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Utility of qualitative metasynthesis: Advancing knowledge on the wellbeing and needs of siblings of children with mental health problems

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Abstract

Qualitative metasynthesis is an interpretive integration of primary qualitative research. It is a relatively new research methodology with questions remaining about utility, validity, and qualitative philosophical integrity. The aim of this article is to present an example of qualitative metasynthesis and to explore the utility, interpretive value, and clinical applications of metasynthesis in advancing our knowledge of the wellbeing and needs of siblings of children with mental health problems. An electronic search of publications from 1990–2011 was conducted. Ten articles were included and analyzed using thematic synthesis and constant targeted comparison. Qualitative metasynthesis allowed novel interpretations beyond those found in primary research in terms of theoretical frameworks and clinical implications. In addition, qualitative metasynthesis produced findings greater in depth and consistency and with more direct clinical implications than primary research and quantitative reviews. Qualitative metasynthesis provides a pathway by which more conclusive, reliable, and generalizable findings are produced and interpretive power and clinical utility are increased. It represents a significant advancement in qualitative methodology with the potential to provide unique contributions to research, theory, and evidence-based practice. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
Utility of Qualitative Metasynthesis: Advancing Knowledge
on the Wellbeing and Needs of Siblings of Children With Mental
Health Problems
Nylanda Ma, Rachel Roberts,
and Helen Winefield
University of Adelaide
Gareth Furber
University of South Australia
Qualitative metasynthesis is an interpretive integration of primary qualitative research.
It is a relatively new research methodology with questions remaining about utility,
validity, and qualitative philosophical integrity. The aim of this article is to present an
example of qualitative metasynthesis and to explore the utility, interpretive value, and
clinical applications of metasynthesis in advancing our knowledge of the wellbeing and
needs of siblings of children with mental health problems. An electronic search of
publications from 1990–2011 was conducted. Ten articles were included and analyzed
using thematic synthesis and constant targeted comparison. Qualitative metasynthesis
allowed novel interpretations beyond those found in primary research in terms of
theoretical frameworks and clinical implications. In addition, qualitative metasynthesis
produced findings greater in depth and consistency and with more direct clinical
implications than primary research and quantitative reviews. Qualitative metasynthesis
provides a pathway by which more conclusive, reliable, and generalizable findings are
produced and interpretive power and clinical utility are increased. It represents a
significant advancement in qualitative methodology with the potential to provide
unique contributions to research, theory, and evidence-based practice.
Keywords: child, mental health, qualitative metasynthesis, sibling
Supplemental materials: http://dx.doi.org/10.1037/qup0000018.supp
In evidence-based practice in health care,
qualitative studies are commonly considered to
produce one of the lowest levels of evidence
(Giacomini, 2001). This is attributable to limi-
tations in primary qualitative studies including
small sample sizes and limited generalizability
of findings (Merriam, 2002). Qualitative meta-
synthesis, a recent development in qualitative
methodologies, may address some of these lim-
itations and provide more ‘conclusive’ findings
with greater value from an evidence-based prac-
tice perspective akin to quantitative systematic
reviews and meta-analyses (Thorne, Jensen,
Kearney, Noblitt, & Sandelowski, 2004).
Qualitative metasynthesis is an “interpretive
integration of qualitative findings in primary
research” (Sandelowski & Barroso, 2007,p.
3816). The term describes a systematic process
of collecting primary research and synthesizing
and interpreting this research using appropriate
qualitative synthesis techniques (Sandelowski
& Barroso, 2007). By synthesizing the findings
of multiple primary studies, qualitative meta-
synthesis can reduce bias from small qualitative
studies and can increase the reliability and gen-
eralizability of findings by identifying consis-
tencies in individual perspectives and experi-
ences across numerous studies and samples
(Thorne et al., 2004). Qualitative metasynthesis
Nylanda Ma, Rachel Roberts, and Helen Winefield,
School of Psychology, University of Adelaide; Gareth
Furber, Health Economics and Social Policy Group, Uni-
versity of South Australia.
We thank Maureen Bell, research librarian at the Univer-
sity of Adelaide, for her expert advice during development
of the search strategy and guidance on the use of electronic
databases.
Correspondence concerning this article should be ad-
dressed to Nylanda Ma, School of Psychology, University
of Adelaide, North Terrace, Adelaide, South Australia 5005,
Australia. E-mail: nylanda.ma@adelaide.edu.au
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Qualitative Psychology © 2015 American Psychological Association
2015, Vol. 2, No. 1, 3–28 2326-3598/15/$12.00 http://dx.doi.org/10.1037/qup0000018
3
can also highlight variations in perspectives and
experiences that appear across numerous stud-
ies and illuminate the role of contextual factors,
such as gender or culture, in shaping individual
perspectives and experiences (Sandelowski &
Barroso, 2007). In addition, qualitative synthe-
sis techniques are designed to aid the formation
of novel interpretations of data that were not
found in primary studies (Thorne et al., 2004;
Sandelowski & Barroso, 2007). In this way,
qualitative metasynthesis has greater interpre-
tive power than primary studies in that it can
provide new insights not found in primary stud-
ies.
However, there are ongoing debates about the
utility, validity, and philosophical integrity of
qualitative metasynthesis (Thorne et al., 2004).
For example, some argue that qualitative meta-
syntheses violate the basic principles of quali-
tative research (Sandelowski & Barroso, 2007).
Qualitative research emphasizes the fallacy of
generalizations, of minimizing differences, and
of looking at the ‘average’ or the views of the
majority, which contradicts the very notion of
synthesis (Thorne et al., 2004). The utility of
qualitative metasynthesis, particularly with re-
gard to clinically useful applications and impli-
cations, also remains unclear (Dixon-Woods,
Agarwal, Jones, Young, & Sutton, 2005). This
is particularly the case with regard to how qual-
itative metasyntheses can complement or con-
tribute to quantitative findings and syntheses
(Dixon-Woods et al., 2005). For example, do
qualitative metasyntheses have substantial ben-
efits in terms of clinically useful conclusions
and implications relative to primary qualitative
studies and quantitative studies that would jus-
tify the use of this methodology in health care?
The debates around qualitative metasynthesis
are unresolved, in part, because of very few
examples of qualitative metasyntheses in the
literature and few evaluations of qualitative me-
tasynthesis techniques that can inform ongoing
debates (Dixon-Woods et al., 2005). Accord-
ingly, the aims of this study are to provide an
example of the use of qualitative metasynthesis
techniques and to explore the utility, interpre-
tive value, and clinical applications of qualita-
tive metasynthesis. The focus of this evaluation
is to explore the utility of qualitative metasyn-
thesis with reference to extending primary qual-
itative research and to extending and comple-
menting syntheses of quantitative research.
Primary qualitative studies on the experi-
ences and coping strategies of siblings of chil-
dren with mental health problems (MHPs) were
chosen as the dataset in this qualitative meta-
synthesis. This dataset was chosen for several
reasons. First, matched systematic reviews of
the quantitative data on the mental health and
wellbeing of siblings of children with MHPs
have been conducted using an identical search
strategy (Ma, Roberts, Winefield, & Furber,
2014a,2014b,2015). Thus, direct comparisons
can be made between syntheses of quantitative
studies and qualitative studies in terms of con-
tribution to knowledge (e.g., useful implications
for clinical practice) and methodological rigor
(i.e., reliability, generalizability, and consis-
tency of findings). Such comparisons allow ex-
ploration of the utility of qualitative metasyn-
thesis in contributing to, complementing, and
extending the findings of quantitative syntheses
and whether the former can provide findings
that are comparable in rigor with the latter. For
example, there were significant gaps in the
quantitative literature that could be addressed
through the use of qualitative methodologies.
The quantitative research, for example, showed
that both sibling relationships and parent-
sibling relationships were more problematic
(e.g., more conflict) in families of children with
MHPs than in control families. This suggests
that there are factors or processes that have an
impact on the entire family system. However,
the quantitative research could not describe the
family level processes that may be occurring in
these families. To understand family level pro-
cesses, in-depth data on individual perceptions,
dyadic relationships, and whole family dynam-
ics are required (Hoffman, 1981). Qualitative
methodologies are well suited to obtaining in-
depth data and provide insight into complex
multifaceted phenomena (Dixon-Woods et al.,
2005;Merriam, 2002). By integrating the find-
ings of the primary qualitative research on these
family processes, qualitative metasynthesis may
provide in-depth data on these processes across
numerous participant samples and settings and
provide a more conclusive evidence base than is
found in primary qualitative research (Thorne et
al., 2004). In this way, qualitative metasynthesis
may be able to address the gaps in the reviews
of the quantitative literature with a comparable
level of methodological rigor and significantly
4 MA, ROBERTS, WINEFIELD, AND FURBER
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contribute to, complement, and extend findings
from systematic reviews of quantitative studies.
Second, the primary qualitative research with
siblings of children with MHPs has been limited
in utility and there has been little incorporation
of findings from primary qualitative research in
psychological etiological frameworks and clin-
ical practice. This provides an opportunity to
explore whether qualitative metasynthesis can
provide significant contributions to theory and
clinical practice beyond those in the primary
qualitative research. For example, family based
treatment programs that include siblings focus
on addressing risk factors and developmental
pathways highlighted in quantitative research,
such as the development of healthy coping skills
(Brotman et al., 2005). In contrast, few pro-
grams include a consideration of the challenges
highlighted in primary qualitative research that
affect the mental health and wellbeing of sib-
lings of children with MHPs. For example, no
known programs include components that ad-
dress caregiving burden issues that are high-
lighted by siblings of children with MHPs (Lit-
zelfelner, 1995). It may be that qualitative
findings have not been extensively incorporated
in clinical practice due to the methodological
criticisms of qualitative research. It may also be
that primary qualitative research has been un-
able to formulate clear, practice-relevant guide-
lines that would facilitate the incorporation of
these findings in treatment programs. That is,
primary qualitative studies may lack the inter-
pretive power to formulate useful clinical im-
plications of qualitative findings. Given the lim-
ited utility of primary qualitative research with
siblings of children with MHPs, this dataset
provides an opportunity to explore whether
qualitative metasynthesis can build on the find-
ings of primary research, address the method-
ological criticisms of primary qualitative re-
search, and formulate novel interpretations of
qualitative data not achieved through primary
analytic strategies. Thus, primary qualitative re-
search with siblings of children with MHPs
provides an excellent dataset from which the
utility of qualitative metasynthesis can be ex-
plored.
In sum, this article aims to provide an exam-
ple and evaluation of the utility of qualitative
metasynthesis using primary qualitative re-
search with siblings of children with MHPs.
The utility of qualitative metasynthesis is eval-
uated with reference to methodological rigor,
interpretive power, and clinical applications of
qualitative metasynthesis and in comparison
with primary qualitative studies and systematic
reviews of quantitative research.
Method
Identification of Studies
Four electronic databases were searched: Cu-
mulative Index to Nursing and Allied Health
Literature (CINAHL), PsycINFO, PubMed, and
SciVerse Scopus using search terms such as
sibling,first degree relative,child,adolescent,
emotional,behavioral,psychiatric,social, and
wellbeing. A full list is provided in the Online
Supplemental Material. Because this review
was part of a larger systematic review (see Ma
et al., 2014a,2014b,2015) that included quan-
titative studies, a search specific to qualitative
articles was not conducted.
