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Journal of Psychosocial
Oncology
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A Group Intervention for

Siblings of Pediatric Cancer
Patients
Maru Barrera PhD

a a

Carly F. Fleming MEd

, Joanna Y. Y. Chung PhD &

c

Department of Psychology and Hematology/

Oncology Program , Hospital for Sick Children ,
555 University Avenue, Toronto, Ontario, M5G 1X8,
Canada
b

Department of Psychology , British Columbia's

Children's Hospital , Vancouver, British Columbia
c

Hematology/Oncology Program , The Hospital for

Sick Children , Toronto
Published online: 25 Sep 2008.

To cite this article: Maru Barrera PhD , Joanna Y. Y. Chung PhD & Carly F. Fleming
MEd (2005) A Group Intervention for Siblings of Pediatric Cancer Patients, Journal of
Psychosocial Oncology, 22:2, 21-39, DOI: 10.1300/J077v22n02_02
To link to this article: http://dx.doi.org/10.1300/J077v22n02_02

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A Group Intervention for Siblings

of Pediatric Cancer Patients
Maru Barrera, PhD
Joanna Y. Y. Chung, PhD
Carly F. Fleming, MEd

ABSTRACT. A group intervention to reduce emotional and behavioral

problems in siblings of children with cancer was evaluated. Forty-seven
siblings aged 6 to 14 years participated in seven groups, with 4 to 9 siblings in each group. Groups consisted of eight weekly two-hour sessions
guided by a manual. Four assessments were conducted: two before the
intervention and two after the intervention. Children completed self-report measures of anxiety, depression, and behavior; parents reported on
siblings anxiety and behavior. After the intervention, siblings reported
Dr. Barrera is a Registered Psychologist and an Associate Scientist, Department of
Psychology and Hematology/Oncology Program, The Hospital for Sick Children, 555
University Avenue, Toronto, Ontario M5G 1X8, Canada (E-mail: maru.barrera@
sickkids.ca). Dr. Chung is a Registered Psychologist, Department of Psychology, British Columbias Childrens Hospital, Vancouver, British Columbia. Ms. Fleming is
Program Coordinator, Hematology/Oncology Program, The Hospital for Sick Children, Toronto.
The authors wish to express their gratitude to the following: the families and children who participated in the Siblings Coping Together (SCT) program; Drs. Norma
DAgostino, Karen Sumbler, Alisa Kenny, Brian Feldman, and Sunita Vohra for their
comments on an early version of the manuscript; Dr. Mohamed Abdolell for his statistical advice; and Dr. Charmaine Miranda, Joanne Bonanno, and Danielle Kuczynski
for their assistance in running SCT groups.
The authors also wish to thank Families of Children with Cancer for funding part of
the project and the National Cancer Institute of Canada and Candlelighters Canada for
supporting Dr. Chungs studentship.
Journal of Psychosocial Oncology, Vol. 22(2) 2004
http://www.haworthpress.com/web/JPO
2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J077v22n02_02

21

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JOURNAL OF PSYCHOSOCIAL ONCOLOGY

significantly reduced symptoms of anxiety and depression, and parents

reported significant reductions in siblings anxiety and behavior problems. An interaction between intervention, age, and gender indicated
that adolescent girls had more depressive symptoms than adolescent
boys did before the intervention and younger girls did after the intervention. The findings suggest that group intervention benefits siblings of
children with cancer, with age and gender influencing this effect. [Article copies available for a fee from The Haworth Document Delivery Service:
1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website:
<http://www.HaworthPress.com> 2004 by The Haworth Press, Inc. All rights
reserved.]

