Siblings of adolescents with anorexia nervosa

There is substantial evidence that family-based treatment (FBT) is an effective intervention for medically stable adolescents with anorexia nervosa (AN). According to the FBT manual, siblings of adolescents with AN should attend FBT sessions with their family to assist their brother or sister in the recovery process. However, the experience of siblings in FBT has not been well researched, and the effects of the illness and treatment on siblings remains unclear. The broad aims of this research were to better understand the sibling experience of FBT and to investigate whether siblings experience increased psychosocial distress in comparison to the general population. A mixed-methods research design was employed to provide a deeper understanding of the sibling experience from various family member perspectives. Three studies from this research are reported within this thesis. In the first study, in-depth semi structured qualitative interviews were conducted with 12 siblings of adolescents undertaking FBT. Interviews were evaluated using thematic analysis to categorise the positive and negative aspects of sibling involvement in FBT and to identify emerging themes about their involvement. The interviews revealed that siblings perceived both positive and negative experiences associated with the illness and their involvement in treatment. Siblings believed that their involvement in FBT enhanced their understanding of the eating disorder, however their treatment attendance decreased as treatment progressed. Several siblings expressed a desire to have attended more treatment sessions in order to better support their ill sibling, however were unable to do so due to practical factors (e.g. transportation and schooling). Siblings also reported both positive and negative changes in their relationship with their ill sibling, which occurred as a result of the illness and treatment. In the second study, 21 in-depth semi structured qualitative interviews were conducted with adolescents undertaking FBT and their parents. Interviews were evaluated using thematic analysis. Results of the study suggested that there was no clear preference among parents and patients regarding whether or not siblings attended treatment sessions. However, both parents and patients believed the treatment and the eating disorder had a significant effect on siblings regardless of the sibling’s frequency of attendance at treatment sessions. Parents and patients were concerned that siblings often had additional stressors that they had to deal with in conjunction with the eating disorder (e.g. school work) and this sometimes limited their involvement in treatment. Siblings were described as supporting their family and the treatment in a variety of ways but the type of support provided varied considerably between families. In the third study, sibling psychosocial well-being was assessed at diagnosis and following completion of FBT using self- and parent-reports on the Strengths and Difficulties Questionnaire (SDQ). A total of 85 parents and 55 siblings completed questionnaires at diagnosis, a total of 88 parents and 46 siblings completed questionnaires following treatment. SDQ scores at diagnosis were compared to population norms, with siblings found to report significantly more emotional and hyperactivity problems than their peers. In contrast, mothers and fathers reported that siblings had significantly lower levels of conduct problems compared to population norms, and mothers also reported that siblings engaged in less prosocial behaviours. Despite a substantial portion of patients, parents, and siblings expressing concern that FBT had a negative impact on sibling well-being, there were no significant differences in reports of sibling psychosocial well-being as measured by the SDQ at diagnosis and following treatment. While these results suggest that there is minimal impact on sibling well-being, other areas of functioning need to be examined, as well as individual factors that may moderate the impact of treatment. Collectively, the findings from these three studies suggest that siblings experience both positives and negatives associated with FBT and the eating disorder. Qualitatively, siblings, parents and patients reported different experiences; however all agreed that the treatment and the eating disorder had a substantial effect on the siblings. Quantitatively, siblings reported poorer well-being in comparison to norms. These findings have implications for our understanding of the sibling experience of FBT and AN, as well as the potential impact on their well-being. From a treatment point of view, therapists are encouraged to actively include siblings in discussions when they are present and to provide families with clear and consistent information regarding how often and for how long siblings are expected to attend treatment sessions. Parents should be encouraged to speak directly to siblings to ascertain their desire to be involved in treatment and address any concerns they may be experiencing. As siblings experience elevated psychological distress, therapists can provide psychoeducation to parents regarding siblings’ needs, and assist in problem solving when necessary, ensuring that the unaffected siblings’ well-being needs are met, and appropriate supports made available.