The quality of the relationship between typically developing children and their siblings with and without intellectual disability: Insights from children's drawings

Research in Developmental Disabilities 96 (2020) 103537

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The quality of the relationship between typically developing children and their siblings with and without intellectual disability: Insights from children's drawings

T

Anat Zaidman-Zaita,*, Miri Yechezkielyb, Dafna Regevb a Constantiner School of Education, Department of School Counseling and Special Education, School of Education, Tel Aviv University, Tel Aviv, 69978 Israel b The Graduate School of Creative Art Therapies and the Emili Sagol Creative Arts, Therapies Research Center, University of Haifa, Israel

A R T IC LE I N F O

ABS TRA CT

Keywords: Intellectual disability Sibling relationships Children's drawings Adjustment

The current study examined the relationships of typically developing (TD) children with siblings with and without intellectual disabilities (ID), as expressed in TD children's drawings and questionnaires answered by TD children and their mothers. It also examined group differences in the sibling relationships, as well as the associations between having a sibling with or without ID and sibling relationships, and TD children's social-emotional adjustment. Participants were mothers and their TD children (8–13 years). Some had ID siblings ID (N=28); others had TD siblings (N=31). Sibling relationships were examined via mothers' and target children's completion of questionnaires, and objective visual indicators (location, size, distance) and observed contentbased indicators (support, investment, presence of parents) of children's drawings were assessed following the art-based phenomenological analytic approach. Mothers reported on children's social-emotional adjustment. Findings indicated differences in sibling relationships, including higher levels of positive relationships for children with ID siblings. Children's drawings also showed positive relationship aspects for these children. Sibling relationship qualities were significantly associated with children's adjustment. Children's drawings may be a useful data gathering tool to deepen our understanding of unique aspects of sibling relationships.

1. Introduction Having a child with a disability, including intellectual disability (ID), in a family affects the diagnosed child and places unique demands on all family members, including typically developing (TD) siblings (Burke, 2010; Roper, Allred, Mandleco, Freeborn, & Dyches, 2014). Burke (2010) terms this "disability by association". ID is a sub-category within a group of developmental disabilities (DD); it includes limitations in intellectual functioning and difficulties in adaptive behavior (Schalock & Luckasson, 2013). Sibling relationships are the typically the longest relationships people have and are central in the everyday lives of children (Cicirelli, 1995). They have multiple roles across the lifespan, including the provision of companionship, nurturance, support, and learning opportunities (McHale, Updegraff, & Whiteman, 2012). Accordingly, they have a substantial impact on development and behavioral and psychosocial adjustment (Feinberg, Solmeyer, & McHale, 2012; Pike, Coldwell, & Dunn, 2005). Research on how having a sibling with DD affects children's social-emotional and behavioral outcomes has mixed findings.

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Corresponding author. E-mail address: [email protected] (A. Zaidman-Zait).

https://doi.org/10.1016/j.ridd.2019.103537 Received 5 February 2019; Received in revised form 30 October 2019; Accepted 5 November 2019 0891-4222/ © 2019 Elsevier Ltd. All rights reserved.

