Enhancing resilience in siblings of children with cancer

Enhancing Resilience in Enhancing Resilience in Siblings of Children with Siblings of Children with

Cancer:Cancer: A group intervention A group intervention

Kelsey Harper, MAKelsey Harper, MAGerald Michaels, PhDGerald Michaels, PhD

Rhoda Olkin, PhDRhoda Olkin, PhD

Enhancing Resilience in Siblings of Children with Cancer: A Group Enhancing Resilience in Siblings of Children with Cancer: A Group InterventionIntervention

Significant numbers of families Significant numbers of families are suddenly thrown onto a vastly are suddenly thrown onto a vastly different and unexpected path, different and unexpected path, one that involves intensive and one that involves intensive and invasive treatments, fluctuations invasive treatments, fluctuations between health and sickness, between health and sickness, threats to the family system, and threats to the family system, and severe emotional distress. The severe emotional distress. The new path begins when a child is new path begins when a child is diagnosed with cancer.diagnosed with cancer.


Following diagnosis, families Following diagnosis, families have a very short time to adjust have a very short time to adjust before the ill child becomes very before the ill child becomes very sick. During treatment, ill sick. During treatment, ill children are consumed by children are consumed by exhaustion, severely limiting or exhaustion, severely limiting or completely eliminating all completely eliminating all activities in order to rest and activities in order to rest and recover from treatment.recover from treatment.


Normal family development is stalled Normal family development is stalled and diverted onto a new path as the and diverted onto a new path as the entire family becomes “sick.” In entire family becomes “sick.” In normal families, the family life cycles normal families, the family life cycles travel along a path involving stages of travel along a path involving stages of relational changes. As the family relational changes. As the family develops through marriage, the birth develops through marriage, the birth and raising of young children, power and raising of young children, power struggles through adolescence, struggles through adolescence, launching children, and moving on launching children, and moving on into later life (Carter & McGoldrick, into later life (Carter & McGoldrick, 2005). 2005).


When a normal developmental When a normal developmental transition happens at the same transition happens at the same time as the unpredictable time as the unpredictable stressful event of the diagnosis of stressful event of the diagnosis of cancer in a child, family members cancer in a child, family members can become significantly can become significantly distressed (Carter & McGoldrick, distressed (Carter & McGoldrick, 2005). 2005).


As parents redefine their roles in As parents redefine their roles in reference to the ill child, siblings of reference to the ill child, siblings of the ill child, are often left to the ill child, are often left to reinterpret their roles within the reinterpret their roles within the family. Siblings may be excluded family. Siblings may be excluded from the new family tasks of caring from the new family tasks of caring for the ill child, leaving siblings for the ill child, leaving siblings struggling to identify a role within struggling to identify a role within the family, a relationship with the ill the family, a relationship with the ill child, and a sense of purpose and child, and a sense of purpose and belonging within the family belonging within the family (Woodgate, 2006). (Woodgate, 2006).


Along with feeling the loss of a place Along with feeling the loss of a place within the family, siblings may within the family, siblings may experience significant psychological experience significant psychological symptoms in the face of the stressors symptoms in the face of the stressors accompanying the diagnosis of the ill accompanying the diagnosis of the ill child. Siblings typically show symptoms child. Siblings typically show symptoms of anxiety, depression, posttraumatic of anxiety, depression, posttraumatic stress disorder, isolation, and guilt, stress disorder, isolation, and guilt, rather than symptoms of aggression and rather than symptoms of aggression and anger, making the struggles of well anger, making the struggles of well siblings harder to notice (Sharpe, 2002).siblings harder to notice (Sharpe, 2002).


Siblings can respond in a resilient way, Siblings can respond in a resilient way, that involves their redefining their that involves their redefining their roles as a caregiver for the family and roles as a caregiver for the family and ill child, and their taking on ill child, and their taking on responsibility and purpose in the responsibility and purpose in the family. Shifting their role provides a family. Shifting their role provides a new, significant and prominent role for new, significant and prominent role for the sibling to play. Including them the sibling to play. Including them within the family tasks, rather than within the family tasks, rather than excluding them, promotes well-being. excluding them, promotes well-being. As well, many siblings learn to respect As well, many siblings learn to respect healthfulness, to identify and develop healthfulness, to identify and develop capability as opposed to disability, and capability as opposed to disability, and to show empathy and compassion to show empathy and compassion (Fleitas, 2000). (Fleitas, 2000).


