group intervention to reduce emotional and behavioralproblems in siblings of children with cancer was evaluated. Forty-sevensiblings aged 6 to 14 years participated in seven groups, with 4 to 9 sib-lings in each group. Groups consisted of eight weekly two-hour sessionsguided by a manual. Four assessments were conducted: two before theintervention and two after the intervention. Children completed self-re-port measures of anxiety, depression, and behavior; parents reported onsiblings anxiety and behavior. After the intervention, siblings reported

Dr. Barrera is a Registered Psychologist and an Associate Scientist, Department ofPsychology and Hematology/Oncology Program, The Hospital for Sick Children, 555University Avenue, Toronto, Ontario M5G 1X8, Canada (E-mail: maru.barrera@sickkids.ca). Dr. Chung is a Registered Psychologist, Department of Psychology, Brit-ish Columbias Childrens Hospital, Vancouver, British Columbia. Ms. Fleming isProgram Coordinator, Hematology/Oncology Program, The Hospital for Sick Chil-dren, Toronto.

The authors wish to express their gratitude to the following: the families and chil-dren who participated in the Siblings Coping Together (SCT) program; Drs. NormaDAgostino, Karen Sumbler, Alisa Kenny, Brian Feldman, and Sunita Vohra for theircomments on an early version of the manuscript; Dr. Mohamed Abdolell for his statis-tical advice; and Dr. Charmaine Miranda, Joanne Bonanno, and Danielle Kuczynskifor their assistance in running SCT groups.

The authors also wish to thank Families of Children with Cancer for funding part ofthe project and the National Cancer Institute of Canada and Candlelighters Canada forsupporting Dr. Chungs studentship.

Journal of Psychosocial Oncology, Vol. 22(2) 2004http://www.haworthpress.com/web/JPO

2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J077v22n02_02 21

Please note that this electronic prepublication galley may contain typographical errors and may be missingartwork, such as charts, photographs, etc. Pagination in this version will differ from the published version.

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significantly reduced symptoms of anxiety and depression, and parentsreported significant reductions in siblings anxiety and behavior prob-lems. An interaction between intervention, age, and gender indicatedthat adolescent girls had more depressive symptoms than adolescentboys did before the intervention and younger girls did after the interven-tion. The findings suggest that group intervention benefits siblings ofchildren with cancer, with age and gender influencing this effect. [Arti-cle copies available for a fee from The Haworth Document Delivery Service:1-800-HAWORTH. E-mail address: Website: 2004 by The Haworth Press, Inc. All rightsreserved.]

KEYWORDS. Siblings, pediatric cancer, group intervention, psycho-logical functioning

Families of children with cancer must adjust to the implications of thediagnosis and the challenges presented by medical treatment. Changes indaily life after a diagnosis of pediatric cancer may result in chronic dis-tress for family members, including siblings, whose well-being is oftenoverlooked. This study focuses on a group intervention program de-signed to prevent or reduce psychological difficulties in siblings of chil-dren with cancer.

REVIEW OF THE LITERATURE

Psychological Adjustment of SiblingsThe diagnosis and treatment of pediatric cancer have been associated

with behavior problems, such as sleeping problems and acting out, andincreased maturation in healthy siblings (Barbarin et al., 1995; Chesler,Allswede, & Barbarin, 1992; Havermans & Eiser, 1994; Heffernan &Zanelli, 1997; Murray, 1999; Sloper & While, 1996). In a large collabo-rative study, Sahler et al. (1994) estimated that 63% of siblings of chil-dren with cancer experience some psychological adjustment difficultiesat any one point after the diagnosis. The impact of pediatric cancer onhealthy siblings is likely to depend on their developmental level (Murray,2000). However, previous studies have been inconclusive regarding ageand gender differences. Siblings aged 6 to 12 years have been reported

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to exhibit more maladaptive levels of anxiety and depression and morebehavior problems than the ill children (Spinetta et al., 1999) or oldersiblings do (Sahler et al., 1994; Sargent et al., 1995). Siblings over 11years of age may be less involved with the family and have more com-plaints about family life than do younger siblings (Madan-Swain et al.,1993). On the other hand, among firstborn or other siblings older thanthe patient, parents have also reported increased maturity, supportive-ness, and independence (Barbarin et al., 1995).