KEYWORDS. Siblings, pediatric cancer, group intervention, psychological functioning

Families of children with cancer must adjust to the implications of the

diagnosis and the challenges presented by medical treatment. Changes in
daily life after a diagnosis of pediatric cancer may result in chronic distress for family members, including siblings, whose well-being is often
overlooked. This study focuses on a group intervention program designed to prevent or reduce psychological difficulties in siblings of children with cancer.
REVIEW OF THE LITERATURE
Psychological Adjustment of Siblings
The diagnosis and treatment of pediatric cancer have been associated
with behavior problems, such as sleeping problems and acting out, and
increased 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 collaborative study, Sahler et al. (1994) estimated that 63% of siblings of children with cancer experience some psychological adjustment difficulties
at any one point after the diagnosis. The impact of pediatric cancer on
healthy siblings is likely to depend on their developmental level (Murray,
2000). However, previous studies have been inconclusive regarding age
and gender differences. Siblings aged 6 to 12 years have been reported

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Barrera, Chung, and Fleming

23

to exhibit more maladaptive levels of anxiety and depression and more

behavior problems than the ill children (Spinetta et al., 1999) or older
siblings do (Sahler et al., 1994; Sargent et al., 1995). Siblings over 11
years of age may be less involved with the family and have more complaints about family life than do younger siblings (Madan-Swain et al.,
1993). On the other hand, among firstborn or other siblings older than
the patient, parents have also reported increased maturity, supportiveness, and independence (Barbarin et al., 1995).
In the general population and among the offspring of parents who
have cancer, adolescent girls have a propensity for expressing more
symptoms 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 in
siblings psychological adjustment to the cancer experience in general
and in the context of intervention specifically.
Psychological Interventions for Siblings
To our knowledge, the only published psychological interventions
for siblings of children with cancer have been in a group format (Adams-Greenly et al., 1986; Barrera et al., 2002; Bedway & HartkopfSmith, 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 programs
has been limited.
Quantitative methodology using pre- and postevaluation has been
used in some studies. Five-week, six-week, and eight-week group
interventions (Houtzager, Grootenhuis, & Last, 2001; Dolgin et al., 1997;
Barrera et al., 2002, respectively) suggested improvements in siblings
moods, interpersonal relations, and reduction of self-reported symptoms
of anxiety. In Dolgin et al.s study (1997), data were reported from a
one-time implementation of the group program, and no efforts were made
to control for factors that may have confounded the effects of the
intervention. In Barrera et al.s study (2002), siblings self-reports suggested reduced symptoms of anxiety and depression after the group intervention, but the sample was too small to generalize these findings. Neither study
controlled 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 described
in detail elsewhere (see Barrera et al., 2002; Chung et al., 1999). Briefly,
we used cognitive behavior theory (e.g., Kendall, 2000) to conceptualize the behavioral difficulties encountered by siblings of children with
cancer and to develop a group intervention to address them. Siblings
may develop behavioral or emotional difficulties as a response to the
increased time parents spend with the ill child (during hospitalizations
and outpatient clinic visits). Siblings also may develop distorted cognitions regarding their status in the family and may experience feelings of
abandonment from or of being less valued by their parents than the ill
child is, resentment toward the ill child, and guilt for being healthy. The
SCT group program was designed to address siblings behavioral and
emotional difficulties as well as their distorted views (cognitions) related to their experience of pediatric cancer.
The purpose of the present study was twofold: to evaluate the effects
of the SCT program on siblings symptoms of anxiety, depression, and
problem behavior and to examine the role of age and gender in siblings
psychological adjustment to pediatric cancer within the context of
group intervention. On the basis of previous empirical research, we hypothesized that (1) compared to baseline assessments, there would be a
reduction in siblings symptoms of anxiety and depression and behavior
problems after the intervention and (2) adolescent girls would manifest
more depressive symptoms than adolescent boys and younger children
of either gender would at both baseline and postintervention assessments.
METHOD
Participants
Between January 1998 and May 2001, 42 siblings (17 boys and 25
girls) of children being treated for cancer in a large pediatric center participated in seven consecutive SCT intervention groups. The siblings
ranged in age from 6 to 14 years (M = 9.93 years, SD = 2.38 years). Each
group consisted of 4 to 9 children of similar developmental age and approximately equal numbers of boys and girls to ensure group cohesion
and 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 (on
or off treatment), (2) being identified by parents as having behavioral or
emotional difficulties (e.g., irritability, acting out, changes in mood)
since the ill child began treatment, and (3) residing within 100 kilometers of the hospital. Siblings who had a developmental or neurological
disorder that impeded their ability to understand and to communicate
verbally in a group or whose ill brother or sister died before the program
began were excluded.
Thirty-five of the 42 siblings (83%) came from Caucasian families; 2
of the remaining siblings were Asian-Canadian, 1 was Afro-Canadian,
and 2 were categorized as mixed Native Canadian. Most of the siblings
came 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-parent
family. The majority of siblings (26) were older than the ill child, and 36
of the ill children were on active treatment. The majority of patients (22)
had been diagnosed with leukemia; the remaining diagnoses were sarcoma (6), brain tumor (5), lymphoma (4), neuroblastoma (2), Wilms
tumor (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 standard for assessing the efficacy of medical and psychological interventions (Chambless & Hollon, 1998), such a study design is not always
feasible or optimal (Kazak et al., 1994). This is especially true when the
focus of the research involves a population, such as siblings of children
with cancer whose families are overburdened with the care of the ill
child and care of the healthy siblings is often delegated to friends and
relatives (Barrera et al., 2002; Spinetta et al., 1999). Thus, we used the
time-series design for the study. The design included two baseline assessments (Pre 1 and Pre 2) to control for a major threat to validity, the
passage of time (Campbell & Stanley, 1972); eight group intervention
sessions; and two postintervention assessments, one immediately after
the last intervention session (Post 1) and a follow-up assessment 6 to 12
months later (Post 2). The two postintervention assessments tested the
consistency of the intervention effect. The six-month range of the Post 2
assessment period was the result of the varying availability of participants for completion of the instruments.