Siblings’ to cope with adversity, Siblings’ to cope with adversity, respond with strength, and develop respond with strength, and develop normally in spite of challenges, shows normally in spite of challenges, shows resilience. Resilient tools are resilience. Resilient tools are developed throughout the lifespan as developed throughout the lifespan as healthy, adjusted responses to healthy, adjusted responses to adverse events (Hirayama, & adverse events (Hirayama, & Hirayama, 2001). These tools can be Hirayama, 2001). These tools can be enhanced through providing social enhanced through providing social support and a secure, safe space to support and a secure, safe space to complete normal developmental complete normal developmental tasks. tasks.


Working with siblings can Working with siblings can enhance resilience; building enhance resilience; building protective tools to respond to the protective tools to respond to the stressors that are a part of being stressors that are a part of being a sibling of a child with cancer a sibling of a child with cancer can assist with strength and can assist with strength and growth and can promote a strong growth and can promote a strong self esteem.self esteem.


The purpose of the group The purpose of the group intervention is to enhance intervention is to enhance resilience in siblings of children resilience in siblings of children with cancer. This will provide with cancer. This will provide siblings with the strength and siblings with the strength and tools necessary to effectively cope tools necessary to effectively cope with the variable, ambiguous, and with the variable, ambiguous, and unpredictable process of cancer.unpredictable process of cancer.


The group is for elementary The group is for elementary school age siblings of children school age siblings of children with cancer. The group spans 12 with cancer. The group spans 12 weeks and covers topics relevant weeks and covers topics relevant to sibling experiences. The to sibling experiences. The sessions include various play sessions include various play activities, games, story telling, activities, games, story telling, role plays, arts and crafts, and role plays, arts and crafts, and family interactions. family interactions.


Each group session will last one Each group session will last one and a half hours and all sessions and a half hours and all sessions will be organized around a will be organized around a schedule for every session that schedule for every session that contains three parts. The first contains three parts. The first part opening each session is the part opening each session is the “Feelings Tree”, followed by “Feelings Tree”, followed by “Roses and Thorns” activities. “Roses and Thorns” activities. Closing each session is the Closing each session is the “Siblings Book” activity. “Siblings Book” activity.


Feelings TreeFeelings Tree– As participants arrive at session, As participants arrive at session,

they will choose an image of a facial they will choose an image of a facial expression that shows how they are expression that shows how they are currently feeling at that time and currently feeling at that time and place it on the “Feelings Tree” by place it on the “Feelings Tree” by their name. This activity focuses on their name. This activity focuses on identifying and expressing identifying and expressing emotions, and includes the emotions, and includes the experience of emotions as a regular experience of emotions as a regular activity throughout the group. activity throughout the group.


Roses and ThornsRoses and Thorns– Once everyone has arrived, each Once everyone has arrived, each

participant will take a turn in participant will take a turn in describing his or her “Roses and describing his or her “Roses and Thorns” of the week: his or her best Thorns” of the week: his or her best moment, and his or her worst moment, and his or her worst moment. This gives siblings the moment. This gives siblings the space to talk about their own space to talk about their own experiences, good and bad, in a experiences, good and bad, in a supportive space. supportive space.


Siblings BookSiblings Book– Closing each session will be a review Closing each session will be a review

of important points of the day, of important points of the day, followed by the activity of adding a followed by the activity of adding a page to each participant’s “Siblings page to each participant’s “Siblings Book”. The Siblings Book has one Book”. The Siblings Book has one page for every session of the group page for every session of the group where siblings draw a picture of or where siblings draw a picture of or write about their favorite part or write about their favorite part or most useful part of the session. At most useful part of the session. At the end of the 12 weeks, siblings will the end of the 12 weeks, siblings will take this book home as a reminder of take this book home as a reminder of the work they did in the group.the work they did in the group.


Plan of sessionsPlan of sessions– Session 1Session 1 IntroductionIntroduction– Session 2Session 2 Myth BustersMyth Busters– Session 3Session 3 Family StructureFamily Structure– Session 4Session 4 Sibling RelationshipSibling Relationship– Session 5Session 5 Understanding FeelingsUnderstanding Feelings– Session 6Session 6 Communication Communication – Session 7Session 7 Scary/Brave StoriesScary/Brave Stories– Session 8Session 8 Scary/Brave StoriesScary/Brave Stories– Session 9Session 9 Loss, GriefLoss, Grief– Session 10Session 10 Social DevelopmentSocial Development

– Session 11Session 11 Social DevelopmentSocial Development– Session 12Session 12 GraduationGraduation


Session one is an introduction to Session one is an introduction to the group to familiarize siblings the group to familiarize siblings with this group, group rules, with this group, group rules, privacy, and introduce their privacy, and introduce their families to the group. families to the group.

Session two is Myth Busters day Session two is Myth Busters day that includes activities to talk that includes activities to talk about common myths siblings about common myths siblings have about cancer, their family, have about cancer, their family, and their experiences. and their experiences.


