In Hannover I have been working as a committee member of the parents support group since our daughter suffered from a Neuroblastoma in 1982. When our family got the terrible diagnosis that our daughter suffered from cancer she was 4 and our son 7 years old. All the time, from the beginning of treatment till her death and even later on, he had been suffering from terrible migraine. In the parents work my special interest is the organization of meetings and festivities for parents with their ill children and of course for the siblings. Those meetings are very interesting because in that free and easy atmosphere you learn to know a lot about the problems of the parents, the children and their siblings. So, I slowly became more and more interested in that topic - problems of siblings.

Trying to find remedies to cope with the situation after the diagnosis I had to realize that nearly nothing can be found in the literature about sibling relationships and how to counsel parents with children with cancer and their healthy children.

Only at the beginning of the early 80s the complete family became the centre of the interest in psychological oncology, up till then the ill child had been in the centre of interest.
We all know that chronic childhood illnesses, such as cancer, create enormous stress on all family members. But the worst thing is, that siblings off ill children are often overlooked.
A common meaning is that a parent feels the immediate emotional and psychological pain twice; once for their ill child and once for themselves.

But the sibling of a child with cancer is assaulted with this pain even on three fronts: they hurt for their ill brother or sister, they hurt for their grieving mother and father, and they hurt for themselves.

Sibling relationships are among the most important precursors to peer and later adult relationships. Siblings function to socialize and educate one another, to mediate parental attention and control, and to provide a peer- like context for intense emotional experience and power negotiation. By one year of age, children spend as much time interacting with their siblings as they do with their mothers and even more time with their siblings than with their fathers - not to mention the time they spend together regarding their whole life. That means siblings relationship is characterised by permanence and continuity. But given significance to the lifelong sibling relationship it is unremarkable that substantial changes in the health or functioning of a sibling will effect the others and these changes may correspond systematically to characteristics of the children, the family, and the disease or disability itself.

How such disruption affects sibling interactions or the family functioning is relatively understudied. Most of the information on siblings of disabled and ill children remains founded on more subjective and anecdotal forms of clinical investigation, such as clinical interview and case report. Few controlled or even empirical investigations exist, and about possible reactions on siblings of children with cancer nearly nothing can be found.

That means talking about results of research of siblings interaction is very difficult. As McKeerer said: "It is unrealistic to hope to be able to obtain valid data about such an affect laden situation as a sibling relationship with a handicapped child when only straightforward techniques are used."

Let me put emphasis again on what I said above that brothers and sisters serve many important functions for each other; these include giving reflected self-appraisal, turning to each other when parents are disorganized; forming cohesive, defensive groups, acting as socializers for one another; and reciprocally controlling behaviour by bringing intense pressure to bear on one another. What happens when this described siblings interaction is disturbed by a serious disease?

I want to present 5 very different results of research on siblings of children with chronic illnesses.

1. Group research generally does not support the popular belief that siblings of disabled and chronically ill children exhibit more problems in overall psychological adjustment than do siblings of healthy children. There is no uniform or direct relationship between a child's illness and psychopathology among his or her siblings. In fact, many siblings of disabled children appear to benefit emotionally and psychologically from their experience. So one result of the research says that nearly half of the siblings of retarded children who were interviewed were rated, in comparison to their peers, as more compassionate, more sensitive, more appreciative of their own good health, and having greater understanding of people. Similarly, teachers rated young siblings of children with diabetes and pervasive developmental disorder as more socially competent and positive with peers than siblings of unaffected children.

2. Another group of researchers has uncovered adverse psychological outcomes, including increases in aggressive behaviour, poor peer relations, anxiety, somatization and depression. But it seems that such adverse reactions appear to be weakly related to sibling constellation, such as sibling sex, birth order, and age spacing, but to more general family factors such as socioeconomic status, mother's social support, and parent reaction to the disability or the disease.

3. Another factor for family functioning and siblings interaction is the amount of time since the diagnosis of the illness or disability.
Based on ratings made by physicians, nurses, psychosocial staff, and parents, most families appeared to be coping well at one year post diagnosis.
When the critical was over, most families achieved a type of stability in which intervention was not needed unless there were complications or relapses.