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Siblings were referred either by staff in the hematology/oncology

program after a parent expressed concerns about the siblings mood or
behavior or by a parent who contacted the program coordinator after
reading about the SCT group program (a newsletter or flyers for parents
were posted in the treatment unit). One parent of each potential participant was interviewed by telephone to screen for inclusion criteria and to
obtain demographic information. Siblings also were interviewed by
phone, after parents provided verbal consent, to screen for their communication 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 or
assent forms and completed the assessment. The same parent was
asked to complete the parent forms at each assessment. Seven siblings
completed the Pre 1 assessment and 42 siblings (including the initial
7) completed the Pre 2 assessment. The difference in the response rate
between the two assessments speaks to the greatest challenge in conducting clinical research with this population. First, we needed to ensure that the siblings had two preintervention assessments eight weeks
apart. Given the demands of caring for the ill child, many parents
found it difficult to come to the centre eight weeks before the scheduled start of the group. Second, we needed enough siblings to run a
group and to schedule a starting date. Unfortunately, some siblings
were referred too close to the groups starting date, preventing us from
obtaining a Pre 1 assessment. The Pre 1 and Pre 2 groups of siblings
were compared with respect to the ill childs age, gender, socioeconomic, and disease characteristics (on or off treatment) using either a
t-test or chi-square analysis. The groups did not differ significantly on
demographic or disease characteristics.
Forty siblings completed the Post 1 assessment, but only 14 completed the Post 2 assessment despite our efforts to encourage families to
do so. The siblings who did and those who did not complete the Post 2
assessment did not differ significantly in gender and age; however, they
did differ significantly with respect to socioeconomic status (2 = 9.0, p <
.05). The children who did not complete the Post 2 assessment came
from families with lower socioeconomic status. It is possible that those
families felt more overwhelmed with daily life, as families with lower
socioeconomic status often do. The following reasons were given for
not completing the SCT program or parts of the assessment protocol:
changes in the ill childs health status, loss of interest in the study, feelings of wanting to get family life back to normal, and conflict between adolescents and parents.