Session three looks at the family Session three looks at the family of the sibling, relationships, and of the sibling, relationships, and re-establishing a role within the re-establishing a role within the family. family.

Session four focuses on the Session four focuses on the sibling relationship by talking sibling relationship by talking about perceptions of others, their about perceptions of others, their unique relationship, and fun unique relationship, and fun things they do together. things they do together.


Session five talks about emotions, Session five talks about emotions, expressing, and communicating expressing, and communicating feelings and building tools to feelings and building tools to cope with feelings. cope with feelings.

Session six builds communication Session six builds communication skills by practicing talking about skills by practicing talking about difficult things with family difficult things with family members, friends, and peers. members, friends, and peers.


Session seven starts a two-Session seven starts a two-session series that reflects upon session series that reflects upon past times of coping despite the past times of coping despite the challenges. challenges.

Session eight concludes the two-Session eight concludes the two-session series, using the siblings’ session series, using the siblings’ own coping to provide tools own coping to provide tools siblings can use now. siblings can use now.


Session nine examines possible Session nine examines possible experiences of loss and grief that experiences of loss and grief that siblings may face. As this is a siblings may face. As this is a very risky subject, it will be very risky subject, it will be handled sensitively. Siblings handled sensitively. Siblings review feelings and coping tools review feelings and coping tools to help manage changes. to help manage changes.


Session ten starts another two-session Session ten starts another two-session series that provides opportunities for series that provides opportunities for social development. In this first social development. In this first session of social development, siblings session of social development, siblings will play a team-building game, and will play a team-building game, and talk about different after school talk about different after school activities.activities.

Session eleven concludes the two Session eleven concludes the two session series of social development session series of social development where siblings get to play different where siblings get to play different games, and activities to build social games, and activities to build social skills.skills.


Session twelve terminates the group Session twelve terminates the group with a graduation ceremony. with a graduation ceremony. Siblings and their families get to Siblings and their families get to celebrate their accomplishments in celebrate their accomplishments in group.group.


Your helpYour help– Please follow the link to the online Please follow the link to the online

survey to tell me your feelings about survey to tell me your feelings about the group, give feedback, and offer the group, give feedback, and offer advice on the needs these families advice on the needs these families face.face.

– http://http://alliant.qualtrics.comalliant.qualtrics.com/SE?SID=SV_8vQgHCC5h6Ut2K0/SE?SID=SV_8vQgHCC5h6Ut2K0


Thank you!Thank you!


ReferencesReferences Carter, B. & McGoldrick, M. (2005). Siblings through Carter, B. & McGoldrick, M. (2005). Siblings through

the life cycle. In B. Carter & M. McGolderick (Eds.), the life cycle. In B. Carter & M. McGolderick (Eds.), The Expanded Family Life CycleThe Expanded Family Life Cycle (pp. 153-168). (pp. 153-168). Massachusetts: Allyn & Bacon.Massachusetts: Allyn & Bacon.

Fleitas, J. (2000). When jack fell down…Jill came Fleitas, J. (2000). When jack fell down…Jill came tumbling after. tumbling after. The American Journal of Maternal The American Journal of Maternal Child Nursing, 25Child Nursing, 25 (5), pp 276-273. (5), pp 276-273.

Hirayama, H., & Hirayama, K. (2001). Fostering Hirayama, H., & Hirayama, K. (2001). Fostering resiliency in children through group work: Instilling resiliency in children through group work: Instilling hope, courage, and life skills. In Kelly, T.B., Rossi, hope, courage, and life skills. In Kelly, T.B., Rossi, T.B., & Palombo, S. (Eds.), T.B., & Palombo, S. (Eds.), Group work: Strategies for Group work: Strategies for strengthening resiliency strengthening resiliency (pp 71 – 83). Birmingham, (pp 71 – 83). Birmingham, NY: The Haworth Press. NY: The Haworth Press.

Sharpe, D. (2002). Siblings of children with a chronic Sharpe, D. (2002). Siblings of children with a chronic illness: A meta-analysisillness: A meta-analysis. Journal of Pediatric . Journal of Pediatric Psychology, 27Psychology, 27 (8), pp 699-710. (8), pp 699-710.

Woodgate, R. L. (2006). Siblings’ experiences with Woodgate, R. L. (2006). Siblings’ experiences with childhood cancer: A different way of being in the childhood cancer: A different way of being in the family. family. Cancer Nursing, 29 Cancer Nursing, 29 (5), pp 406 – 414.(5), pp 406 – 414.

Health & Medicine

Enhancing resilience in siblings of children with cancer