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 Table of Contents  
Year : 2022  |  Volume : 38  |  Issue : 2  |  Page : 182-187

Quality of sibling relations in children with attention-deficit hyperactivity disorder: A case–Control analysis

1 Department of Psychiatry, TNMC and BYL Nair Ch. Hospital, Mumbai, Maharashtra, India
2 Department of Psychiatry, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission13-Jun-2020
Date of Decision12-Jul-2020
Date of Acceptance22-Jul-2020
Date of Web Publication04-Aug-2021

Correspondence Address:
Dr. Hrishikesh Bipin Nachane
Department of Psychiatry, TNMC and BYL Nair Ch. Hospital, Mumbai - 400 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_164_20

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Background: Children with attention-deficit hyperactivity disorder (ADHD) have severe impairment in their social functioning, and such literature from their sibling relations is limited. Sibling relations have several dimensions to them and a more detailed assessment into their impairment in ADHD is needed. We compared quality of sibling relations among ADHD sibling dyads and healthy controls. We also correlated the quality of sibling relations with severity of inattention and hyperactivity in ADHD. Materials and Methods: The present case–control study enrolled 30 cases of ADHD and 30 healthy controls from a child guidance clinic. The quality of their sibling relations was assessed by parent-rated version of the sibling relationship questionnaire (SRQ) on four domains of warmth, power struggle, conflict, and rivalry as well as their respective sub–domains. Their severity of inattention and hyperactivity was assessed using the Vanderbilt ADHD Diagnostic Parents Rating Scale (VADPRS). Results: ADHD sibling pairs had significantly lower warmth, prosocial behavior, affection, companionship, and competition as compared to their healthy counterparts. ADHD child was admired less by the sibling, and they were also seen to nurture each other less. The most significant difference was seen in affection (r = 0.59), followed by nurturance (r = 0.56). Intersibling conflict correlated positively with hyperactivity scores on VADPRS (ρ = 0.410, P = 0.04). Conclusions: Sibling relations are significantly affected in ADHD, with lower warmth and nurturance. Most significant impairment is noted in affection followed by nurturance. Intersibling conflict correlates significantly with severity of hyperactivity.

Keywords: Affection, attention-deficit hyperactivity disorder, nurturance, sibling relations, warmth

How to cite this article:
Nachane HB, Nayak AS, Keshari P, Parkar SR, Saurabh KH, Arora M. Quality of sibling relations in children with attention-deficit hyperactivity disorder: A case–Control analysis. Indian J Soc Psychiatry 2022;38:182-7

How to cite this URL:
Nachane HB, Nayak AS, Keshari P, Parkar SR, Saurabh KH, Arora M. Quality of sibling relations in children with attention-deficit hyperactivity disorder: A case–Control analysis. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 9];38:182-7. Available from: https://www.indjsp.org/text.asp?2022/38/2/182/323114

  Introduction Top

Children with attention-deficit hyperactivity disorder (ADHD) mainly exhibit deficits in their attention spans and motor activity; however, it is their problems in the social realm that mostly impede their development.[1] Recent literature has shown marked impairment in parent – child relations and peer relations, but few have addressed sibling relations in ADHD.[2] Sibling relationships are often an individual's longest-lasting relationship and siblings form an important source of companionship, intimacy, and nurturance.[3] Sibling relationships have been shown to be significant in predicting a child's emotional and behavioral adjustment.[4] Children with ADHD demonstrate problems with inhibition and self-regulation when interacting with peers and siblings which contribute to higher conflict and less warmth in sibling relationships.[5],[6] Siblings of children with ADHD describe their relation as chaotic, conflictual, and exhausting.[7] Sibling dyads with ADHD have also been shown to express high negativity about their relationship and frequent aggression.[8] A combination of behavioral disinhibition and impaired social cognition predisposes children with ADHD to have difficulties attending to conversations, reading social cues, following game rules and taking turns, which translates into their poor quality of sibling relations.[8],[9] Few studies in India have, however, addressed this issue.