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Measures
Instruments completed by siblings. All siblings completed the Child
Depression Inventory (CDI), the self-report State-Trait Anxiety Inventory for Children (STAIC), and the Sibling Group Satisfaction (SGS)
questionnaire. Siblings aged 11 years and older also completed the
Youth Self-Report (YSR), a measure of behavior problems.
The CDI is a 27-item, self-report, symptom-oriented depression scale
(Kovacs, 1992). It has an acceptable test-retest reliability coefficient of
.83 at three weeks and a coefficient of .41 to .69 at one year and has adequate validity (Kovacs, 1992). The total T-score was used for analysis.
The alpha coefficient obtained in our study was .68.
The 20-item State Anxiety subscale of the STAIC (Spielberger,
1983) was used in the study. Adequate reliability and validity were obtained in Spielbergers normative sample: .82 for boys and .87 for girls.
In our study, the alpha coefficient obtained was .65.
The SGS was constructed by our research team and has been described in more detail elsewhere (Barrera et al., 2002). The version
completed by siblings consisted of seven questions: for example, How
useful was the group in reducing your fears/worries about your brother/
sisters cancer? Respondents chose the answer that applied best to each
question on a scale ranging from 1 (Not helpful/useful) to 5 (Helpful/useful).
The YSR consists of 112 items that assess competencies, total problems and internalizing and externalizing behaviors (Achenbach, 1991b).
For the present study, the alpha coefficient was .85.
Instruments completed by parents. Parents completed the STAIC
adapted for parents, the version of the SGS for parents, and the Child
Behavior Checklist (CBCL) and provided demographic information
about the family and medical information about the ill child. Thirty-four
(81%) of the participating parents were mothers and 8 were fathers.
The STAIC-Parent Form was adapted from Spielberger (1983) by
our research group to be identical in form and content to the STAIC.
The scores on the State Anxiety subscale were used for analysis. The alpha coefficient for the present study was .68.
The version of the SGS adapted for parents consisted of six questions: For example, How useful was the group in improving your
childs behavior? The parents also selected answers ranging from 1 to 5.

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JOURNAL OF PSYCHOSOCIAL ONCOLOGY

The CBCL is a 113-item instrument used to assess childrens competencies, total problems, and internalizing and externalizing behaviors
(Achenbach, 1991a). Test-retest reliability and validity for all scores are
adequate (.89 and .90 at one week) for the total behavior problem scales.
In the present study, the alpha coefficient was .78.
The Intervention Program
The SCT program consisted of eight weekly sessions of two hours
each, conducted in a large room in a hospital setting. Eight sessions
were planned based on our pilot work (Barrera et al., 2002). Groups
were facilitated by two therapists (psychology graduate students and research assistants) under the supervision of a registered psychologist. In
accordance with guidelines of the American Psychological Association
(Chambless & Hollon, 1998), a detailed manual was written to address
siblings thoughts and feelings and to develop coping strategies based
on the participants developmental level and specific needs (Barrera et
al., 2002; Chung et al., 1999). The manual describes the conceptual
framework, intervention approaches, and activities for each session. Although each session had predetermined themes and goals, new issues
based on recent experiences in participants daily lives were integrated
into the program.
The themes of Session 1 were development of group rapport and
rules (e.g., respect each other, be on time) and introduction of participants and their families. Medical information related to cancer and its
treatment was the theme of Session 2. A nurse attended this session to
talk with siblings for 30 minutes about cancer cells, diagnoses, and
treatments, using age-appropriate and hands-on visual aids. Siblings
prepared questions before the nurses visit and were encouraged to handle equipment, such as a central line and syringes.
Sessions 3 to 6 each had a specific psychosocial focus: the family
context (e.g., how cancer has affected each member of the family,
changes that have occurred since the ill childs treatment began), siblings feelings (e.g., resentment when parents spend too much time with
the ill child, sadness when the parents and the ill child are in the hospital
and the sibling is staying with relatives), relationships between siblings
(e.g., not spending enough time together because of the demands of
treatment, jealousy related to differential treatment), and the school
context (e.g., problems with peers, difficulty paying attention when
thinking about the ill child).