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Research in the area tends to follow one of two theoretical frameworks. The first describes a deficit model that assumes the presence of a sibling with a disability is risk factor for the TD child’s healthy adjustment (Levy-Wasser & Katz, 2004). Research within this framework finds TD siblings of a child with a DD have a slightly elevated risk of adjustment problems (Sharpe, 2002) and worse outcomes than siblings in comparison groups (Goudie, Havercamp, Jamieson, & Sahr, 2013; Kaminsky & Dewey, 2001; Neely‐Barnes & Graff, 2011; Rodgers et al., 2016; Verté, Roeyers, & Buysse, 2003). The second theoretical framework suggests having a sibling with a disability makes a positive contribution to the TD child's psychosocial development through personal growth imputed by exposure to adverse circumstances (Park & Helgeson, 2006). TD children who offer help to their siblings with disabilities do not experience negative consequences in terms of their peer relationships (Pit-Ten Cate & Loots, 2000; Skotko, Levine, & Goldstein, 2011). Furthermore, TD children who help with the physical care of their siblings with disabilities on a daily basis perceive themselves as having greater responsibility (Cox, Marshall, Mandleco, & Olsen, 2003). Overall, the research suggests having a sibling with DD leads to greater variability in children’s adjustment. Therefore, the relationship characteristics guiding children to adjust in positive or negative ways should be an important research target (McHale et al., 2012). Studies comparing the sibling relationships of TD children with and without a DD sibling have inconsistent findings, with some indicating no differences in relationship qualities (Cuskelly & Gunn, 2003; Stoneman, 2005), and others finding differences in either positive (e.g., closeness, support, warmth) or negative relationship aspects (e.g., conflict) (Kaminsky & Dewey, 2001; Stoneman, 2005). Studies include either siblings within a specific DD group (e.g., Down syndrome, autism spectrum disorders) or siblings with DD in general. Yet recent studies indicate that different disability profiles or diagnoses have different impacts on the family system, including with siblings (Hastings, 2016), highlighting the importance of focusing on a specific sub-group of children. Heeding this call, we looked at the siblings of children with ID. In addition, research on the relationships between TD children and their siblings with ID is relatively scarce, especially for school-aged children. Studies of siblings in families who have children with DD commonly rely on parents’ perceptions of sibling relationships. In several studies, parents’ reports revealed no significant differences in sibling relationships (e.g., Walton & Ingersoll, 2015), but others found differences in status/power differential (e.g., Floyd, Purcell, Richardson, & Kupersmidt, 2009). Studies using children’s reports indicate differences in both positive and negative aspects of the sibling relationship. For example, TD children who have a sibling with DD report less conflict than TD children without a DD sibling (Floyd et al., 2009; Kaminsky & Dewey, 2001), more empathetic feelings toward their siblings, less competition, and less unkindness (Cuskelly & Gunn, 2003; Kaminsky & Dewey, 2001). At the same time, they express more feelings of anxiety about their siblings (Shivers & Dykens, 2017) and report lower levels of involvement (Orsmond, Kuo, & Seltzer, 2009; Walton & Ingersoll, 2015). Children’s self-reports have special value in studies measuring sibling relationship qualities, especially in areas where parents may have less insight (Shivers & Dykens, 2017). Studies using both parents’ and children’s reports find discrepancies in how parents and children report sibling relationship quality; parents generally perceive the sibling relationship to be less positive than the children (Diener, Anderson, Wright, & Dunn, 2015; Glasberg, 2000; Rivers & Stoneman, 2003, 2008). Using children’s reports can be especially helpful in illuminating the sibling relationship because as children reach middle childhood, they have higher contact with siblings (Knott, Lewis, & Williams, 1995) and a more mature understanding of their siblings' disabilities (Glasberg, 2000). Studies on children’s perceptions of their relationship with a DD sibling have commonly used self-report questionnaires. Questionnaires are useful for directly measuring relationship aspects, such as closeness and conflict, but may be limited in revealing other relationship aspects. They may also be affected by children's desire to respond in a socially acceptable manner. In addition, children might not be completely aware of certain components of their “inner world”; this world may be accessible only indirectly through non-verbal means of communication, such as drawings (Gilroy, 2012). If so, a projective drawing task aimed at exploring specific issues could help children express themselves in ways that language cannot (Malchiodi, 1998), allowing them to reveal their personal experiences feelings, and thoughts (Bat Or, Papadaki, Shalev, & Kourkoutas, 2018; Howard et al., 2017; Piperno, Di Biasi, & Levi, 2007; Willats, 2005). According to object relation theorists, drawings provide access to mental representations of interpersonal relationships through images and symbols which capture aspects of relationship experiences (Huss, 2015; McGrath & Carroll, 2012; Robbins, 2001; Zinemanas, 2014). Consequently, drawings are an effective data-gathering technique to obtain information on interpersonal relationships (Leibowitz, 1999; Tharinger & Roberts, 2014). For example, a study assessing mother-child relationships compared drawings done by mothers of children with Down syndrome to the drawings done by mothers of children without Down syndrome; the former drawings showed barriers between the mothers’ and children’s figures, and the children’s figures were more abstract, seeming to reflect difficulties within the parent-child relationship (Lev-Wiesel & Zeevi, 2007). Another study compared the drawings of violent husbands (men found guilty of physical violence against their wives) and nonviolent husbands. In the majority of the physically violent husbands’ drawings, the female figure was larger and placed higher on the page than the male figure. These characteristics may indicate an imbalance within the relationship (Lev-Wiesel, Kacen, & Epstein, 2004). An analysis of drawings of pregnant women with signs of depression identified certain pictorial phenomena, such as limited use of colors, choice of page format, and lack of surrounding elements, as reflecting the women’s inner worlds and maternal representations (Cohen-Yatziv, Snir, Regev, Shofar, & Rechtman, 2018). Children’s drawings can be similarly helpful. When asked to draw their families, children from families with parental alcoholism showed more isolation of their figure from other family members (Holt & Kaiser, 2001). Elsewhere, features of children's drawings were found to be related to their attachment histories (Goldner & Scharf, 2011). However, to the best of our knowledge, children’s drawings have not been used to learn about sibling relationships. There are two main approaches to the analysis of children's drawings. The first is based on the assessment of indicators in drawings according to predetermined pictorial characteristics of family figure drawings, such as the location of the figures. The distance between the figures is considered indicative of the level of closeness, intimacy, or feelings of isolation and status within the 2