Studies (qualitative only and mixed methods
studies) were included if they reported qualita-
tive data on the experiences of siblings of a
target child (aged 18 years or less) with MHPs,
consisted of primary data, were published in a
peer-reviewed journal, and were published in
English. Qualitative data were defined as data
obtained by qualitative data collection methods
(e.g., focus groups) or analyzed using qualita-
tive methods (e.g., thematic analysis). Criteria
for the presence of MHPs in the target child
were defined broadly based on previous re-
search (Ravens-Sieberer et al., 2008) and were
as follows: (a) presence of an established psy-
chiatric diagnosis, (b) positive screen on psy-
chiatric diagnostic measures, (c) clinically ele-
vated scores on psychological measures, (d)
referred to or engaging in mental health treat-
ment, or (e) adjudicated in court for delinquent
behavior suggesting the presence of emotional
and/or behavioral difficulties. Studies were ex-
cluded if the target child had difficulties not
considered primarily emotional, behavioral, or
social, including developmental disabilities and
physical illnesses, and if purposive sampling of
siblings of target children according to the pres-
ence or absence of psychopathology was used
as this may bias the findings. Further, twin
studies were excluded. Twin siblings and non-
twin siblings have been found to differ signifi-
5UTILITY OF QUALITATIVE METASYNTHESIS
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cantly in several aspects that may influence their
experiences of life with a child with MHPs
(e.g., closer sibling relationships; DiLalla, Mul-
lineaux, & Elam, 2008). Further, twin families
may present with different family dynamics and
processes compared with nontwin families.
Last, because twin studies are typically popula-
tion-based studies, they do not recruit based on
the presence of MHPs in a child in the family
and are therefore not well equipped to explore
the impact of MHPs on siblings.
The data selection process involved several
steps. From the initial literature search list, du-
plicate records and nonjournal publications
(such as editorials, book reviews, conference
abstracts, and theses) were removed. The titles
and abstracts of the remaining records were
reviewed against the inclusion/exclusion crite-
ria. Full-text versions of the articles meeting
criteria were retrieved and reviewed for eligi-
bility. To limit data-selection bias, an indepen-
dent researcher reviewed a randomly selected
sample of articles (10% of full-text articles) for
eligibility and 100% interrater agreement was
reached. The reference lists of the eligible arti-
cles were searched for records not captured by
the initial search and these records were
screened for eligibility.
Data Extraction and Analysis
Original research findings from the included
studies were synthesized using the thematic
analysis approach to qualitative synthesis
(Dixon-Woods et al., 2005). Thematic analysis
was considered most appropriate given that it
is well suited for underresearched areas, such as
siblings of children with MHPs (Braun &
Clarke, 2006). Furthermore, given that the ma-
jority of included studies utilized thematic anal-
ysis, it is appropriate to then synthesize them
using a similar methodology. A data-driven ap-
proach was used in the analysis; that is, one
driven by the data from included studies rather
than one designed to evaluate themes through
examination of the existing literature or one
driven by a theoretical framework and based on
a priori hypotheses (Dixon-Woods et al., 2005;
Braun & Clarke, 2006). This was considered
appropriate given that there is no existing the-
oretical framework that we expected could en-
compass our themes.
The thematic synthesis approach used in this
study was based on the work of Braun and
Clarke (2006) and Dixon-Woods and col-
leagues (2005). First, data were extracted from
primary studies without the theme label at-
tached to them by the primary author(s). This
was done to limit the influence of the interpre-
tations of the primary author(s). Both quotes
presented in the primary studies and summary
data were extracted. For example, Kendall
(1999) reported summary data on siblings of
children with attention-deficit hyperactivity dis-
order (ADHD), such as, “all siblings in this
study reported feeling victimized to some de-
gree by aggressive, physical, verbal, and/or ma-
nipulative and controlling acts....Siblings also
reported that their parents often minimized and
disbelieved the seriousness of the aggression”
(p. 8). Kendall also reported direct quotes from
her participants, such as “For the longest time
he had a baseball bat in his room that he would
take out and threaten to whack me with if I
didn’t do what he wanted” (p. 8). Both of these
forms of data were extracted. However, only
summary data were used in analyses and inter-
pretations. Quotes were retained as illustrative
examples. Extracted summary data were read
multiple times to familiarize ourselves with
their content and note initial similarities.
Following this, an initial coding scheme was
formulated based on similarities and salient fea-
tures in the summary data. For example, vio-
lence toward siblings was noted across the data
and became one of the initial ‘codes’ or labels.
Data were then sorted according to this coding
scheme. For example, all summary data relating
to violence toward siblings were grouped under
a ‘sibling violence’ label. Initial themes were
formulated from these initial codes. Codes or
initial themes were identified at a semantic
rather than latent level with themes identified
within the explicit meaning of the data rather
than examination of underlying ideas and as-
sumptions (Braun & Clarke, 2006). The former
examines what is revealed from the content of
what primary authors and participants say, for
example, about the daily challenges associated
with living with a brother or sister with MHPs.
The latter examines what is revealed by the
manner in which primary authors and partici-
pants communicate about a particular topic, as
is used in discourse analytic approaches (e.g.,
political and feminist discourse analysis that
6 MA, ROBERTS, WINEFIELD, AND FURBER
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might reveal underlying beliefs and assump-
tions about women).
Formulated themes were then reviewed in the
context of the entire data set and were named
and defined. For example, in the context of the
entire data set, violence toward siblings was
often discussed together with aggression and
conflict. These data were also described as hav-
ing a similar impact on the lives and wellbeing
of siblings. Therefore, these data were grouped
together and formed a final theme of ‘Violence,
conflict, and aggression.’ Within the context of
the entire data set, two higher-order themes that
fit the lower-order themes were identified,
namely ‘Experiences’ and ‘Coping strategies.’
There have been several methods described
that involve transforming thematic data into
prevalence or effect size data, similar to the
principles of content analysis and akin to meth-
ods used in quantitative meta-analysis (Sand-
elowski & Barroso, 2007). For example, the
percentage of included articles that cover con-
tent about a particular theme can be compared
with those that do not and an effect size or
prevalence estimate can be calculated (Sand-
elowski & Barroso, 2007). This can give the
reader a sense of the saliency of a particular
theme and the consistency to which it has been
found in the existing literature. It was consid-
ered inappropriate to use these methods in this
metasynthesis. The search strategy used cap-
tured sibling-focused articles and those that did
not necessarily focus on siblings but contained
small but relevant excerpts. Prevalence esti-
mates would therefore be inaccurate because the
absence of content related to a particular theme
does not relate to lack of saliency but is an
artifact of the focus of the article. Therefore,
other interpretative techniques are the focus of
this metasynthesis.
Interpretation and theorization to allow con-
sideration of the meaning and implications of
the findings was achieved through the constant
targeted comparison technique. Constant tar-
geted comparison, as described by Sandelowski
and Barroso (2007), involves direct compari-
sons between the population under study and an
extrastudy population with an apparent resem-
blance. This technique can facilitate a deeper
understanding of the population under study by
illuminating key features and findings that are
unique to the population as well as features they
may share with other groups. For example, sim-
ilarities between data from mothers with HIV
and data from healthy mothers can reveal key
features of motherhood, whereas differences
may reveal features specific to experiencing
motherhood within the context of illness (San-
delowski & Barroso, 2007).
In this study, the comparison population cho-
sen for data on sibling experiences was siblings
of children with special needs. Siblings of chil-
dren with MHPs and those of children with
special needs share the experience of living with
a person with an ‘illness’ within the context of
sibling relationships and qualitative research
with these populations both explore the impact
of illness on siblings. Thus, using constant tar-
geted comparison with this population has the
potential to deepen understandings of the com-
mon features of the impact of illness on families
and sibling relationships and how the findings
are related to key differences, such as the nature
of the ‘illness’ (Sandelowski & Barroso, 2007).
A selection of qualitative primary studies ex-
ploring the impact of illness on siblings of chil-
dren with special needs was identified using
search procedures similar to those used to iden-
tify the included studies (seven articles). Al-
though it may be ideal to use synthesized data
from a comparison population, this is not usu-
ally possible because qualitative metasyntheses
are rarely conducted (Sandelowski & Barroso,
2007) and no metasyntheses were found for
extrastudy populations. ‘Special needs’ includes
a large range of ‘illnesses’ including develop-
mental disabilities, physical illnesses, and neu-
rological disabilities. We attempted to include
articles that covered a variety of special needs.
The comparison population chosen for cop-
ing strategies data was siblings of adults with
MHPs (two articles). Siblings of adults with
MHPs and siblings of children with MHPs are
likely to share very similar experiences but sib-
lings of adults are likely older, more develop-
mentally advanced, and may have had more
time and experience in dealing with a brother or
sister with MHPs. Therefore, using siblings of
adults as a comparison group may highlight
similarities and differences between the groups
as a result of key differences in age, experience,
and developmental stage, and identify potential
practice-relevant implications. We did not ob-
tain a large selection of articles on siblings of
adults. Instead, we selected articles specifically
for their relevance to this topic. We chose to
7UTILITY OF QUALITATIVE METASYNTHESIS
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focus on primary research that included a ret-
rospective account from participants on coping
in childhood and adult views and beliefs around
coping strategies. Such data highlight how
choices of coping strategies and views and be-
liefs around coping strategies may change with
age, experience, and developmental stage. This
has direct relevance to clinical practice and
treatment with siblings. Given that an essential
and necessary element of qualitative metasyn-
thesis is that it results in clear and direct impli-
cations for practice as well as research, we
chose to focus on these articles (Sandelowski &
Barroso, 2007).
The data from these two comparison popula-
tions were read multiple times and searched for
data that were consistent with and/or divergent
from the results of our qualitative metasynthe-
sis. Following this, we theorized what might
account for similarities and differences between
the groups and how this might relate to the
nature of ‘illness,’ age, experience, and devel-
opmental stage. The final stage of the qualita-
tive metasynthesis process involved formulat-
ing research and direct clinical implications
from the synthesis data and comparative data.
This was conducted with a focus on the impli-
cations of these findings within the context of
evaluating the utility of qualitative metasynthe-
sis.