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Session 7 focused on the generation of hope for each siblings own future and on generalization of coping and problem-solving strategies learned in the group. Session 8 was a wrap-up and graduation. Children received a certificate of participation at a brief ceremony attended by parents.
Each session began with an ice-breaker activity, such as playing a
cooperative story-building game, followed by an activity to set the
scene for the main theme (e.g., a list of words associated with cancer). A
review of homework followed, either as a review of the information
covered in the previous session (finishing a picture of a favorite activity
with peers) or as preparation for the sessions main activity. Finally, the
group participated in activities specifically designed to address the sessions theme. For example, in Session 4, participants made a feeling
tree based on feelings that were generated through group discussion.
The subsequent activity involved role-playing strategies to make themselves feel better when feeling sad or angry (more details are included in
the SCT manual; Chung et al., 1999).
Data Analysis
To assess the test-retest reliability of the baseline data, we conducted
both paired t-tests and correlations. For the main analysis of intervention
effects, we conducted separate repeated measures ANOVAs for each outcome measure, using time (from Pre 2 to Post 1), age (younger: 6 to 10
years, older: 11 to 14 years), and gender. To assess the consistency of the
postintervention effects, t-tests and correlations for each measure were
conducted using the subsample of 14 participants who completed both
the Post 1 and Post 2 assessments. As Drotar (2002) suggested, we have
reported effect sizes and significance levels in Results.
RESULTS
Preliminary Analysis
The following correlations using the subsample of participants (7
siblings and 7 parents) who completed the two baseline assessments
were found to be significant: parents reports of siblings anxiety and
behavior problems (r = .934, p < .01, and r = .667, p < .05, respectively)
and siblings reports of anxiety (r = .520, p < .05). Paired t-tests yielded
no significant differences on any of the measures. Thus, the correlations
indicate adequate test-retest reliability for the two baseline assessments

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JOURNAL OF PSYCHOSOCIAL ONCOLOGY

across two of the three measures, one of which (the STAIC) was completed by both siblings and parents.
Pre- and Post-Intervention Effects
An ANOVA using the siblings self-reports of depression indicated a
main effect of time suggesting a significant reduction in depressive
symptoms at the end of the intervention (Pre: M = 49.85, SD = 13.71;
Post: M = 45.32, SD = 8.47; F[1,33] = 8.28, p = .007, effect size = .20).
Siblings self-reports of anxiety (Pre: M = 31.30, SD = 7.55; Post: M =
27.92, SD = 6.49; F[1,34] = 8.11, p = .007, effect size = .19) and parents reports of siblings anxiety (Pre: M = 34.99, SD = 7.10; Post: M =
30.62, SD = 5.35; F[1,35] = 18.80, p = .000; effect size = .35) indicated
a significant reduction of siblings symptoms of anxiety. No significant
time effect was found in the siblings self-reports or in the parents reports of behavior problems.
Effects of Age, Gender, and the Intervention
The ANOVA for the self-reports of depression scores indicated a significant three-way interaction of time, age, and gender (F[1,33] = 6.37,
p = .017; effect size = .16), which is depicted in Figure 1. Analysis of
this interaction using t-tests with a Bonferroni correction (p < .02)
showed the following trends:
Adolescent girls had higher depression scores before the intervention than adolescent boys did (M = 59.78, SD = 21.08, and M =
43.50, SD = 7.00, respectively; t[17] = 2.21, p < .05).
Adolescent girls had higher depression scores after the intervention than younger girls did (M = 52.71, SD = 11.73, and M = 43.00,
SD = 6.50, respectively; t[21] = 2.82, p < .05).
Younger boys had the greatest decrease in depression scores from
pre- to postintervention (M = 53.86, SD = 13.75, and M = 42.57,
SD = 7.09, respectively; t[6] = 3.00, p <. 05).
The mean group scores of the adolescent girls were at the borderline
clinical range before the intervention (with a large standard deviation)
and returned to normative levels after the intervention. In addition, there
was a significant age gender interaction (F[1,33] = 6.80, p < .05, effect size = .17), which confirmed the findings of the three-way interaction described above. Adolescent girls tended to have higher depression

