Correspondences to: RPAL0009@regionh.dk

Introduction

Clinical guidance emphasises the importance of considering the whole family when caring for a child with a chronic condition, however, the perspectives of siblings are often neglected (Deavin et al., 2018). The purpose of this article is to shed light on the perspectives of siblings, drawing on findings from a wider study which explores the dynamics between pre-teens (aged 9-12 years) with type 1 diabetes and their families. The overall study’s focus on pre-adolescence is due to its importance in the transition from childhood to adolescence, where family relationships change as children seek more independence (Newbould et al., 2008). In families with type 1 diabetes, these changes play an essential role in diabetes management (Rankin et al., 2018).

Chronic illness disrupts family structures

When a child is diagnosed with a chronic condition, changes occur in family structure and roles. These changes profoundly affect siblings of chronically ill children, and much of family life may revolve around the health of the ill child (Bluebond-Langner, 1996; Havill et al., 2019). Siblings may know little about the condition and are likely to worry about the future health of their ill sibling (Havill et al., 2019). Likewise, studies show that siblings of children with diabetes can feel increased levels of responsibility for their ill sibling (Wennick & Huus, 2012; Loos & Kelly, 2006). At the same time, siblings may experience loss of parental attention, which can result in feelings of jealousy and anger (Havill et al., 2019; Loos & Kelly, 2006). In one study, children with diabetes reported that diabetes had brought them closer to their sibling, but they also indicated that diabetes had complicated their relationship with their sibling (Loos & Kelly, 2006). Thus, relationships between children with diabetes and their families are strongly affected by the condition. However, little is known about the experiences of siblings and relational dynamics and most interventions overlook the value of targeting all key family members.

Methodology

The study employed an exploratory design and makes use of participant observation, semi-structured interviews and workshops. This article reports findings from four workshops with pre-teens with type 1 diabetes (n=17), their parents (n=26) and their siblings (n=14) across four hospital settings in Denmark. The study was approved by the Danish Data Protection Agency and the Regional Committee on Health Research Ethics.

The workshops were facilitated by members of the research team, with each session following the same structure (Table 1). As part of the workshop, participants were divided into three groups: (1) pre-teens with diabetes, (2) siblings and (3) parents to facilitate peer-to-peer communication across families. Each workshop lasted 2.5 hours and was audio recorded and transcribed verbatim.

Table 1

Workshop format

Phases

Activity

Purpose

Participants

1

Introduction

To explain the focus of the workshop

Pre-teens (n=17)

Siblings (n=14)

Parents (n=26)

Participants shared stories about the diagnosis

To encourage open sharing of experiences

Separate groups of parents, pre-teens and siblings

2

Participants placed themselves on either side of the room according to how much space diabetes took up in their lives

To encourage reflection about diabetes in the participants’ lives and to understand why they chose this side

All participants

3

Participants used quotes and picture cards to describe what it was like to have diabetes in the family

Participants selected picture cards to share experiences with support

Participants drew what it was like to have a sibling with type 1 diabetes

To identify and encourage reflection about issues of importance to the families when managing diabetes

To identify and encourage reflection about sources of support

To encourage reflection about and describe experiences of having a sibling with type 1 diabetes

Group 1: parents

Group 2: pre-teens

Group 3: siblings

Participants were invited to ask questions about the workshop

To encourage reflection about the workshop and get suggestions for improvement

All participants

Data were analysed using principles of abductive analysis (Timmermans & Tavory, 2012) in four phases: (1) detailed reading of transcripts and write-ups for each workshop; (2) coding and categorising the data; (3) synthesis of categories into key themes; and (4) transcripts were re-read to identify differences pertaining to the analytical concepts and the data. The concepts of biographical disruption (Bury, 1982) and biographical contingency (Monaghan & Gabe, 2015) were used as guidance in the data analysis. According to Bury (1982), biographical disruption describes how a chronic condition disrupts the normal structure of family life and requires individuals to reappraise their biography and mobilise resources in response to the situation. While acknowledging this perspective on chronic conditions, Monaghan and Gabe (2015) have introduced the notion of biographical contingency which refers to how meanings and consequences of a chronic condition vary depending on aspects of self, social location and medication. Together, these perspectives can shed light on how pre-teens and their families adapt to life with type 1 diabetes.

Results

Three themes characterised the relationship between children with type 1 diabetes and their siblings: 1) diabetes takes up ‘a lot of space’, 2) concealed frustrations, and 3) contradictory wishes for support.

According to all participants, diabetes took up a lot of family space. In line with the concept of ‘biographical disruption’ (Bury, 1982), parents often described diabetes as a critical situation that disrupted the normal rules of family life. They were worried about their child with diabetes and suggested that the family adapted their daily routines to the child. This is indicated by one father:

“It’s important that the family understands that it [sweets] is not just a ‘help yourself’-table. The family has to adapt to [name of pre-teen].”

All family members, however, did not want diabetes to take up too much space.

Pre-teens and parents were aware that diabetes received a great deal of attention in the family at the expense of giving the sibling attention. One mother described that:

“Diabetes can easily split a family apart. In one way or another. Because you [parent] feel that the other children are set aside.”