Results and Discussion
Characteristics of Included Studies
The systematic search strategy located 10
articles reporting qualitative data on the expe-
riences and coping strategies of siblings of chil-
dren with MHPs. Table 1 summarizes the char-
acteristics of the included studies and studies
used as the comparison dataset. The most com-
mon methodology employed was thematic anal-
ysis of interviews or focus groups. Included
studies interviewed parents, siblings, and target
children, however the majority of studies inter-
viewed only one member of the family. Four
studies interviewed siblings exclusively. Sam-
ple sizes ranged from 3–41. Collectively, the
included studies recruited approximately 56 sib-
lings, 32 target children with MHPs, and 107
parents and other relatives, representing 101
families. Siblings ranged in age from 10–19
years old. All studies reported data on the ex-
periences of siblings but fewer than half re-
ported data on the coping strategies used. Few
studies examined the experiences of siblings of
target children with a specific MHP, with the
majority of studies sampling siblings of chil-
dren with a range of MHPs. Four isolated MHPs
were examined: Eating disorders, ADHD,
OCD, and self-harming behavior. The follow-
ing section reports the results of the synthesized
thematic analysis and constant targeted compar-
ison analysis. There are several important issues
that should be considered when interpreting
these results. First, there were significant
variations across studies in the amount of
content and detail focused on siblings. Some
studies, for example, focused on the experi-
ences of parents and included only one or two
excerpts on siblings. This is even more evi-
dent with direct quotes. Direct quotes do not
constitute a large portion of qualitative stud-
ies relative to summary data. Some studies
did not include any direct quotes about sib-
lings and about particular themes. Thus, for
direct quotes, sibling-focused studies with the
most relevant quotes are heavily relied upon
(Barrett, Rasmussen, & Healy, 2001;Garley
& Johnson, 1994;Kendall, 1999;Litzelfelner,
1995). Second, it is important to note that the
themes presented here are discussed as iso-
lated aspects of the siblings’ lives. However,
in the real world, it is not possible to isolate
one aspect of life from another. For example,
changes in relationships will necessarily also
result in changes in self and in daily life
experiences. Further, coping strategies often
have multiple purposes and it may not be
possible to isolate them. For example, accom-
modation strategies may also be viewed as
avoidance strategies because accommodation
can help siblings avoid conflicts and out-
bursts. Although it is necessary to present
them as isolated themes to provide some
structure to an exceedingly complex topic, it
is important to keep in mind the interrelated
nature of the themes presented here.
Experiences of Siblings of Children
With MHPs
Limited mental health knowledge. Five
studies reported that siblings felt they had inad-
equate knowledge of the target child’s MHPs
(Deal & MacLean, 1995;Garley & Johnson,
8 MA, ROBERTS, WINEFIELD, AND FURBER
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Table 1
Summary of Included Studies
Reference Country/Recruitment
site Target child MHPs Age(y)/% Male Participant nSibling Age (y)/%
Male/% Younger Method/Qualitative analytic
approach
Primary dataset: Primary qualitative research with siblings of children with MHPs
Barrett et al. (2001) AUS/GP OCD 10–13/25% Sibling 5 11–12/20%/80% Interviews and questionnaires
on sibling accommodation
and relationship
Parent 4
Deal & MacLean (1995) USA/MHC Psychiatric hospitalization 12–18/60% Sibling 15 9–15/53%/100% Verbal presentation of
Sibling Relationship
Questionnaire items;
questions on best and
worst parts of being
sibling and most important
thing for researchers to
know
Garley & Johnson (1994) Canada/MHC Eating disorders 14–17/0% Sibling 5 15–16/0%/40% Two unstructured interviews
(60 minutes)/Phenomenology
Kendall (1998) USA/MHC; GP ADHD 10/100% Parent 25 Two open-ended individual
interviews (30–90
minutes); Two semi-
structured facilitated
family discussions; Field
notes on observations of
family
interactions/Grounded
theory
Target Child 20
Sibling 14 11/54%/57%
Kendall (1999) Parent 18 Weekly diary entry (8 weeks)
reporting on most
important incident, one
good event and one
disappointing event
Target Child 12
Sibling 13
Litzelfelner (1995) USA/MHC Emotional MHPs Sibling 4 13–19/50%/25% Focus group (90 minutes)/
Thematic analysis
Rissanen et al. (2008) Finland/Research
Study Self-harm Adolescent Parent 4 Open-ended interviews
(45–75 mins)/Inductive
content analysis
Rosenzweig et al. (2002) USA/MHC;
Support Group MHPs 14.7/73.3% Parent 41 Focus group (90
mins)/Thematic analysis
(table continues)
9UTILITY OF QUALITATIVE METASYNTHESIS
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Table 1 (continued)
Reference Country/Recruitment
site Target child MHPs Age(y)/% Male Participant nSibling Age (y)/%
Male/% Younger Method/Qualitative analytic
approach
Slowik et al. (2004) UK/MHC In-patient treatment Adolescent Parent
Other relatives 3–7 Recordings of parent support
group (1 hour, 18
fortnightly
sessions)/Thematic analysis
Tahhan et al. (2010) Canada/MHC Residential treatment for MHPs 11.75/87.5% Parent 8 Interviews (60 mins)/Thematic
analysis
Comparison dataset: Primary qualitative studies with siblings of children with special needs
Kao et al. (2012) USA/GP;
Hospital Developmental disabilities 3–18/53.5% Parent 16 Semi-structured interview on
sibling perspectives and
experiences/Consensual
qualitative research method
Target child 15
Sibling 17 10.4/41.2%/47%
Dauz Williams et al. (2010) USA/GP;
Hospital Developmental disabilities 9.6/43% Parent 151 10.9/46%/— Open-ended question on the
effects of the disability on
their child’s
sibling/Content analysis
Beilby et al. (2012) AUS/Speech
clinic Stuttering 4–11/75% Sibling 12 7–16/25%/8.3% Semi-structured interview on
family relationships and
likes and dislikes/Thematic
analysis
Loos & Kelly (2006) AUS/Hospital Diabetes 6–14/— Parent 16 Semi-structured interview on
sibling knowledge, sibling
impact, and family
communication/Thematic
analysis
Sibling 16 6–14/—
Moyson & Roeyers (2012) Belgium/GP;
Support
services
Intellectual disability 3–18/— Sibling 50 9.16/46%/36% Open-ended interview on
experience of being a
sibling and quality of life
and focus group with
siblings/Thematic analysis
Alderfer et al. (2010) Multiple locations
and recruitment Cancer Sibling Narrative summary of
primary qualitative
research with siblings of
children with cancer
(28 studies)
10 MA, ROBERTS, WINEFIELD, AND FURBER
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Table 1 (continued)
Reference Country/Recruitment
site Target child MHPs Age(y)/% Male Participant nSibling Age (y)/%
Male/% Younger Method/Qualitative analytic
approach
Graff et al. (2012) USA/— Down Syndrome 12/— Sibling
Parent 23 16/48%/0% 60–90 minute semi-structured
interview on perceptions of
living with a child with
Down Syndrome, thoughts
of the future, and sibling
knowledge/Thematic
analysis
Comparison dataset: Primary qualitative studies with siblings of adults with MHPs
Dimitropoulos et al. (2009) Canada/Inpatient
setting Eating disorders 25.4/0% Sibling 12 25.6/0%/— Semi-structured interview on
quality of relationship
prior to illness, impact of
illness on relationship and
supports
available/Thematic analysis
Kinsella et al. (1996) USA/MHC Schizophrenia; Major
depression; Bipolar disorder —/80% Sibling 10 27–56/50%/— 90–120 minute interview on
coping skills, needs, and
strengths/Thematic analysis
Note.—Not reported; AUS Australia; UK United Kingdom; USA United States of America; ADHD Attention deficit hyperactivity disorder; GP General
population; MHC Mental health clinics; MHPs Mental health problems; OCD Obsessive-compulsive disorder.
11UTILITY OF QUALITATIVE METASYNTHESIS
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1994;Kendall, 1999;Litzelfelner, 1995;
Slowik, Wilson, Loh, & Noronha, 2004). In
Litzelfelner’s (1995) study, only one sibling
knew the target child’s diagnosis with one sib-
ling remarking, “they never told us” (p. 270). In
two studies, siblings reported that no one, in-
cluding parents and clinicians, had discussed
MHPs with them or enquired about how they
felt (Deal & MacLean, 1995;Garley & Johnson,
1994).
Siblings had differing views on the causes of
MHPs. Some siblings appealed to genetics and
heredity whereas others believed the target
child’s behavior was entirely controllable and
stemmed from intrapersonal motivations. Be-
liefs about heritability of MHPs led to concerns
about the consequences for the target child’s
children and the sibling’s own children. Attrib-
uting intrapersonal motivations to the target
child’s behavior often underpinned feelings of
anger toward the target child. Other siblings
could not make any sense of the target child’s
behavior.
My grandfather was manic-depressive...andIthink
Johnny got it from him. (p. 270) [Sibling of child with
emotional difficulties; Litzelfelner, 1995]
That’s why she keeps on going [with her behavior]—
‘cause she gets attention from my parents, the hospital,
her friends, and I think she likes all that....Ifshehad
no one to go to, then maybe she’d smarten up. (p. 160)
[Sibling of female with an eating disorder; Garley &
Johnson, 1994]
I’ve had like cake and everything......andshewon’t
even touch cake. She goes, ‘I just don’t feel like it,’ and
everyone must feel like something every now and then
you know, but she always says she doesn’t. (p. 160)
[Sibling of female with an eating disorder; Garley &
Johnson, 1994].
Siblings described fears and doubts about the
future health of the target child and had little
understanding of the possibility of treatment.
For siblings of girls with eating disorders, Gar-
ley and Johnson (1994) found that all siblings
had thoughts of their sister dying at some point
as a result of the disorder. These thoughts were
pervasive, always present, and underpinned
feelings of fear and anxiety. Kendall (1999)
described sibling doubts about recovery, as they
did not expect the target child’s behavior to
change. Many siblings resigned themselves to
their current circumstances, which underpinned
feelings of powerlessness and hopelessness.
In contrast, siblings of children with special
needs (e.g., physical disabilities, neurological
conditions) seem to have a better understanding
of their brother or sister’s difficulty. For exam-
ple, siblings of children with developmental dis-
abilities reported obtaining information about
the etiology and prognosis of the child from
their parents (Kao, Romero-Bosch, Plante, &
Lobato, 2012). Their parents were proactive in
communicating with siblings, which research
suggests helps siblings gain a sense of power
and control over their lives, particularly in re-
gards to managing the target child’s difficulties
or problems (Beilby, Byrnes, & Young, 2012;
Kao et al., 2012). Based on these findings, it
appears that siblings of children with MHPs and
siblings of children with special needs share the
same experience—that is, a need for informa-
tion about their brother or sister’s health or
mental health. However, these groups differ in
how proactive parents are in communicating
and disseminating this information. It may be
that differences in parental communication re-
sult in different emotional outcomes for sib-
lings. Parents of children with MHPs are more
likely to display impaired parenting styles and
have an increased risk of MHPs themselves
(Parritz & Troy, 2011). This may account for
differences between the two groups on the level
of parent to sibling communication. It may also
be that research and support services for chil-
dren with special needs and their families are
more advanced, better established, and are more
effective at informing parents about the impor-
tance of communication and in teaching them
how to communicate with their children. In our
review of the literature, we found that although
support programs for siblings of children with
MHPs were still in the pilot stages (e.g., Pitman
& Matthey, 2004) and very few programs exist
within mental health services, randomized con-
trolled trials and systematic reviews of support
programs had already been conducted for sib-
lings of children with special needs (e.g., Prchal
& Landolt, 2009) and multiple well-established
support systems are in place for these families.
This difference in evidence-based support ser-
vices may account for the difference in out-
comes for siblings of children with special
needs and those of children with MHPs. There
are several other possible explanations includ-
ing stigma associated with MHPs and parental
12 MA, ROBERTS, WINEFIELD, AND FURBER
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guilt, which may make parents reluctant or un-
comfortable discussing the target child’s MHPs.
Impact on daily life.