31

FIGURE 1. Siblings scores on the Child Depression Inventory, by age, time,

and gender. (*The clinical range of the instrument begins at T-score = 60.)
60

ADOLESCENTS

CHILDREN*

55

Mean CDT Total Score

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Barrera, Chung, and Fleming

Pre-Intervention

Pre-Intervention

Post-Intervention

Post-Intervention

50

45

40
Older Males

Older Females

Younger Males

Younger Females

scores compared with younger girls (t[22] = 2.63, p < .05) and adolescent boys (t[17] = 2.43, p < .05).
For parents reports of siblings anxiety scores, there was a significant age gender interaction (F[1,35] = 4.18, p < .05, effect size = .10).
Analysis of this interaction yielded a pattern similar to that of the siblings self-reports of depression scores: Both before and after the intervention, older girls tended to have higher anxiety scores than younger
girls did (Pre: M = 37.00, SD = 7.41; Post: M = 32.63, SD = 6.78; and
Pre: M = 33.75, SD = 5.00, Post: M = 29.07, SD = 4.01, respectively;
t[22] = 1.64, p = .10). Older boys tended to have lower anxiety scores
than younger boys did both before and after the intervention (Pre: M =
33.20, SD = 7.94; Post: M = 29.44, SD = 2.01; and Pre: M = 38.07, SD =
9.44; Post: M = 33.14, SD = 7.99, respectively; t[15] = 1.27, p .10).
Follow-Up Effects
For the subsample of 14 siblings who completed the follow-up measures, the mean scores from postintervention to follow-up were similar
among self-reports of depression (Post 1: M = 43.07; Post 2 M = 41.93)
and anxiety (Post 1: M = 26.14; Post 2: M = 26.29) as well as parents re-

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JOURNAL OF PSYCHOSOCIAL ONCOLOGY

ports of sibling anxiety (Post 1: M = 31.21; Post 2: M = 30.89). All

paired t-tests indicated no significant difference.
Comparisons of parents reports of behavior problems yielded a significant reduction from postintervention to follow-up (Post 1: M =
48.71; Post 2: M = 42.86; t[13] = 2.00, p < .05). No analyses were conducted on siblings behavior scores because at follow-up only four siblings were old enough to complete the YSR.
Correlational data indicated a similar pattern. Siblings self-report
scores on depression and anxiety (r = .632, p < .05, and r = .612, p < .05,
respectively) and parents scores on siblings anxiety (r = .544, p < .05)
were consistent from postintervention to follow-up.
Group Satisfaction
The numbers of siblings who found the group to be Very helpful or
Somewhat helpful cited the following: improving their knowledge of
pediatric cancer (32), reducing their worries about pediatric cancer (30),
expressing their feelings to others (27), dealing with their brother or sisters cancer (26), and getting along with other members of the family
(26). Many siblings expressed sadness about the termination of the program and asked if they could enroll in the group again.
The majority of parents reported reduction of the siblings anxiety
(34) and family distress (23) and improvements in the siblings behavior (32) and expression of feelings (29). In addition, many parents wrote
comments saying the sibling was less irritable, was more cooperative at
home, and generally appeared to be happier. One parent wrote: This
group was very good for my child. I wish it would have lasted longer.
Another parent said: My child told me that the group was important to
him because he got to express his feelings.
DISCUSSION
The present study provides some evidence regarding the benefits of a
manual-guided psychological group intervention for siblings of children with cancer who were experiencing some behavioral problems,
emotional difficulties, or both related to pediatric cancer in the family
before the intervention. The study also illustrates the role of age and
gender in the psychological adjustment of siblings before and after the
intervention. In addition, it highlights the importance of including more