Various factors have been shown to predict the quality of sibling relations.[2] Among those studied were age, sex, severity of inattention, hyperactivity, presence of externalizing and internalizing disorders, and aggression.[2] There has been considerable variation in methods applied to assess sibling relations.[8] This is also because there are various dimensions to the nature of sibling relations.[2] Furman and Buhrmester developed the sibling relationship questionnaire (SRQ) which assesses the nature of sibling relations on four principal domains – warmth/closeness, relative status/power struggle, conflict, and rivalry.[3] Each domain is further divided into several sub–domains which enquire into more basic factors such as intimacy, affection, and quarrelling. Having such exhaustive measures help in elucidating the exact nature of sibling relations and can help in focusing our interventions. It has been seen that negative sibling relations can lead to further problematic behaviors and psychopathology such as intersibling bullying, depression, anxiety and self-harm in adolescence, and early adulthood.[10] This implies a need to consider interventions specifically targeting focused aspects of sibling relations in ADHD.[11]

The present study analyzed sibling relations in four domains: warmth, power struggle, conflict and sibling rivalry, and their respective subdomains among children with ADHD and compared it with normal children. We also correlated the various domains of sibling relations with severity of attention and hyperactivity.

  Materials and Methods Top

The present study is an exploratory study of the case––control observational variety, which was conducted in the child guidance clinic of the department of psychiatry in a tertiary hospital in Mumbai. Ethical clearance was taken from the Institutional Ethics Committee. Each parent and child was explained the nature of the study, and a written informed consent was taken from the parent, and a written assent was taken from the child and the sibling. A total of sixty samples; thirty cases and thirty controls were enrolled. Cases were defined as children diagnosed with ADHD as per the Diagnostic and Statistical Manual of Mental Disorders–5 criteria,[12] between the ages of five and twelve, with clinically normal intelligence, with at least one live sibling. Children who were on medications or had any major medical or surgical illness were excluded from the study. Controls were defined as children of similar age group with at least one live sibling, having average intelligence and without any major medical, surgical or psychiatric illness in either the child or the sibling. These were recruited from the general population, mainly relatives of patients or those who had no active psychopathology. The study was completed over 6 months and purposive sampling method was used. A semi-structured pro forma was used to collect the basic sociodemographic details of the participants and their siblings. The parent rated versions of SRQ and Vanderbilt ADHD Diagnostic Parents Rating Scale (VADPRS) were then administered to the parents in their vernacular languages to assess the quality of sibling relations and severity of inattention and hyperactivity, respectively. The entire interview was completed in one sitting and took about 20 min.


Sibling Relationship Questionnaire

SRQ is a 48-item commonly used, well-validated scale for assessing sibling relations.[3] Each item is scored on a five-point Likert scale: from 1 (hardly at all) to 5 (extremely much). The parent version of the questionnaire was used and filled by the parent accompanying the child. In case of multiple siblings, the sibling relation was assessed with the sibling nearest to age with respect to the child with ADHD. For the present analysis, both the domains and the sub–domains were analyzed. The domains of sibling relations as assessed by the SRQ are warmth/closeness, relative status/power struggle, sibling rivalry, and conflict. Each domain is calculated from the scores of its respective subdomains. The subdomains for Warmth/Closeness factor include intimacy, prosocial behavior, companionship, similarity, admiration by sibling, admiration of sibling, and affection. For relative status/power struggle, they consist of nurturance of sibling, dominance of sibling, nurturance by sibling, and dominance by sibling. Conflict domain consists of quarreling, antagonism, and competition. The Rivalry domain is made up of maternal and paternal partiality.

Vanderbilt attention-deficit hyperactivity disorder diagnostic parents rating scale

This scale has been used widely in research on ADHD.[13] It consists of 47 questions which are rated on a four-point Likert scale ranging from 0 to 3. It has two domain scores for inattention and hyperactivity and additional questions for screening of comorbid disorders such as oppositional defiant disorder, conduct disorder and emotional issues. It also has questions for rating the child's performance. Internal consistency of VADPRS is good, with a reliability of 93% and overall Cronbach's alpha ≥0.90 being reported in previous studies.[13]

Statistical analysis

IBM SPSS Statistics (version 20.0) was used for analysis (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY: IBM Corp.). For comparison of age and sex between cases and controls, the Mann––Whitney U-test and Fisher's exact test were used, respectively. The comparison of sibling relations between cases and controls was done using the Mann–Whitney U-test and median plus or minus interquartile range, mean ranks, Z score and Mann–Whitney U statistic are reported. Effect size “r” was calculated as Z divided by the square root of total sample size. Domain/sub – domain scores with higher mean ranks were considered to be higher in that respective group. Spearman's rank correlation was used to correlate domain scores of SRQ with inattention and hyperactivity scores of VADPRS. P < 0.05 was considered significant.