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relationship (Abraham, 2002; Lev–Wiesel & Drori, 2000; Lev-Wiesel et al., 2004). The location of a figure on the page reflects position and involvement in the family (Abraham, 2002) and the importance of the person represented to the creator's emotional world and to others or to the environment (Raz, 2012). The size of the figure reflects the importance attributed to the person represented (Abraham, 2002; Raz, 2012). The second type of assessment analyzes drawings according to phenomenological artistic observation of the drawings and the identification of pictorial content-based phenomena that appear in the completed drawings (Betensky, 1995; Eisenbach, Snir, & Regev, 2015; Rubin, 2010). According to this approach, viewers make assessments based on visual facts, not on personal interpretations. The use of projective drawing is a well-established and common quantitative methodological approach (e.g., Cohen-Yatziv et al., 2018; Eisenbach et al., 2015; Lev-Wiesel et al., 2004; Lev–Wiesel & Drori, 2000). We drew on this literature and the basic assumption that artistic creation allows internal content to be expressed visually (Robbins, 2001). Specifically, our study was designed to examine the use of a projective sibling relationship drawing task to compare the pictorial phenomena in the drawings of children with ID siblings to those in the drawings of children whose siblings did not have ID. One of the strengths of this approach in comparison to gathering children's verbal accounts of their experience is the art-theory-based underlying assumption that artistic expression can reflect the external embodiment of an internal issue that is partly unconscious and not otherwise directly accessible to the individual (Cohen, Hammer, & Singer, 1988; Gilroy, Tipple, & Brown, 2012). Thus, a projective drawing task aimed at exploring specific issues provides valuable clinical information (Neale & Rosal, 1993) and could reveal unique features of children's personal experiences. In addition, we examined the associations between indictors of children’s drawing and mothers’ and TD children’s perceptions of the sibling relationship through questionnaires. We also probed the associations between the sibling relationships and TD children’s externalizing, internalizing, and prosocial behaviors. To the best of our knowledge, this was the first study to directly study this type of sibling relationship (TD-ID vs TD-TD) using children’s and mothers’ verbal reports and children’s nonverbal reflections on the relationship. The study focused on three key questions. First, do mothers’ perceptions, children’s perceptions, and children’s reflections based on their drawings suggest different relationships between TD-TD siblings and TD-ID siblings? Second, are sibling groups (siblings with vs siblings without ID) and sibling relationships, as these relationships are perceived by mothers (based on questionnaires), associated with children’s social behavioral adjustment? Third, are sibling groups (siblings with vs siblings without ID) and sibling relationships, as these are perceived by children (based on questionnaires and drawings), associated with children’s social behavioral adjustment? 2. Material and methods 2.1. Participants Mothers and their children aged 8–13 years (N = 59) participated in the study. There were two groups. The first was a group of TD children whose siblings had ID (N = 28; referred to as the Siblings-ID group); 50 % were boys, with a mean age of 10.4 years (SD = 1.3); 53.6 % were same-sex sibling pairs with, on average, an age difference of 4.68 years (SD = 2.29). The siblings with ID were, on average, 11.4 years old (SD = 5.3), and 60.7 % were boys. The diagnoses were confirmed by parental reports. At the time of data collection, all the ID children attended special education programs and schools specifically for children with ID. The second was a group of TD children with typically developing siblings (N = 31; referred to as the Siblings-TD group); 51.6 % were boys, with a mean age of 9.9 years (SD = 1.3) 48.4 % were same-sex sibling pairs with, on average, an age difference of 4.19 years (SD = 1.94). The TD siblings were 9.8 years old, on average (SD= 4.8), and 38.7 % were boys. To examine group differences in demographic variables, we conducted χ2 tests and t-tests. There were no significant differences between the groups for subjects' sex, siblings' sex, subjects' age, siblings' age, and mothers’ marital status. However, there were significant differences between the groups in mothers’ education level. Hence, we included mothers’ education in subsequent analyses (see Table 1 for the demographic characteristics by Table 1 Child and family demographic variables by sibling group. Variable

Children (participants) Age in years M (SD) Age difference in years M (SD) Gender (% boys) Same gender pair Siblings Age in years of sibling Gender (% boys) Mothers Marital status (% married) Education (% with college degree or higher)

χ2 or t

Siblings-TD

Siblings-ID

(N = 31)

(N = 28)