Violence, conflict, and aggression. Five
studies reported that siblings experienced vio-
lence, conflict, and aggression on a daily basis
(Barrett et al., 2001;Deal & MacLean, 1995;
Kendall, 1999;Litzelfelner, 1995;Tahhan, St.
Pierre, Stewart, Leschied, & Cook, 2010). With
regard to violence and aggression, target chil-
dren would often verbally and physically attack
their siblings. Physical violence included acts
such as being chased with knives, being
punched or kicked, scratching, and being
pushed in front of cars. Violent and destructive
acts against the house were also described (e.g.,
making holes in the walls). Verbal attacks in-
cluded insults and threats of violence.
My brother, he’s 13, he gets very violent, he threatens
me with knives and one time he hit me in the back with
a broom so hard it left three welts on my back. (p. 268)
[Sibling of child with emotional difficulties; Litzelfel-
ner, 1995]
He hits me every day. He just all of a sudden hauls off
and hits me all of a sudden. I don’t know why...the
other day he sat on me and it was hard to breathe. But
I know that if I fight him back it will be worse. So I try
to wait it out. I worry sometimes that he might kill me.
(p. 8) [8 yo brother of 13 yo male with ADHD;
Kendall, 1999]
Siblings described themselves as being ‘easy
targets’ (Kendall, 1999, p. 8) as they are more
accessible and available than parents. In addi-
tion, siblings believed that they were attacked as
their parents did not intervene or sufficiently
discipline the target child. Instead of firmly dis-
ciplining the target child, parents typically min-
imized or justified the behavior as normal sib-
ling rivalry. Siblings believed that the lack of
intervention was also due to parents being too
exhausted or overwhelmed. Target children also
minimized or justified the attacks, which added
to the siblings’ feelings of anger and victimiza-
tion. This can be seen in the quote below from
a target child with ADHD discussing his violent
behavior toward his sibling.
Why not hit him? He’s right there in my face all the
time and he’s always bothering me. Nothing ever hap-
pens when I do—he yells and tells Mom and Mom
sends us both to our room. Big deal. I can’t hit anybody
at school even though I want to a lot. I’d get in too
much trouble. So when I get home, yeah my brother
gets most of it. I don’t care. He deserves it for being in
my face all the time. (p. 8) [14 yo male with ADHD;
Kendall, 1999]
In addition to violence and aggression, con-
flict between family members, such as yelling
and frequent arguments, was a common expe-
rience for siblings. Conflict was described as
frequent and ongoing. Collectively, these expe-
riences were described as leading to a chaotic
and unpredictable home life. As can be seen in
the above quotes, violence could occur “all of a
sudden” and seemingly without any significant
provocation. Siblings reported never knowing
what to expect and feeling constantly “on-
guard” (Kendall, 1999,p.8).
These negative experiences and behaviors
were identified by participants in included stud-
ies as the most significant problem and as hav-
ing the greatest impact on their daily lives.
Siblings discussed these issues constantly and
spontaneously even when discussing other top-
ics. Lack of parental management of sibling
conflict and violence was highlighted as the
primary maintaining factor. In contrast, re-
search with siblings of children with special
needs is inconsistent. Some studies report in-
creased conflict between siblings and the target
child with special needs (Dauz Williams et al.,
2010) but others report decreased rivalry and
competition within the sibling relationship (Ka-
minsky & Dewey, 2001). Of those that report
increased conflict, some of the experiences re-
ported are similar to those of siblings of chil-
dren with MHPs, for example, destruction of
property and tantrums (Dauz Williams et al.,
2010). Violence toward the sibling however, is
rarely mentioned. More typically, the direction
appears to be opposite to that reported in this
review. Siblings of children with MHPs often
depicted themselves as being the victim of con-
flict and aggression rather than the instigators.
In contrast, siblings of children with develop-
mental disabilities, for example, are the ones
expressing anger and frustration toward their
brother or sister (Dauz Williams et al., 2010).
For example, siblings would insult their brother
or sister and get angry with them for their lack
of social skills (Dauz Williams et al., 2010).
Although directionality of behavior within the
sibling relationship differs across the groups,
there is a similar underlying act of blaming the
child with MHPs or special needs. Both groups
of siblings blame the child for their behavior
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and exhibit similar emotional outcomes, partic-
ularly anger. However, although conflict and
aggression is a consistent finding across quali-
tative studies of siblings of children with MHPs,
this is not the case for siblings of children with
special needs. Furthermore, sibling violence is a
prominent narrative within the accounts of sib-
lings of children with MHPs. Thus, although
similar in some ways, it seems that siblings of
children with MHPs face more consistent, fre-
quent, and severe forms of conflict, violence,
and aggression than siblings of children with
special needs.
Being another parent. Four studies re-
ported findings that suggested that siblings’ role
in families of children with MHPs were more
akin to that of a parent than a sibling (Deal &
MacLean, 1995;Garley & Johnson, 1994;Ken-
dall, 1999;Rosenzweig, Brennan & Ogilvie,
2002). Siblings reported that their parents ex-
pected them to care for the target child when
they were unavailable (e.g., at school, after
school care in families with working parents) or
in need of respite. Responsibilities included su-
pervising the child, helping them with home-
work, resolving conflicts with neighbors, pre-
venting the target child from acting impulsively,
and covering up for misbehavior. Extended
family rarely provided care on a regular basis.
Afterschool care programs were described as
ill-equipped to manage the target child and the
child was often asked to leave the program after
displaying behavior problems. Both parents and
siblings described siblings as the main second-
ary caregivers.
Before she was like my equal...nowshe’s like a little
puppy, you know. I feel like I have to carry her around
with me, like make sure she’s OK. (p. 161) [Sibling of
female with an eating disorder; Garley & Johnson,
1994]
Mostly my teenage daughter takes care of him after
school and definitely on the weekends...Ihave to do
this in order to support four kids. I can’t afford to pay
somebody to watch a special needs kid. (p. 418) [At-
tendee of a support group for parents with children
with MHPs; Rosenzweig et al., 2002]
Sibling reactions to these responsibilities var-
ied, although the majority of siblings described
negative reactions. Only two of all siblings (n
56) in the included studies reported enjoying the
increased responsibilities. These siblings were
both younger sisters of older brothers with
ADHD. They viewed it positively as it gave
them a specific role or job within the family
(Kendall, 1999). However, the vast majority of
siblings viewed the responsibility as burden-
some.
Siblings also stated that they were expected
to provide care for the target child without com-
plaining and often without reward or recogni-
tion. Siblings felt this was unreasonable and
unfair. Sibling perspectives are supported by
parental accounts. Parents stated that siblings
were a major source of care yet did not ac-
knowledge the impact on this on the siblings’
lives or make statements displaying gratitude or
any rewards for siblings. Parents minimized the
burden placed on siblings by describing the
responsibilities as what siblings “just do” (Ken-
dall, 1999, p. 9): they take care of each other.
Furthermore, siblings were not given the same
consideration as parents even though they were
taking on parent-like responsibilities. Parents
spoke about frequently relying on siblings to
provide respite yet siblings were only given
respite when the target child was sent to camps
or was receiving inpatient treatment. This oc-
curred very rarely (e.g., once a year for summer
camps). In addition, siblings reported feeling
confused about the level of their responsibility.
They were expected to care for the target child
yet did not have any input in the decision-
making process. This left siblings feeling pow-
erless, impotent, and stuck in the middle. They
had all the responsibility of a parent but none of
the power and control, and had little respite
compared to parents.
Last, siblings seem to internalize the expec-
tations of others regarding their responsibilities
toward the target child. Many siblings felt a
strong sense of responsibility for their brother or
sister, were worried and protective of them, and
felt it was their responsibility or fault if the
target child relapsed, got hurt, or was hospital-
ized.
I worry about him getting hurt by somebody else. He
doesn’t listen, and one of these times he’s going to get
into real trouble, and like if he bad-talks somebody and
he doesn’t have control of himself and then they say,
“I’m going to punch you,” and he doesn’t hear them,
then he’s going to get his lights knocked out. So I try
to make sure he doesn’t get into that kind of trouble. (p.
9) [11 yo brother of 10 yo male with ADHD; Kendall,
1999]
Siblings of children with special needs simi-
larly report increased parent-like responsibili-
14 MA, ROBERTS, WINEFIELD, AND FURBER
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ties. Siblings of children with diabetes, for ex-
ample, provide physical support (e.g., getting
equipment and helping with medication admin-
istration) and emotional support (e.g., holding
the child’s hand during a procedure) and were
described as acting as a ‘pseudoparent’ (Loos &
Kelly, 2006). However, there is a point of dif-
ference between siblings of children with MHPs
and siblings of children with other special
needs. Most of the siblings of children with
MHPs in this review perceived the responsibil-
ities as unreasonable and burdensome. In con-
trast, the majority of siblings of children with
other special needs enjoy caretaking responsi-
bilities (Loos & Kelly, 2006). Both groups of
siblings share the same experience but differ in
their perceptions of these experiences. There are
several ways in which families of children with
MHPs and those with children with special
needs may differ that influence the siblings’
perception of caretaking responsibilities. First,
the nature of caretaking activities may differ
across families. Siblings of children with spe-
cial needs often engage in treatment support and
practical support while siblings of children with
MHPs describe needing to manage behavioral
problems and outbursts. Behavioral problems in
the ‘affected’ individual has been found to be
the strongest predictor of caregiver burden,
whereas physical impairments and level of care
needed were less predictive (Pinquart & Sö-
rensen, 2003). Thus, we would expect siblings
of children with MHPs to perceive greater bur-
den associated with their responsibilities than
those of children with special needs. Second,
siblings of children with special needs report
being included in decision-making processes,
which helped them feel constructive and bol-
stered a sense of pride (Beilby et al., 2012).
Inclusion in decision-making may also help to
reduce feelings of being imposed upon as the
siblings are jointly engaged in caregiving with
their parents. On the other hand, siblings of
children with MHPs are excluded from deci-
sion-making processes and are handed down
caregiving responsibilities from parents. Last, it
may be that siblings of children with special
needs receive more positive reinforcement and
recognition than siblings of children with
MHPs. Parents of children with MHPs are more
likely to display impaired parenting styles, such
as being overly critical of their children and
each other, and may therefore provide less pos-
itive reinforcement than other parents (Daniels
& Moos, 1990).
Life dominated by the target child. Given
siblings’ daily lives are spent dealing with vio-
lence, conflict, and aggression and the burden of
parent-like responsibilities, it is not surprising
that siblings feel their lives are dominated by
the target child. Siblings reported the target
child and their behavior interfered with all parts
of their daily life, such as routine activities, in
ways other than through those described above.
N takes ages to have a shower (half an hour), to dry
herself (half an hour), and to get dressed (45 minutes).
I am never at school on time, and we have to go to the
office and get a late note, and it is very embarrassing
...wearenever on time, and I am late for my job at
the restaurant (their father’s)...(p.95)[11yofemale
with an 13 yo sister with obsessive–compulsive disor-
der; Barrett et al., 2001]
When we’re traveling...andwehave to stop and eat,
it’s always the biggest issue. We can’t go to McDon-
ald’s because there’s nothing there my sister would eat
...wehave to go to a restaurant that has waitresses...
orto...aBurger King with a salad bar. (p. 161)
[Sibling of female with an eating disorder; Garley &
Johnson, 1994]
Other examples included being locked out of
the house for hours and no hot water for show-
ers because of compulsive behaviors. In addi-
tion, being able to arrange family activities was
often dependent on the target child’s behavior
and how manageable their behavior was that
day. The target child’s behavior also interfered
with events considered a part of normal child-
hood, such as birthday parties. As a result, sib-
lings reported that they could no longer look
forward to these events.