  Results Top

The present analysis analyzed thirty cases and thirty controls. The mean age of cases was 9.96 ± 2.83 years and that of controls was 9.27 ± 1.94 years, whereas that of their siblings' was 9.27 ± 1.94 years and 10.2 ± 3.78 years, respectively. 88.6% of the cases were males, whereas 73.3% of the controls were males. While 47.1% of the siblings of the cases were males, 30% of the siblings of controls were males. Forty percent of both the cases and controls were same-sex sibling pairs (male-male or female-female), whereas 60% were opposite-sex sibling pairs. There was no statistically significant difference in the two groups on any of these factors.

[Table 1],[Table 2],[Table 3],[Table 4] compare the sibling relations on the four domains and their respective sub – domains. With respect to the main domains, only warmth was seen to be significantly lower in cases than controls (U = 249.50, P = 0.003). The difference between various subdomain scores revealed that ADHD sibling pairs had significant lower prosocial behavior (U = 244.50, P = 0.002), companionship (U = 236.50, P = 0.001), affection (U = 144.50, P < 0.001), and admiration by sibling (U = 292.00, P = 0.017). ADHD sibling pairs nurtured each other less as compared to controls (P < 0.001), but overall power struggle was unaffected. With respect to conflict domain, only competition subdomain differed, being lesser in ADHD sibling pairs (U = 236.50, P = 0.001). Looking at the effect sizes of all the variables, only three variables had r > 0.5, which were affection (r = 0.59) and nurturance of and by sibling (r = 0.56 for both), indicating these two factors were the most affected. All the other factors which came significant had effect size >0.3, indicating medium effect and were hence moderately affected.
Table 1: Differences in warmth domain and its subdomains' scores

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Table 2: Differences in power struggle domain and its subdomains' scores

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Table 3: Differences in conflict domain and its subdomains' scores

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Table 4: Differences in sibling rivalry domain and its subdomains' scores

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On the VADPRS, cases had an average score of 16.83 ± 4.98 on the inattention subscale and 17.77 ± 6.22 on the hyperactivity subscale. [Table 5] demonstrates the correlation of severity of inattention and hyperactivity with the four domains of SRQ. There was no statistically significant correlation between sibling relations domains and inattention scores (P > 0.05). However, sibling conflict had positive correlation with hyperactivity scores (P = 0.410, P = 0.04). The Spearman's rho was found to be 0.41, indicating a moderate correlation between the variables.
Table 5: Correlation of sibling relations with inattention/hyperactivity scores

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  Discussion Top

Children with ADHD have significant impairment in their social relations with parents and peers.[2] The present analysis shows that sibling relations in ADHD are similarly affected. Research done earlier based on parent-reported sibling relations has shown that parents usually report their sibling relations as poor, and our findings are in keeping with theirs.[14] Our analysis further revealed that sibling pairs with ADHD express significantly lower warmth and closeness as compared to controls. Lack of inhibition and self-regulation during routine interaction with siblings result in lower warmth.[5],[6] This is seen chiefly as lesser prosocial behavior, lesser affection and companionship than their non-ADHD counterparts. Studies done on ADHD sibling dyads have shown that sharing and prosocial behaviors during play is impaired and our findings are in keeping with them.[8] Lack of knowledge of social reciprocity and impairment in conflict resolution have been established in ADHD, which accounts for lesser affection and companionship in their sibling relations.[7],[8] ADHD children have been shown to be less desirable by other children owing to them engaging in higher rates of gross motor movement, positive and negative verbalizations, and inappropriate and unexpected acts, and this explains lesser companionship with siblings and being less desired by their sibling.[15] Children having siblings affected with ADHD have been shown to prefer other children for play and companionship, such as their peers.