9.90 (1.3) 4.19 (1.9) 51.6 48.4 %

10.40 (1.3) 4.68 (2.3). 50.0 53.6 %

t = -0.39 t = 1.14 χ2 = 0.01 χ2 = 1.54

9.84 (4.8) 38.7

11.43 (5.3) 60.7

t= -1.20 χ2 = 2.85

90.3 80.7

89.3 57.1

χ2 = 3.02 χ2 = 17.66*

* p < .05. 3

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sibling group (Siblings-ID, Siblings-TD). 2.2. Measures 2.2.1. Family background questionnaire This questionnaire collected personal and demographic information on families and children, including parents’ education level, number of children in the family, children's age, sex, birth order, and disabilities. 2.2.2. Sibling relationship quality Mothers completed the Sibling Inventory of Behavior (SIB; Hetherington et al., 1999; Schaeffer & Edgerton, 1981) used to assess sibling relationship quality in families with and without a child with disabilities. It includes 32 items, comprising six subscales, including: empathy (e.g., "Shows sympathy when things are hard for his sibling"), rivalry (e.g., "Is jealous of sibling"), aggression (e.g., "Gets angry with sibling"), avoidance (e.g., "Stays away from sibling if possible"), teaching (e.g., "Teaches sibling new skills"), and companionship (e.g., "Has fun at home with sibling"). Responses are rated on a 5-point Likert scale, ranging from 1 (never) to 5 (always). Similar to previous studies (Cuskelly & Gunn, 2003; Cuskelly, 2016; Volling & Blandon, 2005), Cronbach’s alpha for the sample indicated acceptable internal consistency for all subscales: empathy (α = .85), rivalry (α = .77), aggression (α = .86), avoidance (α = .78), teaching (α = .87), and companionship (α = .91). 2.2.3. Sibling relationship questionnaire Siblings in both groups completed the Sibling Relationship Questionnaire (SRQ; Furman & Buhrmester, 1985). The SRQ consists of 39 items, comprising four scales: closeness, describing aspects of intimacy, pro-social behavior, companionship, similarity, admiration by sibling, admiration of sibling, and affection (e.g., "How much do you and this sibling care about each other?"); power, describing nurturance of sibling, dominance of sibling, nurturance by sibling, and dominance by sibling (e.g., "How much do you tell this sibling what to do?"); conflict, describing quarreling, antagonism, and competition between siblings (e.g., "How much do you and this sibling disagree and quarrel with each other?"); rivalry, measuring maternal and parental partiality (e.g., "Who usually gets treated better by your mother, you or this sibling?"). Items are rated on a 5-point Likert scale, ranging from 1 (hardly at all) to 5 (very much). Cronbach’s alpha for the four SRQ scales was acceptable and consistent with previous reports: closeness (α = .91); power (α = 0.73); conflict (α = .87); rivalry (α = 0.89). 2.2.4. Drawings of sibling relationship Children were told to draw themselves and their sibling (referring by name to the ID sibling in the study group or to the TD sibling in the control group) on a sheet of A4 paper using a set of 12 colored pencils. After completing the drawing, they were asked to indicate the identity of the figures in their drawing. Children's drawings were coded on the basis of three predetermined visual indicators reflecting characteristics of sibling relationships: the distance between the figures, the figures' proportional size, and the location of the figures on the page (Abraham, 2002; Lev-Wiesel et al., 2004). Distance between the figures was measured by the number of centimeters separating them. The proportional size was measured by comparing the size of the figure representing the subject to the size of the figure representing the sibling with ID or TD, with size measured in square centimeters. To evaluate the location of the figures, the page was divided into two equal sections - upper and lower. The figure position was determined by the location of the head of the figure in relation to the division of the page and was scored nominally (“upper/lower”). In addition, guided by the phenomenological analytic approach, the second and third authors reviewed the drawings and listed observed pictorial content based indicators reflecting relationship aspects (Janesick, 2000). They identified three salient features: extent to which figures support each other (i.e., evidence of support and/or assistance between the figures); extent of investment in drawing the sibling (i.e., more or less investment in drawing the sibling's figure than the figure of the self as reflected by using more colors, adding more details, etc.); presence of a parent (i.e., inclusion of parents in drawing). To increase the reliability of the measure, three independent evaluators (all experienced art therapists) were asked to code the drawings according to the identified relationship indicators. The three judges assessed each indicator separately as present or absent in each drawing. Then, the ratings of all the evaluators were averaged. A value closer to 1 indicated an absence of the indicator in the drawing, and an average closer to 2 indicated the presence of the indicator. Intraclass correlation coefficient (ICC) were computed for interrater reliability. Based on the ICC results, the computed interrater reliabilities for the content-based indicators were moderate to excellent (ICC = 0.65 -0.96; p < .05) (Koo & Li, 2016). All evaluators were professional art therapists and experienced in analyzing drawings according to the phenomenological approach. None had any knowledge of the participants’ group membership. 2.2.5. Children's emotional and behavioral adjustment Mothers completed the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) for the target sibling. The SDQ consists of 25 items, divided into five scales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Items are rated on a 3-point scale ranging from 0 (not true) to 2 (certainly true). The SDQ also includes an internalizing behaviors composite score made up of the emotional symptoms and peer problems scales and an externalizing behaviors composite score made up of the hyperactivity and conduct problems scale score and a prosocial behavior subscale score (Goodman, Lamping, & Ploubidis, 2010). The SDQ has strong psychometric properties and has been used in a range of studies of psychological adjustment in children (Goodman & Goodman, 2009; Mathai, Anderson, & Bourne, 2003). Cronbach’s alpha was .71, .83, and .72 for externalizing, internalizing, and prosocial behaviors, respectively. 4