In addition, siblings were sometimes annoyed that diabetes affected their daily life. They reported often waking up at night because of the alarm on the insulin pump, a medical device to administer insulin for the treatment of diabetes.

Despite these issues, siblings concealed their frustrations from their siblings and parents as they felt sorry for their sibling with diabetes. A brother expressed this situation:

“I feel sorry for him [brother]. It’s like a delicate balance between what I feel and what I can say about it”.

One sister reported not saying anything about the needles that were everywhere in their home although she was annoyed by them:

“Well in a way I feel that I can’t allow myself to be very angry about it right... because he [brother] lives with it every day.”

Pre-teens with diabetes reported that their siblings had limited knowledge about diabetes. However, they did not want diabetes to interfere with their relationship with their sibling and preferred them not to worry about diabetes. Accordingly, a pre-teen mentioned that his brother was not part of his ‘diabetes life’:

“He’s not that involved in, what should I call it, my diabetes life. He’s more a part of my normal life […] we do a lot of stuff together”.

Furthermore, pre-teens resented waking up their parents and siblings at night because of the alarms on the insulin pump.

As suggested by Bury (1982), diabetes changed family relationships and required pre-teens as well as their family members to mobilise resources in response to the situation. Although pre-teens did not want to attract attention to diabetes, they appreciated help from their parents and siblings. Siblings expressed a wish to support their sibling with diabetes but were unsure how. As one brother reported:

”I don’t know how to help her [sister]. And that’s one of the reasons I don’t interfere with her diabetes.”

They were sometimes afraid of doing something wrong when they were home alone with their sibling. At the same time, they did not perceive diabetes care as their responsibility. Accordingly, parents found it very difficult to balance the involvement of siblings in diabetes as indicated by one mother:

“It’s a balancing act that’s very difficult, I think, but important.”

Despite the challenges that the families reported in relation to managing the burden of type 1 diabetes, they constructed a sense of normality by accepting the variability of the condition and remaining optimistic. In particular, this seemed to be the case for pre-teens. This finding is related to the concept of ‘biographical contingency’ which emphasises the contingencies of the illness experience rather than the single shocking event of receiving a diagnosis (Monaghan & Gabe, 2015).

Discussion

It is clear that managing diabetes within the family while negotiating relationships is challenging for many families. Although research is lacking on families with children with type 1 diabetes, the findings can be related to work on families living with other chronic conditions. Bluebond-Langner (1996) has shown how families living with cystic fibrosis cope with the intrusion of the condition. She identified different strategies used by parents to contain the intrusion e.g. redefining normal and reassessing priorities. These strategies reflect how parents in this study adjusted to life with diabetes. However, they did not want diabetes to dominate family life and struggled to balance this with the comprehensive daily treatment that diabetes entails. Furthermore, Bluebond-Langner (1996) described that siblings often live ‘in the shadow’ of their ill sibling which corresponds to our finding that siblings resented the attention their parents gave the child with diabetes. However, they also felt sorry for their sibling with diabetes and wanted to provide support. Other studies have reported that siblings often experience strong and contradictory feelings about their ill sibling (Deavin et al., 2018; Loos & Kelly, 2006). This includes feelings of anger and sadness, as well as feelings of protection and pride (Havill et al., 2019; Deavin et al., 2018). Furthermore, we found that siblings often concealed their emotions from the family. A study by Wennick and Huus (2012) demonstrated that siblings were often silent about their own feelings, because they thought their parents had enough to worry about. In addition, research has revealed that parents did not talk to the siblings about the illness, to protect them from difficult aspects of it (Malcolm et al., 2014). Likewise, parents and pre-teens in our study did not want siblings to become too involved in diabetes. Accordingly, research has demonstrated that pre-teens wanted to alleviate the burden diabetes placed on their families (Rankin et al., 2018).

However, these systems that family members set up to protect each other may reduce communication and cause them to suppress their own needs (Deavin et al., 2018). Although siblings understood why parents gave more time and attention to their ill siblings, they felt left out. We found that siblings requested knowledge about how to best support their ill sibling. This did not only pertain to practical contributions, but also to how they could emotionally support their sibling which has also been reported by Loos and Kelly (2006). However, our study indicates that older siblings were more likely to feel protective towards their ill sibling compared to younger siblings. Accordingly, some studies suggest that siblings’ involvement in the illness may differ according to age (Havill et al., 2019).

Conclusion and Recommendations for Practice

Diabetes received a lot of attention in the families which could be frustrating for siblings. However, siblings were very supportive toward their ill sibling. Nevertheless, they were unsure how to support and concealed their frustrations from family members. Pre-teens valued support from family members, but did not want to attract attention to their diabetes. To address siblings’ needs, we suggest that parents and professionals encourage open communication in families, seek siblings’ perspectives and tailor information and support accordingly. Peer-to-peer support is important so providing a forum where siblings can meet and share experiences may also be helpful. Clearly, siblings should always be ‘seen and heard’ and their needs taken into account in development of future interventions for diabetes care of pre-teens. Promoting family-centred care is essential in the care of children with chronic conditions.