4. Research not made on psychological and behavioural problems but on comparisons of home and child-care routines of siblings of children with hearing impairments and other developmental disabilities showed that siblings of handicapped children often have to help a lot in the house. So it is found that female siblings of handicapped children have the greatest degree of responsibility for child care and household tasks, and furthermore sisters of handicapped children received significantly fewer privileges and experienced more restrictions on social routines while brothers of handicapped children experienced the opposite - more privileges and fewer restrictions on social activities.

5. What seems to have a positive influence on the sibling's self-esteem is the amount and the quality of conversation between the parents and the sibling about the illness of the brother or sister.
The parents of 22 healthy siblings of 8 children with leukemia were asked to rate each sibling's knowledge of the threat to life posed by the patient's illness. The parents also indicated how much information about the disease had been discussed at home and how often the siblings questioned them about the ill child's disease. Each sibling also rated the health status and life expectancy of himself/herself and the patient. Overall adjustment was positively related to the level of communication between parents and siblings. 
In connection to the topic "the informed parent is a better 'co-therapist' we can emphasize that a better informed sibling is a healthier and luckier sibling.

Those different results show again the big problem in research about siblings interaction. The discussion among researchers is about the many different variables that should or could be investigated and about the methods. As long as there is no agreement we won't get valid results. 

Nevertheless, we can say that research proved that siblings of children with cancer or other chronical illnesses change their behaviour.
1. In a review Sourkes (1980) says that siblings of children with cancer often show psychosomatic reactions.
2. Those reactions are different during the illness. Depending on the time passed from the diagnosis they are more or less intensive.
3. Medical explanation cannot avoid that siblings look for a private reason for the disease of the brother or sister, the develloping of those private reasons often cause magical links, and with that anxiety and guilt.
4. The situation of the siblings is ambivalent. They are angry about the privileges of the ill child, at the same time they feel guilty for being healthy.
If there is a change in behaviour - how do we know and which reactions do the children show?
Younger children tend to manifest their fear, confusion and pain in disguised ways, such as:
bedwetting, rashes, eating and sleeping difficulties (including nightmares),
hyperactivity, increased sibling rivalry, temper tantrums and angry outbursts. Such confusion may culminate in a child who is afraid to separate from his parent or to go to school, who broods or cries a lot, or who is withdrawn.

Older children and teenagers may show:
- psychosomatic illnesses (unexplanied stomachaches, headaches or backaches)
- inability to concentrate, sleep disorders, fears, phobias, panic attacks, 
- plummeting school grades, increased oppositional behaviour, or even alcohol or drug abuse. 

They alienate from their parents, they look for company that often has no positive influence on them.
Many siblings think they could contract their brother's or sister's cancer, or conclude that it is their fault that their brother or sister has cancer, or even wish that their ill brother or sister would disappear or pass away.
12 years ago Cunningham organised a so-called sibling-group in her clinic. Her opinion was that siblings of brothers and sisters with cancer have similar problems, and that on the other hand by comparing their own problems with those of other siblings they could see personal things like guilt a bit easier. The main topics talked about in those groups were: the privileges of the ill child, the difficulty to talk about the illness, the sense of shame for the illness and guilt feelings, the lack of control of their own situation and the loneliness. All group members (siblings) were especially concerned with the family functioning and the emotional situation of the parents. 

All researchers show that the family functioning is most important for sibling interactions. How can adults and especially the parents help to reduce the problems of siblings?
I here quote the suggestions of the Candlelighters - the Childhood Cancer Foundation in the USA:
1. Provide information about cancer and its treatment.
2. Share your feelings with your children. 
3. Include the well children in family decisions whenever possible. 
4. Reward him/her when he/she takes extra responsibilities. 
5. Let them be as involved in the medical side as they wish to be. 
6. Maintain a positive outlook as much as possible.
7. Keep connection in little ways when you are away.
8. Tell teachers about your home situation. 
9. Offer emotional support and tutorial help with schoolwork.
10. The healthy child should get presents as well.
11. A relative or friend should spend time with the healthy children. 

Let me finish with the hope and the wish that each and every member of the family remains healthy and well adjusted in order to overcome one of the worst hardships that any family can endure. Our healthy children keep us in touch with reality, and let us know that our families and our lives must continue, despite having a child with cancer.