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2.3. Procedure Ethical approval was obtained from the Ministry of Social Affairs and the University Institutional Review Board. Participants were recruited through government and community agencies, intervention centers, and educational settings associated with families of children with developmental disabilities. During the first meeting, participants filled out an informed consent form. Mothers were asked to complete the study’s questionnaires. Children were invited to join the researcher in a separate room (without the mother) where they were asked to make a drawing and to fill out the sibling relationship questionnaire referring to the sibling (with or without ID). The researcher read one question after another to the children and marked the answers on a separate form. The session lasted approximately 45 min. 2.4. Data analysis To compare sibling relationships across the two groups, we performed a multivariate analysis of covariance (MANCOVA) with mothers’ education, and children’s and siblings’ ages and sex as covariates. Pearson correlations were conducted to examine the relationships between sibling relationships as expressed by children’s drawings and questionnaires completed by the children and their mothers. In addition, we conducted stepwise regression analyses to determine the associations between sibling relationships (separate models for each of the different reports on sibling relationships) and children’s emotional behavioral adjustment domains (i.e., externalizing, internalizing, and prosocial). Stepwise regression analyses were used to reduce the number of predictors in the models (Tabachnick & Fidell, 2007) and to identify a parsimonious model with the combination of independent variables that best predicted each dependent variable (Argyrous, 2000; Tabachnick & Fidell, 2007). In each stepwise regression, children’s age, sex, group membership, and sibling relationship measures were regressed against internalizing, externalizing, and prosocial behaviors. Assumptions of multiple regressions were tested for the final models. VIF was less than 10 and tolerance greater than 0.2 for all variables, indicating an absence of collinearity (Tabachnick & Fidell, 2007). The Durbin–Watson test indicated that the independence of errors assumption was upheld. Further analysis revealed no evidence of heteroscedasticity, and the distribution of errors was normal. From these analyses, the models were deemed to meet the assumptions of multiple regression and were accepted. 3. Results 3.1. Differences in sibling relationships across sibling groups (TD, ID) Examination of group differences in sibling relationships based on mothers’ reports indicated a significant effect of group, overall with medium effect size (Wilks’ Lambda = .58, F(6, 47) = 5.72, p < .001, partial η2 = .42). The Siblings–ID group had a significantly higher score for empathy (F (1, 52) = 11.06, p < .001, partial η2 = .27) and teaching (F(1, 52) = 5.23, p < .05, partial η2 =. 10), and a lower score for rivalry (F(1, 52) = 3.00, p < .01, partial η2 = .13) and conflict (F(1, 52) = 5.19, p < .01, partial η2 = .21) than the Siblings-TD group (see Table 2). Examination of group differences in sibling relationships based on children’s self-reports indicated a significant effect of group, overall with medium effect size (Wilks’ Lambda = .72, F(4, 49) = 4.82, p < .01, partial η2 = .28). The Siblings-ID group reported Table 2 Mean and standard deviations for sibling relationships by siblings’ group. Variable

Siblings-TD (N = 31) M (SD)

Siblings-ID (N = 28) M (SD)

F

ηp2

Mother's reports Empathy Companionship Teaching Rivalry Conflict Avoidance

3.45 3.15 2.88 2.48 2.60 1.78

4.35 3.43 3.73 2.00 2.05 1.82

19.07*** 1.46 10.28** 8.08** 10.50** <1

0.26 0.02 0.16 0.13 0.16 0

Children's reports Closeness Conflict Rivalry Power Children's drawings Support Investment Parent presence Location Distance Size proportion

(.14) (.16) (.18) (.11) (.11) (.13)

(.14) (.17) (.19) (.12) (.12) (.14)

2.92 (.14) 2.61 (.17) .34 (.11) 2.37 (.12)

3.65 (.15) 1.92 (.17) .63 (.11) 2.61 (.12)

11.74** 7.76** 3.09 1.73

0.18 0.12 0.05 0.03

1.06 (.05) 1.08 (.05) 1.01 (.04) 1.69 (.12) 3.68 (.45) −.01 (.18)

1.26 (.05) 1.25 (.05) 1.11 (.04) 1.52 (.13) 4.21 (.47) .02 (.19)

6.56* 5.45* 2.93 <1 <1 <1

0.11 0.09 0.05 0.01 0.01 0

Note: *p < .05; **p < .01; *** p < .001. Covariates in the model include: children and siblings’ age and gender. 5

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Fig. 1. Examples of inductive indicators of childrens drawings.

more closeness than the Siblings–TD group (F(1, 52) = 7.42, p < .01, partial η2 =.19) and fewer conflicts (F(1, 52) = 9.037, p < .01, partial η2 =.18). Examination of children's drawing indicators showed a significant effect of group (Wilks’ Lambda = .69, F (7, 47) = 2.56, p < .05, partial η2 = .31). The Siblings-ID group demonstrated more figure support in drawings (F(1, 53) = .57, p < .05, partial η2 = .11) and increased effort to draw the sibling (F(1, 53) =.39, p < .05, partial η2 = .09). Examples of drawings are provided in Fig. 1. There were no significant differences in any of the predetermined indicators (i.e., distance between figures, figures' proportional size, and location of figures on the page (see Table 2). Bivariate correlations for the study’s sibling relationships variables are presented in Table 3. As the table shows, in terms of predetermined visual indicators in the children’s drawings, increased distance between the figures was related to increased conflict 6