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Barrera, Chung, and Fleming

33

than one informant and several measures of outcome in studies of children. These findings are discussed further below.
Benefits of the Intervention
The comparisons of siblings self-reports on depression and anxiety
before and after the intervention suggests that the siblings psychological adjustment improved after the intervention. This finding was supported by parents reports of siblings anxiety, which provided another
perspective concerning the effects of the intervention. The reliability of
these findings is supported by the consistency of scores on measures of
anxiety and behavior before the group intervention and by the scores on
depression and anxiety at the follow-up assessment as well as by siblings and parents subjective reports of satisfaction at the end of the intervention. Notwithstanding the limitations of the study, which are
described below, the combined data collected provide substantial evidence of the interventions effects.
Given that our sample was not selected on the basis of clinical levels
of depression, anxiety, or behavior problems, it was not surprising that
the intervention effect sizes were weak and that the group mean scores
for the measures were within normal ranges at baseline. This renders the
results conservative because there was little room for improvement, yet
improvement seems to have occurred as a result of the intervention. Although the small effect size and the lack of a control group may make
these findings inconclusive with regard to the interventions efficacy,
they seem to have clinical significance and relevance. As Kazak et al.
(1994) pointed out, in siblings of children with cancer, it is likely that
the types of differences seen are not indicative of psychopathology, but
are related to more subtle aspects of adjustment and coping (p. 75).
According to Kazdin (1999), clinical significance refers to the practical value and the importance of the effect of an intervention in the
childs everyday life. Kazdin suggested that, depending on the type of
problems and goals of treatment, clinical significance can be measured
in several ways: by small changes in symptoms that affect the individuals everyday life, by subjective judgments, and by return to normative
levels. In the current study, the siblings who participated in the SCT
group were referred for psychological intervention through the hematology/oncology program because of parental concerns about their
mood and behavior. Thus, subtle improvements in the areas of parental
concerns had practical value for these families. Additional evidence of
clinical significance of the group intervention was provided by the sib-

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lings and parents reported reduction of symptoms of depression and

anxiety at the end of intervention, by the adolescent girls return to normative levels of depression, and by the siblings and parents subjective
ratings of satisfaction and the comments they provided. The combined
sources of evidence suggest that the group intervention contributed to
the reduction of the burden of suffering in these families and therefore
improved their overall quality of life.
We suggest that the reasons for the interventions clinical significance were related to siblings increased understanding of pediatric
cancer and its effects on every family member, their role and status
within the family, and the acquisition of concrete strategies regarding
how to cope with their situation. In addition, by enrolling the sibling in
the SCT group, parents demonstrated their concern for patients siblings and made efforts to spend special time with them. As one father
put it, We look forward to having triple D days: Daddy-Daughter-Days.
The present findings are consistent with a previous preliminary study
of siblings self-reports (Barrera et al., 2002), but they expand the earlier findings with methodological improvements: repeated measures at
baseline to test for one major threat to validity, the passage of time; a
follow-up assessment; and a larger sample. The study also expanded
Dolgin et al.s previous suggestions (1997) of emotional improvements
in siblings after a group intervention by using standardized measures of
depression, anxiety, and behavior problems.
Siblings age and gender appeared to be critical factors in psychological adjustment to pediatric cancer in general as well as with respect to
intervention, which confirmed previous suggestions (e.g., Sahler et al.,
1994). The greatest reduction in depression scores after the SCT group
was in young boys, which may indicate that they are the most receptive
to group intervention during this time of family stress. Adolescent girls
in general reported the greatest symptoms of depression at baseline, although their scores were in the normal range after the intervention. Adolescent girls also displayed more anxiety than younger girls did,
supporting the notion that symptoms of anxiety and depression tap similar internalizing processes (Achenbach, 1991a).
The results regarding depression are consistent with previous reports
of the general population of adolescent females and of adolescent females whose parents have cancer (e.g., Chubb, Fertman, & Ross, 1997;
Compas et al., 1996; Fleming & Offord, 1990; Nolen-Hoeksema, 1994). In
families of adolescents whose parents have cancer, families seem to expect adolescent girls to take on increased family responsibilities in