Siblings reported a lack of autonomy and
feeling as though they were unable to control
their involvement with the target child or to
distance themselves. Furthermore, several sib-
lings reported having their privacy invaded and
being unable to have any space or time to them-
selves. They believed that their family was pre-
occupied with the target child and that no one
else’s needs were being met. Siblings reported
feeling resentful that their entire life was seem-
ingly dictated and controlled by the target child.
Similarly, siblings of children with special
needs feel as if their life is dominated by the
child’s illness (Dauz Williams et al., 2010). Yet,
in contrast, siblings of children with other spe-
cial needs report still being able to find time for
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themselves and for their own needs and goals
(Moyson & Roeyers, 2012). They found that
this helped them cope with their daily chal-
lenges (Moyson & Roeyers, 2012). There may
be several reasons that explain the difference
between groups. As above, parents of children
with MHPs are more likely to display impaired
parenting styles and may not be as well
equipped to ensure and encourage siblings to
find time for themselves. Further, siblings of
children with MHPs are more likely to display
impaired psychosocial functioning (Ma et al.,
2014a) and may not have the coping skills nec-
essary to adapt around their environment and
find time for themselves. It may be that MHPs
have a more pervasive and ever-present effect
on family members and siblings. At this point, it
is unclear what might account for the differ-
ences between the groups.
Impact on family relationships. Nine
studies reported changes in family relationships
as a result of living with a child with MHPs
(Barrett et al., 2001;Deal & MacLean, 1995;
Garley & Johnson, 1994;Kendall, 1998,1999;
Rissanen, Kylma, & Laukkanen, 2008;Rosen-
zweig et al., 2002;Slowik et al., 2004;Tahhan
et al., 2010). These changes were most often
described in the context of parent–child rela-
tionships and target child–sibling relationships.
Extended family relationships and peer relation-
ships were briefly mentioned with little detail
and were discussed by few studies. First, in
parent–child relationships, studies reported that
siblings felt distant from their parents while the
target child and their parents became closer.
It feels like it’s two against one sometimes...itmakes
me worry about...meandmymom. The relationship
between me and her has drifted...thetwoarereally
tight, you know. (p. 160) [Sibling of female with an
eating disorder; Garley & Johnson, 1994]
The distance in the parent–sibling relation-
ship was, in part, attributable to siblings per-
ceiving parental favoritism toward the target
child and feeling that their relationship with
their parents was nonreciprocal. Siblings felt
their parents favored the target child, spending
more time and attention on them while often
overlooking or neglecting the siblings. For ex-
ample, a sibling of a child with an eating dis-
order reported that her mother would buy gro-
ceries according to what the target child liked
and simply assumed that the sibling would ac-
commodate and adapt to the child’s eating hab-
its. Siblings felt they were expected to be invis-
ible, not requiring too much time and attention
from the parents. One sibling likened this to
being a pedestrian, a person who just walks
through, taking up space but is not really no-
ticed. Siblings felt they were “just there, not
doing anything to cause anyone to notice” (Ken-
dall, 1999, p. 10). This is confirmed in parental
accounts with very little mention of siblings in
parent accounts of having a child with MHPs.
Although some parents did express sadness
over neglecting their other children and a desire
for more time with them, most implied that they
were only able to provide the sibling time and
attention if the target child was away at respite
programs or attending inpatient treatment.
Creating further distance in the parent–
sibling relationships, siblings did not often ap-
proach their parents with their needs or prob-
lems. They tried not to bother them as they
thought their parents were already overbur-
dened. When they did need help or attention,
parents often minimized the problem and dis-
missed them without providing any real support
or attention. Siblings felt their concerns were
seen as minor compared to those of the target
child. This often led to feelings of injustice,
resentment, and frustration.
I don’t ask for much, I’m just here and that’s about it.
Go to school, take care of my brother, that’s about it.
(p. 9) [Sibling of male with ADHD; Kendall, 1999]
In addition to feeling neglected, siblings per-
ceived their relationship with their parents as
nonreciprocal causing tension between siblings
and parents. Siblings stated that parents ex-
pected them to be tolerant, understanding, and
sensitive to the needs of the target child. Yet
parents often made these requests in a harsh and
insensitive manner. Further, siblings felt that
parents expected a lot from them (e.g., caretak-
ing responsibilities), yet little was given in re-
turn.
Siblings of children with special needs simi-
larly reported parental favoritism and differen-
tial treatment. Siblings of children with intellec-
tual disabilities, for example, report being
treated differently than their brother or sister
and receiving less attention from their parents
(Moyson & Roeyers, 2012). Furthermore, sib-
lings of children with special needs similarly
report not discussing their needs or problems
16 MA, ROBERTS, WINEFIELD, AND FURBER
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with their parents. For example, siblings of chil-
dren with cancer report hiding their feelings to
protect the wellbeing of their parents (Alderfer
et al., 2010). Thus, this is a shared experience
among these two groups of siblings.
Second, living with a child with MHPs im-
pacted on the sibling relationship. Although
some siblings reported a strong sense of loyalty
and reported feeling closer to the target child
since learning of their MHPs, most siblings
described mourning and feelings of loss of not
having a ‘normal’ sibling or ‘normal’ sibling
relationship.
She’s just drifted, like she’s no longer...inthepicture
. . . she doesn’t really want to come out. It’s like hard
for me. I miss my sister. Even though I see her every
night, she’s not the same. She used to be so hyper, you
know. She’d do funny things and now she’s just like
hunched over...shelooks drained. (p. 160) [Sibling
of female with an eating disorder; Garley & Johnson,
1994]
In addition to feelings of loss, siblings per-
ceived the target child as manipulative, control-
ling, attention seeking, and self-centered, which
underpinned feelings of anger and resentment.
Compounding these issues, target children often
rejected others and pushed them away causing
further relationship strain. In contrast to siblings
of children with MHPs, the majority of siblings
of children with other special needs tend to
report improved relationships, emphasizing the
positive aspects of the relationship. For exam-
ple, siblings of children with developmental dis-
abilities emphasize the positive aspects of the
relationship including closeness, shared activi-
ties, and commonalities between them and their
brother or sister (Kao et al., 2012). However,
similarly to siblings of children with MHPs,
siblings of children with special needs also re-
port feelings of loss of a ‘normal’ sibling. For
example, siblings of children with Down Syn-
drome report feelings of loss of a ‘normal’
sibling and needing to develop different behav-
ior patterns (e.g., communication skills) to
adapt around this as some of the major chal-
lenges they face (Graff et al., 2012). Thus, both
groups of siblings experience loss but siblings
of children with MHPs experience greater rela-
tionship strain. It may be that the increased
frequency and severity of conflict, aggression,
and violence described above explains the in-
creased relationship problems for siblings of
children with MHPs. Further, although blaming
seems to be a common feature among siblings
of children with MHPs and those of children
with special needs, as discussed above, it seems
that siblings of children with MHPs ascribe
negative intentions to the actions of their
brother or sister, such as manipulative or atten-
tion-seeking. This would likely result in more
significant relationship problems and greater re-
lationship strain. Although siblings of children
with special needs appear to blame the child for
their behavior, they do not seem to attach inten-
tion to this. For example, they may become
annoyed or angry when their brother or sister
does something embarrassing (Dauz Williams
et al., 2010), but there are no reports of siblings
believing that the child purposively did this to
attract attention, to manipulate others, or the
like. It may be that siblings of children with
special needs have a better understanding of the
nature of their brother or sister’s special needs
and the reasons for their behaviors, as outlined
above. On the other hand, siblings of children
with MHPs have a more limited understanding
of MHPs, which may result in misunderstand-
ing about the causes of their behavior and the
degree of controllability.
Impact on self. Six studies reported on the
impact on self for siblings living with a child
with MHPs (Barrett et al., 2001;Deal & Ma-
cLean, 1995;Garley & Johnson, 1994;Kendall,
1999;Litzelfelner, 1995;Slowik et al., 2004).
First, siblings reported difficulty developing a
positive self-image. They viewed themselves as
unworthy of love, attention, or care. This was,
in large part, due to the behavior of the target
child and of the parents (e.g., parental neglect
and minimization of the target child’s behav-
ior). Furthermore, some siblings of children
with eating disorders compared themselves to
the target child and developed a negative body
image.
It’s like she’s a mouse compared to me, like if I stand
in the mirror next to her I feel like I’m two of her...
I just feel big compared to her...really bulky, and
dirty sort of you know, like fat and ughh. (p. 160)
[Sibling of female with an eating disorder; Garley &
Johnson, 1994]
Siblings of children with other difficulties
similarly compared themselves with the target
child. They viewed themselves as extremely
different from the target child in terms of their
personality and behavior. This was not found in
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control children who were more likely to iden-
tify with their brother or sister. Siblings of chil-
dren with MHPs believed they exhibited better
behavior and more emotional stability than the
target child. They strongly emphasized that they
would not act like the target child and did not
have the same emotional and behavioral diffi-
culties as them. These findings suggest that sib-
lings perceive a great divide between them and
the target child. On the other hand, siblings also
had difficulty forming a sense of self and iden-
tity separate from being a sibling of a child with
MHPs. This is not surprising given that they
feel their life is dominated by the target child.
Second, as a result of the experiences de-
scribed in the sections above, siblings experi-
enced a wide range of emotions, which collec-
tively took a significant toll on the wellbeing of
siblings. Siblings reported feelings of anger,
resentment, fear, grief, frustration, injustice,
sadness, worthlessness, hopelessness, guilt,
pity, and empathy. They also reported feeling
overwhelmed, anxious, and stressed. Kendall
(1999) described a nonlinear progression of
emotions for siblings. Siblings experience in-
tense anger when mistreated. This then changes
to sadness and resignation when they realize the
permanency of their circumstances. Siblings of-
ten switch back and forth in these emotions.
Often these feelings are contradictory, which
adds to the emotional toll on siblings. For ex-
ample, siblings may feel anger toward the target
child yet feel they should be tolerant, leading to
feelings of guilt and ambivalence. This contra-
diction and ambivalence is mirrored in some of
the experiences siblings have. For example, sib-
lings felt neglected and desired more attention
from their parents, yet they did not approach
their parents for help out of guilt and consider-
ation for their already overburdened lives.
Similar emotions are reported by siblings of
children who stutter (Beilby et al., 2012), sib-
lings of children with developmental disabilities
(Kao et al., 2012), siblings of children with
Down Syndrome (Graff et al., 2012), and by
siblings of children with diabetes (Loos &
Kelly, 2006). However, in contrast to siblings of
children with MHPs, siblings of children with
special needs frequently report a positive emo-
tional impact as well. They report feelings such
as empathy, compassion, fun, and pride (Alder-
fer et al., 2010;Dauz Williams et al., 2010;
Graff et al., 2012;Moyson & Roeyers, 2012). In
addition, they frequently report personal growth
and increased maturity as a positive outcome of
their experience of being a sibling of a child
with a special need (e.g., Loos & Kelly, 2006;
Dauz Williams et al., 2010). It seems that sib-
lings of children with special needs are able to
take a more positive perspective on their cir-
cumstances to balance the negative aspects. As
with the sections discussed above, there may be
several reasons why these two groups differ
including parenting styles, increased risk of
maladaptive behaviors (including cognitive bi-
ases) and coping strategies in siblings, and dif-
ferences in the nature of the ‘illness’ in their
brother or sister.
