Background:  Siblings of children with serious illness often experience psychosocial distress during and after their sibling’s illness (1).  Their psychosocial wellbeing may not receive adequate focus due to their sibling’s illness.  This Fast Fact will discuss sibling emotions and identify effective ways clinicians can support them. See Fast Facts #47 & 138 for information about the developmental stages for how children conceptualize death and illness. 

Common feelings of siblings:  Siblings of children with serious illness often process feelings distinctly from parents or grandparents (1). They are at a different developmental stage and require parental attention. Children may read the body language of others and may question if they are having “normal” reactions. They are often keenly aware of the care needed by the sibling and may feel overlooked by their family or excluded from their ill sibling’s life, especially if they are not included in the discussions about the illness (2). Empowering siblings to feel informed and to participate in major health decisions may help them feel assured of their importance in the family. Clinicians should be aware of developmentally appropriate explanations and interventions to help comprehension (see Fast Facts#47 and 138) and educate parents and other family members about them.  Referrals to licensed social workers, psychologists, palliative care specialists, and child-life specialists should be considered if available.

Common behavioral reactions:  Like parents, most siblings crave control over illness (3). These feelings manifest via a variety of behaviors (see table below). Many siblings defer their own needs, “pause” their emotions, or act as if they are not having emotions (4). Others may act as if the situation is not happening (4). Most children need to have their emotions acknowledged and explored by others to help them adjust to a new normal (5). Since many children struggle with articulating feelings, especially to distressed parents, clinicians often play a vital role in helping them name and normalize their emotions. Support groups for siblings of children receiving palliative care also may be available which can offer opportunities for siblings to speak openly with peers and thereby reduce feelings of isolation (2). 

Common Sibling Reactions	Ways to Promote Positive Coping
Fear:  concern for their own death; concern for the future for self/family. May manifest as nightmares, social withdrawal, acting out	Clarify illness misconceptions; explain how/when death typically occurs; acknowledge uncertainty in age appropriate terms (see Fast Fact #138)
Regression:  acting younger than age, loss of new habits and the adoption of old habits	Keep schedules, routines, and rituals.
Over-achieving:  compensating for helpless feelings by attaining to be “the golden child,” or deferring one’s needs for the needs of the ill child.	Provide reassurance. Model vulnerability and coping strategies
Displays of Power:  mischievous behaviors at home or school to get attention	Allow the sibling to participate by providing a specific care role in the patient’s care (e.g. bringing food/water/medications to the bedside).
Guilt:  Reactions differ depending on age (see Fast Fact #138), but children 6 or younger especially may worry they caused or our liable for their siblings illness.	Reassure the sibling they did not cause the illness via bad thoughts or fighting with sibling
Anger:  feelings of hostility are most often directed towards their sibling or parents	Validate feelings over defending one’s prior actions. Consider developmentally appropriate relaxation techniques.
Sorrow: though difficult for many family members to witness, sorrow can signify acceptance.	Validate feelings; help children understand what they are feeling is OK; meet other grief-stricken children. Role-model coping with sadness.

Respite Care:  Parents may benefit from dedicated time with their healthy children. Respite care services allow the primary caregiver temporary relief from the stress that is associated with caring for a chronically ill or dying child.  Respite may improve family stability and improve the relationship of parents with their children.  Recent studies show that a sibling’s grief process is influenced by parental grief, the level of family unity, and the caregiving atmosphere (4). Siblings may be best supported by supporting the overall functioning of the family (5). Psychologists, social workers, and child-life specialists may be available in respite care which can help parents frame candid and developmentally appropriate discussions to help siblings cope with death and dying (5). 

References

1. Lovgren M, Bylund-Grenklo T, Jalmsell L, Wallin AE, Kreicbergs U. Bereaved Siblings’ Advice to Health Care Professionals Working with Children with Cancer and their Families. J Pedi Onc Nurs 2016;33(4): 297-305.
2. Carter BS, Levetown M, Friebert SE. Palliative Care for Infants, Children and Adolescents: A Practical Handbook, 2^nd Ed., Baltimore, MA: The Johns Hopkins University Press, 2011;209-223.
3. Helping Children Cope and Deal with Grief. Downloaded from https://healgrief.org/healping-children-cope-with-grief/ on 12/20/2018.
4. Carter BS, Levetown M, Friebert SE. Palliative Care for Infants, Children and Adolescents: A Practical Handbook, 2^nd Ed., Baltimore, MA: The Johns Hopkins University Press, 2011;284-285.
5. Humphrey LM, Hill DL, Carroll KW, Rourke M, Kang TI, Feudtner C. Psychological Well-Being and Family Environment of Siblings of Children with Life Threatening Illness. J Pall Med 2015;18(11): 981-984.
6. Warnick AL. Supporting youth grieving the dying or death of a sibling or parent: Considerations for parents, professionals and communities.  Curr Opin Support Palliat Care 2015;9(1):58-63.

Authors’ Affiliations: University of Michigan, Ann Arbor, MI

Conflicts of Interest: None

Version History:  originally edited by Sean Marks MD; first electronically published in March 2020.