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Table 3 Correlations among sibling relationship variables. Children's drawings

Child report

Visual indicators Location Distance Size proportion Support Investment Parent presence

Closeness −.04 −.18 −.12 .32* .44** .10

Mother report Conflict .10 .35** −.05 −.32* −.25 −.01

Rivalry −.02 .21 .27* .08 −.03 .26*

Power .04 −.03 −.26* .26* .33* .16

Empathy −.05 −.11 −.20 .32* .19 −.06

Companionship −.04 −.09 −.17 .13 .16 −.17

Teaching .05 −.16 −.04 .39** .20 .11

Rivalry .11 −.10 .13 −.18 .01 −.14

Conflict .17 .30* .03 −.32* −.21 −.16

Avoidance −.14 .35** .20 −.18 −.15 .12

* p < .05; **p < .01.

(mothers’ and children’s reports) and avoidance (mothers’ reports), while the proportion of the figure sizes was associated with decreased power and increased rivalry. In terms of observed pictorial content-based indicators, the observed “support” indicator was associated with higher levels of closeness and power (children’s reports) and with increased empathy and teaching behaviors (mothers’ reports) and with lower conflict (children’s and mothers’ reports). In addition, the observed content indictor of investment was positively associated with closeness and power (children’s reports).

3.2. Sibling group, relationships, and children's emotional behavioral adjustment Results of the stepwise regression models are summarized in Table 4. Findings from the final step of the stepwise regression analysis predicting externalizing behaviors by sibling group and sibling relationship based on children’s drawings indicated that only the indicator of distance between the figures was significantly and positively associated with externalizing behaviors. Findings from the model examining the effect of sibling group and sibling relationship based on children's reports indicated that rivalry, power, and conflict were significantly and positively associated with externalizing behaviors. Meanwhile, stepwise regression models with sibling group and mothers' reports on sibling relationships indicated that avoidance, teaching, and conflict components of siblings’ relationships were significantly associated with externalizing behaviors. Stepwise regression models with internalizing behaviors as the dependent variable indicated that the presence of a parent, as reflected in children's drawings, was a positive significant predictor. Based on group and children's self-reports, rivalry was positively associated with internalizing behaviors as well as child's sex. Finally, in the model with sibling group and mothers' report on sibling relationships, only child’s sex was a significant variable. Overall, boys were reported to demonstrate more internalizing behaviors than girls. Stepwise models predicting prosocial behaviors indicated that children’s reports of conflict and rivalry and mothers’ reports of avoidance in sibling relationships were negatively associated with children's prosocial behaviors, while mothers’ reported empathy was positively associated with prosocial behaviors. Based on children’s drawings, only the figures' proportional size was negatively associated with prosocial behavior. Table 4 Final models of the stepwise regression models of effect of sibling relationship on externalizing, internalizing, and prosocial behaviors. Variable

Child drawings Child Que

Mother Que

Child drawings Child Que Mother Que Child drawings Child Que Mother Que

Distance Rivalry Power Conflict Avoidance Teaching Conflict Presence of parents Child sex Rivalry Child sex Child sex Size proportion Rivalry Conflict Empathy Avoidance

b Externalizing behaviors 0.40 1.91 1.64 0.92 2.26 1.45 1.40 Internalizing behaviors 3.57 −1.71 1.34 −1.79 Prosocial behavior 0.50 −1.73 −0.83 −0.76 1.06 −0.63