Coping Strategies
Kendall (1999) found that siblings spend
most of their energy coping with the target
child’s behavior. Four studies (Barrett et al.,
2001;Garley & Johnson, 1994;Kendall, 1999;
Litzelfelner, 1995) described coping strategies
used by siblings to cope with the negative im-
pact the target child’s MHPs has on the lives of
siblings. Three major themes were identified:
Avoidance, Accommodation, and Normaliza-
tion. Other coping strategies were identified in-
cluding retaliating against physical attacks, re-
maining optimistic but also ambivalent to cope
with doubts over recovery, and seeking support
from people outside of the family. However,
these were discussed in few studies and by few
participants and are therefore not discussed in
detail here.
Avoidance. Avoidance was identified as
one of the primary coping strategies used by
siblings. Following recognition that the target
child’s behavior was long-term or permanent,
many siblings resigned themselves to their cir-
cumstances and learned to use avoidance to
cope. Siblings would avoid home and avoid the
child to cope with their behavioral problems.
I just stay out of his way most of the time and try to just
go with the flow...Iknow to get out of his path when
he gets angry and raises his voice. I try to avoid the
situation until he cools down. (p. 10) [Sibling of male
with ADHD; Kendall, 1999]
Siblings recognized that there was less of an
emotional toll and impact when they did not
have to interact with the target child and come
face-to-face with their difficulties.
18 MA, ROBERTS, WINEFIELD, AND FURBER
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Usually I don’t like it when she’s here [at home]
because...that’s when I know about the problems,
and I don’t like knowing about it. If I don’t know about
it...itcan’t bug me, but if she’s home and she’s sick,
then I know about it and it bugs me. (p. 161) [Sibling
of female with an eating disorder; Garley & Johnson,
1994]
It doesn’t really effect [sic] my life much because I
spend a lot of time at work and school and stuff, but
when I’m home it does. (p. 268) [Sibling of child with
emotional difficulties; Litzelfelner, 1995]
Similarly, some siblings believed that other
brothers and sisters in the family were not im-
pacted by the target child because they re-
mained largely uninvolved in the target child’s
life and avoided parent-imposed responsibili-
ties.
In addition to physical avoidance, siblings
also avoided the intense emotions that arose as
a result of their experiences through cognitive
techniques. For example, siblings would fanta-
size about the day they could move out of home
and live independently.
Accommodation. Accommodation was
also named as one of the primary coping strat-
egies used. Siblings alter their behavior to adapt
around the needs and behaviors of the target
child. Siblings would go along with the behav-
iors of the child including only eating certain
foods, helping with compulsive rituals, and
avoiding situations and events feared by the
target child. Furthermore, siblings would adapt
around the moods of the target child. Examples
include talking only when it is clear the child
wants to talk, talking to them when they are
bored, and reassuring them when they are wor-
ried or anxious. Last, siblings would ensure
their behavior did not exacerbate the target
child’s disruptive behavior, not even to stop a
physical attack (e.g., agree with them and do not
challenge them, do not fight back when being
attacked).
I’ve learned to check to see how he’s feeling before I
even say hi when I come home from school. If he looks
upset I don’t say anything because I know he will yell
at me. If he looks bored then I know I better talk with
him or he’ll yell at me. If I don’t do what he wants right
when he says it I know he will be awful to me all night.
I dread coming home sometimes. (p. 10) [Sibling of
male with ADHD; Kendall, 1999]
When he wants you to listen, listen, and that way he
won’t get so mad. So—when you’re listening to him,
don’t butt in or anything because that also gets him real
mad. I’ve learned not to talk to him about what’s
important to me because he won’t listen or he’ll say its
stupid. So I only talk to him about what he wants to
talk about and that way he won’t get mad at me. (p. 10)
[Sibling of male with ADHD; Kendall, 1999]
As can be seen from the quotes, accommo-
dating the target child’s behavior helps the sib-
ling cope by preventing additional outbursts and
escalation of problem behaviors.
The use of avoidance and accommodation
strategies as primary coping strategies may have
significant consequences, such as ceasing all
contact with family members, generalization of
avoidant coping strategies leading to long-term
issues (e.g., substance abuse; Eftekhari, Turner,
& Larimer, 2004), and maintenance of the target
child’s behaviors through accommodation (Bar-
rett et al., 2001). No known studies have quan-
titatively evaluated the effectiveness of these
strategies and the long-term outcomes in this
population. Qualitative research with siblings of
adults with MHPs may, however, provide some
insight. The research findings suggest that cur-
rent coping strategies used by siblings of adults
with MHPs differ from those used by siblings of
children with MHPs. Accounts from siblings of
adults with MHPs suggest they do not use ac-
commodation strategies and actually argued
with their parents when they would accommo-
date the eating disordered behavior (e.g., clean-
ing up after vomiting, preparing foods in accor-
dance with the target individual’s restrictions;
Dimitropoulos et al., 2009). They viewed parent
behaviors such as these as enabling and over-
protective, which prevented the target individ-
ual with MHPs from taking responsibility for
their own wellbeing and recovery (Dimitropou-
los et al., 2009). Similarly, Kinsella, Anderson,
and Anderson (1996) found that coping strate-
gies such as avoidance and accommodation
were described as unhealthy by siblings of
adults. They were described as effective for
survival as children but often had negative con-
sequences including emotional immaturity and
difficulty maintaining relationships (Kinsella et
al., 1996). Findings from studies with siblings
of adults with MHPs suggest that separating or
externalizing the illness is a very helpful strat-
egy (Dimitropoulos et al., 2009). This involves
understanding that the illness or difficulty is
separate from their brother or sister. That is,
they consciously defined the problem as the
illness rather than viewing their brother or sister
as the problem. The following from Kinsella
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and colleagues’ study (1996) provides a de-
scription of this coping strategy by a sibling of
an individual with schizophrenia:
Separate the illness from the person and say it’s all
right to hate the illness and it’s best to love the person,
and to remember the two are entirely separate. It allows
you to have and to vent your frustration and anger at
the illness and at the same time it keeps you loving the
person you once knew. [Adult sibling of adult with
schizophrenia; Kinsella et al., 1996; Accessed online]
As this quotes shows, this strategy helps the
sibling relate better to the individual and re-
duces negative emotions toward the individual
by helping siblings not to personalize the be-
havior toward them and not to personalize it if
the individual relapses (Dimitropoulos et al.,
2009). Siblings of children with MHPs and sib-
lings of adults with MHPs differ both develop-
mentally and in the amount of time spent man-
aging their brother or sister’s MHPs. It may be
that siblings of children with MHPs are not yet
sufficiently emotionally or cognitively devel-
oped to form more healthy coping strategies. It
may also be that more healthy strategies, such
as externalizing the illness, can only be learned
through long-term exposure to MHPs, through a
trial and error process with less healthy coping
strategies. Last, it may be that siblings of adults
have received some form of support or treat-
ment that siblings of children with MHPs have
not yet received. However, research suggests
that very few siblings actively seek treatment
(Kinsella et al., 1996). At this stage, it remains
unclear why siblings of children with MHPs do
not use similar coping strategies to siblings of
adults. However, the findings from siblings of
adults with MHPs suggest that it may be highly
beneficial to teach this strategy to siblings of
children with MHPs.
Normalization. Last, siblings would nor-
malize the experiences and difficulties they face
in comparison to ‘normal’ families. These strat-
egies serve to reduce the severity of the diffi-
culties they experience or justify them as rea-
sonable making it easier for siblings to feel they
can cope with them. In addition, normalizing
and minimizing may serve to reduce blame to-
ward the target child for the difficulties experi-
enced. This may, in turn, reduce the emotional
toll of feelings associated with blaming, such as
anger and resentment, and the internal conflict
with the desire to be tolerant and understanding.
Everyone comes from a dysfunctional family, to blame
that on the problems you’re having right now is a cop
out. (p. 269) [Sibling of child with emotional difficul-
ties; Litzelfelner, 1995]
Furthermore, siblings would justify and nor-
malize the behaviors of their parents.
He gets more attention because he’s the baby of the
family. (p. 269) [Sibling of child with emotional dif-
ficulties; Litzelfelner, 1995]
I do lots more because I’m the oldest, when mom
stayed in bed a lot I took over the responsibilities. (p.
269) [Sibling of child with emotional difficulties; Lit-
zelfelner, 1995]
This strategy may help them cope with the
consequences of attributing the lack of attention
to something related to them as an individual.
As described above, the lack of parental atten-
tion can lead to feelings of unworthiness and of
being unlovable. If the sibling believes the lack
of attention is attributable to the target child
justifiably needing more attention, this means
it’s not a problem with them as a person and can
help them cope with or avoid the above emo-
tional consequences. Furthermore, this strategy
may help them cope with feelings of resentment
that comes with perceptions of unreasonable
and unrewarded responsibilities. If siblings be-
lieve they have more responsibilities because
they are older, they may not feel resentful, as
it’s normal and not unreasonable for older chil-
dren to have more responsibility without re-
wards.
Interestingly, as with contradictions de-
scribed above, siblings felt resentment and an-
ger when their parents would minimize or jus-
tify the disruptive behaviors of the target child.
Yet, they themselves also minimize and justify
behaviors.
Variations Associated With the Type of
MHP in the Target Child
Few studies examined specific MHPs, with
the majority of studies sampling siblings of
children with a range of behavior problems.
Four isolated MHPs were examined in the in-
cluded studies: ADHD, eating disorders, obses-
sive–compulsive disorder (OCD), and self-
harming behavior. Although the majority of
experiences and coping strategies were consis-
tent across difficulties and studies, some expe-
riences were found to be specific to siblings of
target children with particular difficulties. No
20 MA, ROBERTS, WINEFIELD, AND FURBER
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variations in the key coping strategies were
found.
First, thoughts of the target child dying were
only found for sisters of adolescent females
with eating disorders. This is not surprising
given eating disorders can lead to fatalities
(Hoek, 2006). For siblings of children with
other difficulties, thoughts of the future re-
volved around concerns about recovery and per-
manency of their circumstances. Second, sib-
lings of children with eating disorders and OCD
did not describe being victimized by violence
from the target child. This too is not surprising
given these disorders are not typically charac-
terized by externalizing behavior problems. It
may be that within the broad category of MHPs,
there are key differences relating to types of
MHPs that impact on the experiences of siblings
and that this category is too broad to allow an
extensive or sufficiently in-depth understanding
of the experiences of siblings. Third, only sis-
ters of adolescent sisters with eating disorders
reported positive effects on their relationships.
Perhaps there is a gender-based difference. It is
possible that female siblings are more likely to
perceive positive outcomes. It may also be that
there is less impact on relationships for siblings
of children with eating disorders. The experi-
ences of siblings of children with eating disor-
ders are more closely aligned with those of
children with special needs. Siblings of children
with special needs similarly reported a positive
effect on their relationship with the target child.