In the general population and among the offspring of parents whohave cancer, adolescent girls have a propensity for expressing moresymptoms of depression than younger girls or boys do (Chubb, Fertman, &Ross, 1997; Compas et al., 1996; Fleming & Offord, 1990). Clearly,there is a need for further investigation of age and gender differences insiblings psychological adjustment to the cancer experience in generaland in the context of intervention specifically.

Psychological Interventions for SiblingsTo our knowledge, the only published psychological interventions

for siblings of children with cancer have been in a group format (Ad-ams-Greenly et al., 1986; Barrera et al., 2002; Bedway & Hartkopf-Smith, 1996; Chung, 1999; Dolgin et al., 1997; Heiney et al., 1990;Houtzager, Grootenhuis, & Last, 2001; Sahler & Carpenter, 1989).These group interventions have varied in form from a one-day program(Bedway & Hartkopf-Smith, 1996) to a longer-term summer program(e.g., Sahler & Carpenter, 1989). Formal evaluation of these programshas been limited.

Quantitative methodology using pre- and postevaluation has beenused in some studies. Five-week, six-week, and eight-week groupinterventions (Houtzager, Grootenhuis, & Last, 2001; Dolgin et al., 1997;Barrera et al., 2002, respectively) suggested improvements in siblingsmoods, interpersonal relations, and reduction of self-reported symptomsof anxiety. In Dolgin et al.s study (1997), data were reported from aone-time implementation of the group program, and no efforts were madeto control for factors that may have confounded the effects of theintervention. In Barrera et al.s study (2002), siblings self-reports sug-gested reduced symptoms of anxiety and depression after the group interven-tion, but the sample was too small to generalize these findings. Neither studycontrolled for the reliability of the pre and post comparisons.

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THE SIBLINGS COPING TOGETHER PROGRAM

The conceptual model adapted for the Siblings Coping Together(SCT) intervention program discussed in this article has been describedin detail elsewhere (see Barrera et al., 2002; Chung et al., 1999). Briefly,we used cognitive behavior theory (e.g., Kendall, 2000) to conceptual-ize the behavioral difficulties encountered by siblings of children withcancer and to develop a group intervention to address them. Siblingsmay develop behavioral or emotional difficulties as a response to theincreased time parents spend with the ill child (during hospitalizationsand outpatient clinic visits). Siblings also may develop distorted cogni-tions regarding their status in the family and may experience feelings ofabandonment from or of being less valued by their parents than the illchild is, resentment toward the ill child, and guilt for being healthy. TheSCT group program was designed to address siblings behavioral andemotional difficulties as well as their distorted views (cognitions) re-lated to their experience of pediatric cancer.

The purpose of the present study was twofold: to evaluate the effectsof the SCT program on siblings symptoms of anxiety, depression, andproblem behavior and to examine the role of age and gender in siblingspsychological adjustment to pediatric cancer within the context ofgroup intervention. On the basis of previous empirical research, we hy-pothesized that (1) compared to baseline assessments, there would be areduction in siblings symptoms of anxiety and depression and behaviorproblems after the intervention and (2) adolescent girls would manifestmore depressive symptoms than adolescent boys and younger childrenof either gender would at both baseline and postintervention assess-ments.

METHOD

Participants

Between January 1998 and May 2001, 42 siblings (17 boys and 25girls) of children being treated for cancer in a large pediatric center par-ticipated in seven consecutive SCT intervention groups. The siblingsranged in age from 6 to 14 years (M = 9.93 years, SD = 2.38 years). Eachgroup consisted of 4 to 9 children of similar developmental age and ap-proximately equal numbers of boys and girls to ensure group cohesionand to plan developmentally appropriate activities for each session. The

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criteria for inclusion were (1) having a brother or sister with cancer (onor off treatment), (2) being identified by parents as having behavioral oremotional difficulties (e.g., irritability, acting out, changes in mood)since the ill child began treatment, and (3) residing within 100 kilome-ters of the hospital. Siblings who had a developmental or neurologicaldisorder that impeded their ability to understand and to communicateverbally in a group or whose ill brother or sister died before the programbegan were excluded.