* p < .05. 7

SE

β

t

.19 .73 .69 .45 .69 .46 .65

.27 .31 .28 .24 .43 .41 .27

2.08* 2.60* 2.37* 2.05* 3.26* 3.17* 2.16*

1.69 .73 .60 .75

.27 −.29 .27 −.30

2.11* −2.36* 2.24* −2.39*

.45 .59 .36 .23 .25 .30

.13 −.36 −.27 −.40 .48 −.23

1.10 −2.90* −2.33* −3.33* 4.28* −2.07*

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4. Discussion Our study examined the relationships of TD children with siblings with and without ID, as expressed in the TD children’s drawings and in questionnaires answered by the TD children and their mothers. It also examined group differences in the sibling relationships, as well as the impact of having a sibling with or without ID and aspects of the sibling relationship on TD children’s social-emotional adjustment. To the best of our knowledge, this is the first study to identify and assess expressions of sibling relationships in drawings; thus, it may be considered novel exploratory work, with the potential for developing a useful data gathering tool. Findings revealed differences in the nature of the relationship between siblings when one has ID (the Siblings-ID group) and when both are TD (the Siblings-TD group). According to the mothers’ reports, sibling relationships in the former group were characterized by higher levels of empathy and teaching behaviors and lower levels of conflict and rivalry. These findings are consistent with a previous study where mothers reported more positive relationships among children in the Siblings-DD group than in the Siblings-TD group (Roper et al., 2014). Another study found that parents of children with disabilities perceived a positive impact on siblings, including learning about diversity and appreciation (Taunt & Hastings, 2002). In their responses to the questionnaire, the TD children in the Siblings-ID group reported lower levels of conflict and higher levels of closeness within the relationship. The finding resonates with studies using children's reports; less negative sibling relationship aspects, including quarreling, competition (Kaminsky & Dewey, 2001) and unkindness (Cuskelly & Gunn, 2003), were found among children with DD siblings than among children with TD siblings, along with more positive interactions with and appreciation of their DD siblings (Mascha & Boucher, 2006; Petalas, Hastings, Nash, Lloyd, & Dowey, 2009). Children's drawings provided consistent evidence of positive relationship aspects among children in the Siblings-ID group. Specifically, the drawing analysis using observed pictorial content-based indicators indicated that children in the Siblings-ID group displayed stronger indicators of support and investment than their comparators in the Siblings-TD group. Because of the unique sibling context, these observed indicators might reflect children’s perceived obligation to support siblings with ID and their dedication to make an increased effort within their sibling relationship. Both content indicators (support and investment) highlight the increased caregiving demands on the family when a child has DD, including from their siblings (Burke, 2010; Graff et al., 2012). In a recent study, adults whose siblings had autism spectrum disorder said that since childhood, they had felt an obligation to support their siblings, recognizing their vulnerability (Tomeny, Barry, & Fair, 2017). Commonly, adults with ID/DD siblings support these siblings (Burke, Taylor, Urbano, & Hodapp, 2012; Orsmond & Seltzer, 2000). In families of children with disabilities, there may be an increased emphasis on “familism”, a family orientation characterized by interdependence and high priority on the needs of the whole family (Marín & Marín, 1991). This, in turn, may influence TD siblings’ acceptance of their care responsibilities (Updegraff, McHale, Whiteman, Thayer, & Delgado, 2005). Overall, the research suggests children whose siblings have ID experience personal growth and gain emotional strength, and this is reflected in character traits such as perseverance, motivation, a sense of responsibility, maturity, and developed social skills (Scorgie & Sobsey, 2000; Skotko et al., 2011). Arguably, having a family member with a disability makes the rest of the family, including the TD children, more attentive to the needs of others. The significant associations between these content-based indicators and aspects of sibling relationships as subjectively reported by mothers and children provide initial support of their validity in sibling relationship assessment. The relatively small effect of the associations is not surprising considering the expected gap between information obtained from the subjective reports and the non-verbal observed information (i.e., the drawings) which, among other things, is related to unconscious aspects expressed during creative activity. The identification of the unique content-based indicators in children’s drawings suggests the promise inherent in using drawings to assess aspects of sibling relationships. As drawing is considered a projective technique that can provide insight into a subject’s inner world, the use of projective drawings may reveal more than might emerge by relying solely on verbally based measures such as questionnaires and narratives. Questionnaires are commonly developed to assess the relationships of TD children with their TD siblings, but they might miss important aspects of relationships between TD children and ID siblings. Using such measures as SRQ (Furman & Buhrmester, 1985) in atypical samples (such as children whose siblings have ID or other disabilities) assumes the instrument’s validity in “normative” samples (such as parents of children with TD siblings) will hold true across populations. However, the characteristics of sibling relationship within families of children with disabilities may differ from those of typical populations in important ways, including both positive and negative unique relationship aspects. Although the predetermined visual art-based indicators (distance, size, and location) are known to be related to aspects of perceived relationships (Lev-Wiesel & Zeevi, 2007) and to affective characterizations (Burkitt, Barrett, & Davis, 2003), we found no significant group differences in them. Perhaps they were not sensitive enough to capture differences reflecting specific aspects of sibling relationships within the two groups, as discussed above. This might also reflect findings from previous studies; differences in sibling relationships are not consistent in the relational dimensions measured, with some studies finding differences between groups and others not finding such differences. Two indictors (proportion of size and distance between figures) were significantly associated with relationship aspects reported by the children and mothers in the questionnaires, including conflict, power, rivalry, and avoidance, a finding also demonstrated elsewhere (Abraham, 2002; Holt & Kaiser, 2001; Lev-Wiesel et al., 2004). Overall, our findings are in line with previous studies indicating that having a sibling with ID is beneficial to the sibling relationship, strengthening family bonds and averting hostility between siblings (Pit-Ten Cate & Loots, 2000; Scorgie & Sobsey, 2000; Skotko et al., 2011). Arguably, the nurturing needs of children with ID might encourage the development of positive aspects within relationships. Siblings and parents reported on gaining meaningful benefits from their sibling relationships, along with ongoing challenges (Mulroy, Robertson, Aiberti, Leonard, & Bower, 2008).