Eating disorders share several commonalities
with special needs, particularly those of a phys-
ical nature, such as requiring hospital-based
medical treatment (e.g., intravenous feeding),
the possibility of death, and in some cases, a
physically notable feature (e.g., emaciated
physical appearance). Other MHPs do not typ-
ically have these features present. Thus, it may
be that to develop a more in-depth understand-
ing of the experiences of siblings, the nature of
the illness requires a more in-depth analysis
than the division between mental health and
physical, neurological, or developmental dis-
abilities. Although we’ve followed this dichot-
omy in this article to reflect the divisions seen in
the existing research, more specific illness fea-
tures may mold sibling experiences than those
features captured by this dichotomy. For exam-
ple, eating disorders may be a more ‘visible’
disability than anxiety or depression whereas
autism spectrum disorders (ASDs) may be more
‘invisible’ than cancer or Down Syndrome. It
may be that the level of visibility of the disabil-
ity may shape siblings’ experience, for exam-
ple, in the support services available, the em-
pathic response from extended family and peer
networks, and in the willingness of the parents
to openly discuss these issues with siblings.
However, several critical differences were
noted between siblings of children with MHPs
and siblings of children with special needs sug-
gesting that this division is still useful. Thus, it
may be that this system needs to be slightly
altered and fine-tuned to allow more targeted
and specific intervention for siblings and to
refine future research directions. For example, it
may be that siblings of children with eating
disorders may benefit more from a support pro-
gram for siblings of children with cancer that
discusses thoughts about dying rather than one
for siblings of children with ADHD that ad-
dresses sibling violence. Future research could
then explore whether siblings of children with
an eating disorder or cancer are more likely to
develop anxiety symptoms and if siblings of
children with ADHD or those of children with
ASDs who present with violent outbursts are
more likely to mimic violent behavior.
Another variation found was that only female
younger siblings of children with ADHD re-
ported enjoying the increased responsibilities
imposed on them. The rest of the study’s sample
described these responsibilities as burdensome
and unreasonable. It may be that younger sib-
lings of target children enjoy increased respon-
sibilities. Younger siblings may be asked to
complete less emotionally taxing responsibili-
ties than those asked of older siblings. It may
also be that female siblings are less likely to
perceive increased responsibilities as burden-
some. This variation points to the potential role
that contextual factors such as birth order and
gender may have on the experiences of siblings.
It highlights another level of depth needed in
this research beyond examining the specific
MHPs of the target child.
It should be noted however that the majority
of studies used open-ended interview formats
and relied on spontaneous responses from par-
ticipants. It may be that siblings of children with
other types of MHPs have similar experiences,
but a discussion of these did not spontaneously
arise. For example, thoughts of dying may also
21UTILITY OF QUALITATIVE METASYNTHESIS
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be experienced by siblings of children with sub-
stance abuse problems (e.g., fear of overdose),
conduct problems (e.g., through gang associa-
tions), or depression (e.g., through self-harm
behaviors). Direct questioning on these topics
may reveal shared experiences.
Conclusion
This article outlined a qualitative metasyn-
thesis of the existing literature on the experi-
ences and coping strategies of siblings of chil-
dren with MHPs. The methodology and findings
of this synthesis have significant implications
for research and clinical practice. Each of these
implications are further considered within the
context of how this metasynthesis has contrib-
uted to and extended the findings from primary
qualitative research and systematic reviews of
quantitative research. As such, the following
sections highlight the implications of this paper
for ongoing debates around the utility of quali-
tative metasynthesis.
Implications for Qualitative Methodology
First, this article provides an example of
methodology used in qualitative metasynthesis.
Given the rarity of qualitative metasyntheses
and the relatively new methodologies used in
this area, clear and comprehensive examples of
this methodology are needed. This article has
outlined in detail each step of the methodology
used and presents a qualitative metasynthesis
from beginning to end, from introduction to
conclusion, and from findings to interpretation
and implications.
Second, this article highlights the utility of
qualitative metasynthesis techniques in extend-
ing findings from primary qualitative research.
Qualitative metasynthesis has enabled several
conclusions to be made about siblings of chil-
dren with MHPs with greater methodological
rigor than in primary qualitative studies. Sib-
lings have a range of experiences associated
with living with a child with MHPs. The ma-
jority of reports and the emphasis from siblings
were on the negative aspects and negative im-
pact of having a brother or sister with MHPs.
Benefits were rarely discussed, were discussed
by only a few siblings, and were reported to be
a less salient aspect of their life with the target
child. This was found for all areas of the sib-
ling’s life including relationships, self, and
daily life. These experiences and coping strate-
gies were found, for the most part, to be shared
experiences of siblings regardless of the type of
MHPs in the target child. Synthesis of primary
research strengthened the final conclusions, in
terms of reliability and generalizability, as they
are based on multiple studies and show that
these findings are consistent across a wide range
of participants. Thus, synthesis enabled more
reliable conclusions, generalizable findings, and
resulted in findings of a higher level of evi-
dence. Given that qualitative research is still
considered to be at one of the lower levels of
evidence, it is essential that qualitative method-
ology evolves to include more rigorous methods
that can provide more conclusive, reliable, and
generalizable findings (Thorne et al., 2004).
The methodological rigor of the results of
qualitative metasyntheses, in terms of consis-
tency, reliability, and generalizability, is com-
parable with that found in systematic reviews of
quantitative data. In this metasynthesis, the key
experiences and coping strategies were found
consistently across numerous studies and par-
ticipant populations. This suggests that the find-
ings are reliable and can be generalized to the
majority of siblings of children with MHPs. In
systematic reviews of quantitative data, the
findings and key data trends were similarly con-
sistent across studies. For example, the majority
of studies found that siblings of children with
MHPs have higher rates of psychopathology
than control siblings (Ma et al., 2015). How-
ever, in quantitative methodology, there are ad-
ditional factors to consider in assessing the re-
liability of quantitative data, such as statistical
significance and effect sizes (Valentine, Pigott,
& Rothstein, 2010). From this perspective, the
findings in our systematic reviews of quantita-
tive data were less consistent than those of this
qualitative metasynthesis. For example, al-
though the majority of studies reported statisti-
cally significant differences between siblings of
children with MHPs and control siblings in
symptoms of psychiatric disorders, this was not
consistently found across studies and effect
sizes often varied (Ma et al., 2014a). Thus,
qualitative metasynthesis may build a more
conclusive evidence base than primary qualita-
tive research that is comparable to that achieved
through quantitative synthesis techniques.
22 MA, ROBERTS, WINEFIELD, AND FURBER
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In addition, the use of constant targeted com-
parison with siblings of children with special
needs has provided novel interpretations of
qualitative data that were not evident in the
primary studies. Siblings of children with
MHPs and siblings of children with special
needs share very similar experiences, which
suggests that there are common features that
underpin the impact of illness on siblings. Loss
of a ‘normal’ sibling relationship, parental fa-
voritism, and increased caregiving responsibil-
ities seem to be commonalities across the two
groups and represent key features that underpin
the impact of illness on siblings. However, they
also differ in several important ways and these
highlight the key differences that arise from
different types of ‘illnesses’—namely, those
that are primarily physical, developmental, or
neurobiological in nature compared with those
primarily emotional, behavioral, and social in
nature. First, the severity, frequency, and per-
vasiveness of the impact of MHPs on siblings’
lives was greater than that described by siblings
of children with special needs. Second, because
of the increased risk of MHPs in parents and
siblings of children with MHPs, they may be
less able to adapt around the child’s problems
and may be less able to reduce the impact of
MHPs on their lives. This may result in poorer
outcomes for siblings of children with MHPs.
Third, the nature of MHPs may be more chal-
lenging than that of special needs, particularly
in regards to caretaking activities, which may
lead to perceptions of greater burden. Last, we
found a considerable discrepancy between the
amount of well-established research and sup-
port efforts between the two groups. If families
of children with special needs are better sup-
ported, this may account for differences be-
tween the impact of ‘illness’ on the lives of
siblings of children with MHPs and those of
children with special needs. Thus, this article
shows that qualitative metasynthesis has greater
interpretive power than primary qualitative
studies in that it can lead to novel interpretations
of data that cannot be formed in primary qual-
itative research.
Third, this article highlights the value of
qualitative metasynthesis in extending the find-
ings from systematic reviews of quantitative
research. Qualitative research with siblings of
children with MHPs has provided a level of
detail that has not been found in the quantitative
research. For example, although our reviews in
quantitative research with siblings of children
with MHPs found that they have significantly
greater impairment in family relationships,
these data revealed little about why they were
more impaired and what processes underpinned
this finding (Ma et al., 2014b). In contrast, this
qualitative metasynthesis has highlighted sev-
eral processes occurring within families of chil-
dren with MHPs that may explain the relation-
ship difficulties found in quantitative research,
such as parental differential treatment with ac-
companying feelings of resentment and unwor-
thiness and increased caregiving responsibilities
with accompanying feelings of burden and a
lack of recognition. Importantly, as highlighted
above, these processes have been consistently
reported across numerous studies and partici-
pant populations, which suggests that these
findings are reliable and generalizable.
Implications for Clinical Practice
The use of qualitative metasynthesis tech-
niques has enabled several practice guidelines
to be formed based on the existing literature.
Through the use of constant targeted compari-
son, several key similarities and differences be-
tween siblings of children with MHPs and those
of children with special needs were noted.
These findings suggest that prevention, treat-
ment, and support programs designed for one
group of siblings may similarly translate and be
of benefit to the other. As previously discussed,
the evidence base for support programs is far
more advanced for siblings of children with
special needs than for siblings of children with
MHPs. Therefore, it may be useful to adopt or
translate these programs and treatment strate-
gies with siblings of children with MHPs. How-
ever, key differences between the two groups
were also noted that limit the generalizability of
support programs between groups of siblings.
For example, based on developmental psycho-
pathology theories and research, siblings and
parents are both at increased risk of mental
health issues due to shared genetic and environ-
mental risk factors with the target child with
MHPs (Parritz & Troy, 2011). This risk is spe-
cific to siblings of children with MHPs and
programs that have been adapted from siblings
of children with special needs must include
additional material, such as components in ex-
23UTILITY OF QUALITATIVE METASYNTHESIS
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isting well-established child prevention pro-
grams such as the Incredible Years Program
(Webster-Stratton, 2011), to address these risk
factors.
Furthermore, constant targeted comparison
with siblings of adults with MHPs highlighted
important differences in choice of coping strat-
egy and beliefs about coping strategies attribut-
able to age, experience, and developmental
stage. Research with siblings of adults with
MHPs emphasizes the usefulness of ‘separating
the illness’ and the potentially detrimental na-
ture of the coping strategies used by siblings of
children with MHPs. Prevention, treatment, and
support programs should devote considerable
attention to teaching this coping strategy to sib-
lings of target children and to teaching strate-
gies to limit the use of more unhealthy coping
strategies.