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times of family crisis. This interpretation also may apply to the adolescent girls in our study. Thus, future studies need to examine what factors may be related to depressive symptoms in adolescent girls in the
face of pediatric cancer.
Our findings also support the importance of obtaining reports from
more than one informant on outcome measures (La Greca & Lemanek,
1996). Children or adolescents may choose not to express their thoughts,
worries, and feelings openly with others outside their circle of trust.
This type of underreporting has been documented with survivors of pediatric cancer (Phipps & Srivastava, 1997). Siblings in our study may
have underreported their symptoms of anxiety and depression during
the preintervention assessments before they had the opportunity to develop trusting relationships within the group. As well, parents may not
have been aware of the extent of the emotional and behavioral problems
that their healthy children were experiencing because of their intense involvement with the ill child. If this was the case, the measure of change
after the group intervention may represent an underestimation of the interventions effect.
It is evident in this study that most siblings of children with cancer are
not at risk for major behavioral or emotional difficulties. Clearly, many
siblings demonstrate resilience in the face of adversity, perhaps because
of the protective role of family resources and environmental circumstances, because of their own personal characteristics, or a combination
of both. We are currently investigating protective and risk factors that
may contribute to siblings resilience to psychological stressors associated with the experience of pediatric cancer in the family or that may be
associated with increased psychological difficulties among siblings.
Limitations of the Study
Despite its strengths, the study had several limitations. One limitation
was the lack of a control group. A number of clinically relevant difficulties conducting this research, such as parental priorities, scheduling, and forming cohesive groups of siblings, led to an alternative
time-series within-subject, repeated measures (baseline to postintervention) design. This design may be more useful in clinical research.
A second limitation was the small sample size at the first preintervention assessment and at the follow-up assessment because of the
logistical problems described in Method. Parents often cited transportation and child care for the ill child and other siblings as obstacles to
maintaining siblings in a study that required commitment for repeated

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assessments and numerous visits to the centre. This situation is supported by the difference in socioeconomic status between families that
completed the follow-up assessment and families that did not, suggesting that limited resources were a factor in attrition at the follow-up assessment. Although a multicenter collaborative study would overcome
the problem of sample size, such a study often proves to be overly costly
and logistically difficult. Differences in barriers to implementing the
group intervention program across sites may result in an aggregation of
data that cannot be interpreted, though some of these barriers may be
overcome by having an intervention guided by a manual.
CONCLUSION
Despite its obstacles and limitations, the study provides the most substantial evidence to date of the clinical significance of group intervention for siblings of children with cancer and some evidence of its
effectiveness. The study has several methodological improvements
over previous intervention studies that strengthen the validity of its
findings. First, the study included strategies to control for, with a small
sample, the major threat to validity for a pre-post designthe effect of
passage of time (Campbell & Stanley, 1972). Second, the program was
based on a manual that provided specific conceptual and practical directions for the intervention. Third, the effect of the intervention was assessed using standardized, objective measures and subjective reports
completed by siblings and parents. Fourth, the follow-up assessment,
although limited by sample size, provided some evidence of the consistency of the interventions effect. Finally, the data on depression and
anxiety identified age and gender as crucial factors influencing the effect of the intervention and supported previous suggestions that adolescent girls seem to be at the highest risk for depression when confronting
a life-threatening illness in the family. These findings have clear implications for family intervention efforts and provide several new directions for research in this field.
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Received: August 15, 2002

Revised: July 1, 2003
Accepted: September 1, 2003