Nurturance among siblings was also found to be impaired in ADHD. Nurturance requires understanding of each other's needs and appropriate response on correctly interpreted social cues, which are characteristically lacking in children with ADHD.[16] Lack of nurturance in our study had a reciprocal relation, as the ADHD child not only nurtured their siblings less, but were also nurtured less in return. It is a common experience that any sibling experience is easily reciprocal,[8] and it appears that lack of nurturance also follows a similar trend in ADHD sibling dyads.

Competition among ADHD sibling pairs is less as compared to healthy controls. It is a well-known fact that siblings compete with each other in a variety of areas from academics to sports to even seeking their parent's love and approval.[17] Such behavior may be considered essential for a well-rounded development of a child and having less competition may thus have a negative impact rather than a positive one on the child's development. Lack of intersibling competition can also be due to rejection of the sibling.[8] ADHD children demonstrate an elevated rate of social activity engagement which usually results in them engaging in a disproportionate number of aversive social exchanges.[18] This pattern has shown to make ADHD children less desirable for group activities and play, which leads to reduced companionship and competition.[19],[20]

Other studies have highlighted that sibling relations in ADHD are more negativistic and include adverse behaviors such as more antagonism and quarrelling.[21],[22] Power struggle and conflict have been emphatically shown to be altered in children with ADHD, with higher than normal conflict in ADHD sibling pairs.[2] However, the present analysis did not find any significant differences in these domains. Our findings on the other hand show more of absence of warmth and nurturance, rather than the presence of rivalry or conflict in ADHD. Poor sibling relations in ADHD have also been accounted to siblings being withdrawn and distant from one another and this supports our findings.[2] The most significant difference in our study was seen in affection, followed by nurturance. This is important as lesser affection can significantly hamper self–esteem and quality of life in both the child and the sibling.[11] ADHD children and their siblings have been shown to have low self-esteem and quality of life, and this can be translated into lower affection scores.[11] This has also been shown to progress to sibling bullying both by and of the ADHD child. Siblings of ADHD children have also reported lesser happiness in studies.[11] Studies from India looking into sibling relations in ADHD, particularly using the SRQ, are lacking and to our knowledge, ours is the first. A recent follow-up study from India showed that social functioning in ADHD was impaired with regard to parents, peers and teachers, however not with siblings after 3 years of treatment.[23] However, no mention of pretreatment details were available. Our study, on the contrary, not only shows social impairment in ADHD sibling dyads, but also the exact areas of involvement. This difference could be because we assessed them at pretreatment level and due to the use of a more specific instrument in our study to assess sibling relations. Further research on remission in sibling discord in ADHD posttreatment is thus warranted.

Sibling discord in ADHD could be attributed to the presence of excessive impulsivity and hyperactivity leading to a chaotic bond with the sibling.[8] It could be a result of inattention which leads to difficulty in attending to social cues or sustaining attention for a long period during play and conversations.[24] Guevremont and Dumas suggest that children with ADHD may display biases and deficits in social-cognitive skills, such as interpretation of social information and attention to relevant cues.[19] Our findings showed only conflict scores to correlate moderately with hyperactivity. This was a positive correlation, indicating that severe hyperactivity is associated with more intersibling conflict. Other studies have demonstrated similar findings.[2] Aggression has been shown as one of the strongest predictors of poor peer relations and sibling relations in ADHD.[8] Thus interventions targeting hyperactivity might reduce intersibling conflict in ADHD.

Our study was not without limitations. Sample size of the study was small, and this could explain why several of the factors were not significant in our study. Comorbid disorders, known to affect sibling relations in ADHD were not included in the present analysis. Having studies with prospective designs can shed better light on the nature and dynamics of sibling relations in ADHD.

  Conclusions Top

To conclude, sibling relations are impaired in ADHD and ADHD sibling dyads express lesser warmth, prosocial behavior, affection, companionship, and competition. ADHD children are admired less by their siblings. They were also seen to nurture each other less. Affection proved to be the most severely affected area, followed by nurturance. Intersibling conflict is positively correlated with hyperactivity in ADHD. Many nonpharmacological strategies focus on parent–child relations and siblings are usually ignored. Our analysis entails sibling relations to be given equal importance. As problematic sibling relations can lead to further impairment in functioning and quality of life, our study highlights the areas where relations are impaired, so that more focused interventions can be planned.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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[PUBMED]  [Full text]  
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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