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4.1. Sibling relationships and children’s social emotional adjustment Echoing previous findings, although there were group differences in sibling relationship, we found no direct effect of sibling group (having a sibling with ID or a TD sibling) on children’s social-emotional adjustment. Our findings are consistent with a meta-analysis conclusion that having a sibling with a DD has no negative impact or only a small impact on children’s adjustment (Rossiter & Sharpe, 2001). Other variables that provide more descriptive information about the siblings’ characteristics and their relationships, as well as parenting and family factors, are arguably more important in explaining variability in children’s adjustment outcomes (Neece, Blacher, & Baker, 2010). Yet, in our study, sibling relationship qualities were significantly associated with children’s adjustment based on children’s and mothers’ reports and children’s drawings. Specifically, consistent with previous studies, increased negative relationship dimensions (e.g., rivalry, power, conflict) explained significant variance in children’s externalizing behaviors (Criss & Shaw, 2005). Regardless of group membership, previous studies on children with TD or DD siblings found that sibling conflict and children’s behavior problems were positively associated (Begum & Blacher, 2011; Hastings, 2003; 2007). In contrast to previous findings on the contribution of negative dimensions of sibling relationships to increased internalizing symptoms (Campione-Barr, Greer, & Kruse, 2013; Padilla-Walker, Harper, & Jensen, 2010; Pollard, Barry, Freedman, & Kotchick, 2013), the relationship aspects we found related to children’s internalizing problems were the presence of parents in their drawings and children’s reports on rivalry (these are also associated with each other, albeit with small effect). The effect of the presence of parents in the children’s drawings was consistent with the increased caregiving burden for parents of ID children (Abbeduto et al., 2004; Mulroy et al., 2008). This may spill over into the sibling subsystem, resulting in increased parental involvement in sibling relationships. The increased parental involvement indicated in the drawings might be motivated by parents foreseeing the importance of sibling relationships in the future when they are no longer able to manage their ID child’s care. In any event, the drawings suggested parental influence was crucial to the relationship between the siblings and the way the TD siblings perceived the complex situation and dealt with it. Negative relationship dimensions reported by mothers (avoidance behaviors) and by children (conflict and rivalry) were negatively associated with children’s prosocial behaviors. Mothers reported empathy in the relationship was positively associated with prosocial behaviors. In addition, the indicator of size proportion in the children’s drawings was negatively associated with prosocial behaviors. The size and proximity of figures in family drawings yield information on aspects of family interaction and represent children’s relational experiences (Abraham, 2002; Holt & Kaiser, 2001). A number of researchers have suggested that the size and placement of a human figure in a drawing reflect the drawers’ perception of their own social role, including feelings of inferiority to the demands of the environment and decreased confidence in their social status (e.g., Machover, 1949; Hammer & Piotrowski, 1997). Other studies corroborate the hypothesis that a sibling relationship able to provide support, companionship, affection, and other positive qualities may improve the development of prosocial competences (Harper, Padilla-Walker, & Jensen, 2016; Padilla-Walker et al., 2010; Pike et al., 2005). In effect, sibling relationship quality is a form of social support related to psychological adjustment (Buist, Deković, & Prinzie, 2013). Thus, difficulties in sibling relationships, over and above having a sibling with ID, have implications for children’s adjustment. 4.2. Implications, limitations, and future research This study had number of limitations. The sample size was relatively small and thus likely limited in yielding a clearer and more thorough picture and had low statistical power. Furthermore, the cross-sectional design of the research did not permit us to investigate the direction of effects. Mothers were the only reporters on children’s adjustment, and this may have produced different results than if children reported on themselves (Braconnier, Coffman, Kelso, & Wolf, 2018). Previous research has indicated differences in self-reports and point to the importance of including children’s reports on adjustment, especially for internalizing symptoms (Shivers, McGregor, & Hough, 2019). To better investigate the developmental processes examined here and to understand them correctly, we need longitudinal studies. The current study lacked information on the adaptive functioning and behavioral characteristics of the siblings with ID. Several studies indicated the impact of siblings with DD behavior problems and positive and negative outcomes among siblings (Begum & Blacher, 2011; Hastings, 2003; 2007; Petalas et al., 2012). Our study did not include children's own interpretations of the drawings. Future studies should advance the methodology by asking children to draw themselves and, at the same time, provide a qualitative narrative for the drawing process, the product itself, and its personal meaning (Roth, Lev-Wiesel, & Shochat, 2019) could deepen our understanding of the pictorial phenomenon, its validity as an art-based data gathering tool, and sibling relationships. Furthermore, the request to draw a family might be experienced by the individual as too direct, and thus may activate defenses (Kaiser, 1996). Hence, future studies might consider other approaches such as asking children to draw a subject that would elicit the identified target material indirectly, for example drawings tasks that include inanimate objects such as a ‘Person Picking an Apple from a Tree (Bat Or & Ishai, 2016). Nevertheless, our study makes a valuable contribution to the literature by using an art-based data gathering task to shed new light on the unique aspects of the relationships of children with their ID siblings that are not revealed in verbal reports. As such, it may serve as a basis for further research into art-based tools that elicit and document the subjective experience of the child. Further investigation of a large sample of children with and without a sibling with ID would better assess the utility of these and other drawing indicators. The use of drawings for this specific population might complement our understanding of sibling relationships in these families and help children with siblings with ID or other disabilities and professionals by enabling children to express their 9

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