Thirty-five of the 42 siblings (83%) came from Caucasian families; 2of the remaining siblings were Asian-Canadian, 1 was Afro-Canadian,and 2 were categorized as mixed Native Canadian. Most of the siblingscame from families with middle-class socioeconomic backgrounds(Hollingshead, 1975): Level I (9), Level II (11), Level III (10), Level IV(6), and level unknown (6). All but 3 siblings came from a two-parentfamily. The majority of siblings (26) were older than the ill child, and 36of the ill children were on active treatment. The majority of patients (22)had been diagnosed with leukemia; the remaining diagnoses were sar-coma (6), brain tumor (5), lymphoma (4), neuroblastoma (2), Wilmstumor (2), and Other (1).Design and Procedure

The study was approved by the Institutional Ethics Review Board.Although a randomized controlled trial is considered to be the gold stan-dard for assessing the efficacy of medical and psychological interven-tions (Chambless & Hollon, 1998), such a study design is not alwaysfeasible or optimal (Kazak et al., 1994). This is especially true when thefocus of the research involves a population, such as siblings of childrenwith cancer whose families are overburdened with the care of the illchild and care of the healthy siblings is often delegated to friends andrelatives (Barrera et al., 2002; Spinetta et al., 1999). Thus, we used thetime-series design for the study. The design included two baseline as-sessments (Pre 1 and Pre 2) to control for a major threat to validity, thepassage of time (Campbell & Stanley, 1972); eight group interventionsessions; and two postintervention assessments, one immediately afterthe last intervention session (Post 1) and a follow-up assessment 6 to 12months later (Post 2). The two postintervention assessments tested theconsistency of the intervention effect. The six-month range of the Post 2assessment period was the result of the varying availability of partici-pants for completion of the instruments.

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Siblings were referred either by staff in the hematology/oncologyprogram after a parent expressed concerns about the siblings mood orbehavior or by a parent who contacted the program coordinator afterreading about the SCT group program (a newsletter or flyers for parentswere posted in the treatment unit). One parent of each potential partici-pant was interviewed by telephone to screen for inclusion criteria and toobtain demographic information. Siblings also were interviewed byphone, after parents provided verbal consent, to screen for their commu-nication skills and willingness to participate.

During the initial assessment, siblings and parents read or were read(if under Grade 3 reading level in the case of siblings) the consent orassent forms and completed the assessment. The same parent wasasked to complete the parent forms at each assessment. Seven siblingscompleted the Pre 1 assessment and 42 siblings (including the initial7) completed the Pre 2 assessment. The difference in the response ratebetween the two assessments speaks to the greatest challenge in con-ducting clinical research with this population. First, we needed to en-sure that the siblings had two preintervention assessments eight weeksapart. Given the demands of caring for the ill child, many parentsfound it difficult to come to the centre eight weeks before the sched-uled start of the group. Second, we needed enough siblings to run agroup and to schedule a starting date. Unfortunately, some siblingswere referred too close to the groups starting date, preventing us fromobtaining a Pre 1 assessment. The Pre 1 and Pre 2 groups of siblingswere compared with respect to the ill childs age, gender, socioeco-nomic, and disease characteristics (on or off treatment) using either at-test or chi-square analysis. The groups did not differ significantly ondemographic or disease characteristics.

Forty siblings completed the Post 1 assessment, but only 14 com-pleted the Post 2 assessment despite our efforts to encourage families todo so. The siblings who did and those who did not complete the Post 2assessment did not differ significantly in gender and age; however, theydid differ significantly with respect to socioeconomic status (2 = 9.0, p