Using qualitative metasynthesis techniques
has resulted in clear, direct recommendations
for clinical practice that had not been formed
from the primary qualitative research. It has
revealed components of existing programs with
siblings of children with special needs that
could be adapted for siblings of children with
MHPs and has revealed what additional com-
ponents should be included. Furthermore, this
metasynthesis led to specific recommendations
for clinical practice that could not be achieved
in the matched quantitative systematic reviews
(Ma et al., 2014a,2014b,2015). In this way, it
has extended the findings of both systematic
reviews of quantitative research and primary
qualitative studies.
In sum, this article demonstrates the utility of
qualitative metasynthesis in advancing scien-
tific knowledge in ways that have not been
achieved by quantitative synthesis techniques or
through primary qualitative research. The
strength of this technique is that it highlights
differences as well as similarities and can reveal
common human experiences as well as individ-
uality. Qualitative metasynthesis represents a
significant advancement in research methodol-
ogy that contributes novel insight and a deeper
understanding of complex psychological phe-
nomena.
Limitations
There are several limitations in the included
studies and in the synthesis process that should
be considered. First, unlike quantitative studies
described in our previous reviews (Ma et al.,
2014a,2014b,2015), the majority of qualitative
studies have investigated siblings of children
with a range of MHPs and have grouped them
together. This may influence the experiences of
siblings reported. For example, if the target
children mostly had externalizing difficulties,
then one might expect frequent reports of ag-
gressive or violent behavior whereas if they
mostly had internalizing difficulties, one might
expect more reports of anxiety and worry in
siblings. Limited data, as discussed above, sup-
port some variation in experiences based on the
type of MHP in the target child. Future research
should explore these variations in more detail to
provide more conclusive data on how sibling
experiences might vary. Second, several in-
cluded studies focused on parental accounts of
living with a child with MHPs and provided
little information about the siblings’ experi-
ences. Third, several included studies presented
data from the perspective of parents or target
children. It is important when interpreting these
findings that the data come from multiple per-
spectives and may not accurately reflect sib-
lings’ views on their experiences of having a
brother or sister with MHPs.
In terms of limitations of synthesis process,
first, as identified by Dixon-Woods and col-
leagues (2005), synthesis using thematic analy-
sis can be problematic as authors do not com-
prehensively describe the processes used (e.g.,
data-driven or theory-driven). However, we
have attempted to address this by explicitly
describing the processes used in this review.
Furthermore, Dixon-Woods and colleagues
(2005) stated that if thematic synthesis involves
simply providing a summary of themes found in
primary studies, then it might not offer much
beyond the existing literature. We have at-
tempted to address this by using the constant
targeted comparison technique described by
Sandelowski and Barroso (2007) to provide
novel interpretations with implications beyond
those that could be derived from the original
studies in regards to how experiences may differ
based on the nature of the ‘illness’ and the age
and developmental stage of the sibling. Second,
this review did not include the use of an inde-
pendent coder to assess the reliability of the
researchers’ interpretations and coding of the
data due to limitations in resources. However,
24 MA, ROBERTS, WINEFIELD, AND FURBER
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the majority of themes and interpretations re-
sulting from the synthesized thematic analysis
of the experiences of siblings of children with
MHPs in this review were similar to the inter-
pretations made by the primary study authors,
suggesting reliable interpretations and coding in
this analysis. Third, the search strategy used in
this review did not include searching for unpub-
lished works or searching the gray literature.
However, as suggested by experts in the field of
reviews and qualitative synthesis (including the
Cochrane Qualitative Research Methods
Group), exhaustive searches may not be appro-
priate for qualitative synthesis, with the key
issues being data saturation and disconfirming
cases (Dixon-Woods et al., 2006;Higgins &
Green, 2011). Data saturation was achieved in
this review with no new major themes emerging
from the included studies that were analyzed
latest in the process. Furthermore, no discon-
firming cases were found to refute the themes
found in our analyses. Last, sufficient emphasis
on contextual factors could not be achieved in
this metasynthesis. There has been ongoing de-
bate in the field as to whether metasyntheses can
attend to contextual factors, an important ele-
ment of qualitative research, or whether this
feature is lost by combining numerous studies
conducted with different populations (Sand-
elowski & Barroso, 2007). Given the state of the
primary literature with siblings of children with
MHPs, this metasynthesis cannot shed light on
this debate. Due consideration was not given to
these factors in the primary studies, with most
failing to report detailed information or to con-
sider the impact of these factors on the partici-
pants’ responses. For the most part, the data
were reported as equally applying to all siblings
in their sample without consideration of gender,
birth order, or the type of MHPs in the target
child. Thus, it is unclear whether this article had
limited contextualization due to limits of the
metasynthesis process or due to limitations in
the primary literature. However, it should be
noted that in the discussion of variations of
experiences, we were able to highlight several
contextual factors that warrant consideration in
future sibling research. The importance of these
factors had not been established based on pri-
mary research. This was mostly because pri-
mary authors had failed to consider these factors
or had insufficient information to determine the
importance of these factors. For example, in
focusing on eating disorders, Garley and John-
son (1994) were unable to examine the role of
target child diagnosis in participant responses.
By combining results from numerous studies,
we were able to explore siblings of children
with a range of MHPs and note differences in
experiences that may possibly relate to target
child diagnosis. Thus, metasynthesis may offer
insight into contextual factors that cannot be
achieved in primary research. However, further
research is needed in this area, particularly us-
ing primary studies that have given due consid-
eration to contextual factors. Such research
would demonstrate whether contextualization is
lost or even possibly enhanced by metasynthe-
sis processes.
Future Directions
There are several other significant gaps in the
literature on the siblings of children with MHPs
that have been highlighted through the qualita-
tive metasynthesis process. Research should in-
vestigate the coping skills of siblings and how
effective or helpful they are. This is essential to
understanding how siblings are to be effectively
supported. As previously discussed, the primary
coping strategies used by siblings are avoidance
and accommodation. However, none of the in-
cluded studies explored the usefulness of these
strategies, particularly the long-term outcomes
of the use of these strategies. In addition, re-
search with siblings of adults with MHPs has
highlighted that separating or externalizing the
illness from the target child is a particularly
useful strategy. Future research should explore
whether this is effective for siblings of children
with MHPs and how parents, clinicians, and
support program facilitators can facilitate the
development of this coping strategy. Second, it
would be useful to explore whether siblings
have different experiences based on the contex-
tual factors highlighted in this metasynthesis.
For example, do older siblings have to take on
more caregiving related burdens than younger
siblings? Are female siblings more likely to
focus on the positive aspects of their experi-
ences and challenges? Separate data on subsets
of siblings would pave the way for additional
qualitative metasyntheses using constant tar-
geted comparison and would provide a deeper
understanding of the experiences of siblings.
We recommend that a metasynthesis be con-
25UTILITY OF QUALITATIVE METASYNTHESIS
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ducted that includes primary research on sib-
lings of children with other types of disability or
special needs to further our understanding of the
impact of illness on siblings. This will allow
greater attention to be paid to contextual factors
relating to illness features such as the visibility
of the illness, treatment requirements, and
stigma associated with the diagnosis. It may be
that the dichotomy used in this analysis between
MHPs and special needs is not the most infor-
mative division to understanding the experi-
ences of siblings. Analyzing features of illness,
unrelated to the label of the disability, may
illuminate the key elements of living with a
brother or sister with an illness that impact on
the wellbeing of siblings. These data could then
be compared with primary qualitative research
on the features of sibling relationships in the
general population to highlight the impact of
illness and how this changes ‘normal’ sibling
interactions and experiences.
Last, further qualitative metasyntheses are
greatly needed. Very few examples of metasyn-
theses exist and more are needed to guide re-
searchers who are unfamiliar with the tech-
niques, to inform debates in this area and efforts
to refine, systematize, and improve qualitative
metasynthesis procedures, and to highlight the
value of qualitative research within a continu-
ingly quantitatively dominated field.
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Accepted November 30, 2014
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... Given that family systems theory posits that the health of one member of a family can have an impact on the well-being of other family members [3], the siblings of children with mental disorders are at increased risk for mental disorders themselves [4]. Furthermore, as parents are required to invest significant time and resources to support their child with the mental disorder, they express concern about their capacity to devote attention to the health and development of the siblings [5]. Despite these concerns, evidence-based programs designed specifically to support the siblings of children with mental disorders are lacking. ...
... Despite these concerns, evidence-based programs designed specifically to support the siblings of children with mental disorders are lacking. Without support, there is an increased risk that the needs of siblings will be left unrecognized and/or unmet [5,6]. Understanding the needs of siblings of children with mental disorders and the scope of potential existing resources directed at these siblings is needed to reduce the risk to siblings and benefit their family's health. ...
... Given this 10-year gap in our current knowledge, it is unclear what has been done recently to investigate this significant issue. Furthermore, while one study described the potential needs of siblings (i.e., coping skills) [5], no studies have attempted to identify and map evidence on potential resources directed specifically at the siblings of children with mental disorders. Therefore, an updated review of this evidence that extends previous work by identifying and describing existing resources for siblings would provide an important step towards investing in siblings' health. ...
Article
Full-text available
Introduction: Mental disorders affect 1 in 5 children having consequences for both the child and their family. Indeed, the siblings of these children are not insulated from these consequences and may experience elevated levels of psychological distress, placing them at increased risk for developing mental disorders. This protocol describes the methodology for a scoping review that will examine how mental disorders in children impact the mental health of their sibling(s). Further, we aim to examine the role of sex, gender, birth order, age of each child, and familial factors (e.g., parent mental illness, family structure), in sibling mental health. The proposed review will also identify resources that aim to support the needs of siblings of children with mental disorders. Taken together, this proposed review aims to take a fundamental step towards determining intervention targets to reduce the transmission of risk between siblings. Aim: The proposed scoping review aims to address the following questions: i) how do mental disorders (in children <18 years of age) impact the mental health of their sibling(s) (also <18 years of age)? ii) Can we identify resources designed to address the needs of siblings of children with mental disorders? Methods: We will conduct the proposed scoping review in keeping with the six-stage Arksey and O'Malley Framework and the scoping review methodology provided by the Joanna Briggs Institute. In section i) we outline our research questions. In section ii) we describe our process for identifying studies that examine the mental health of siblings of a child with a mental disorder and studies that provide evidence on resources directed specifically at these siblings. We will search peer-review and grey literature published between 2011 and 2022 from OVID MEDLINE, OVID EMBASE, CINAHL Complete, Proquest Nursing and Allied Health, PsycINFO (via APA platform), Proquest Sociology Collection and Web of Science Core Collection and Proquest Theses and Dissertations. Section iii) describes our process for selecting relevant studies. In sections iv and v, we describe our methods for charting and summarizing relevant data. Finally, in section vi) we describe our integrative knowledge translation plan that aims to include knowledge users in interpretating and translating evidence gathered from the proposed review.
... The method used in this review has been described in detail elsewhere (Ma et al., 2015a(Ma et al., , 2015bMa, Roberts, Winefield, & Furber, 2017). Briefly, four electronic databases were searched from January 1990 to July 2011: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PubMed, and SciVerse Scopus using terms such as sibling; first degree relative; child; emotional; behavioural. ...
... For example, it may be that siblings of children with MHPs are also at increased risk of learning disorders that are linked to decreased social competence in the school setting (Nowicki, 2003). It may also be that siblings of children with MHPs experience significant home life disruptions (Ma, Roberts, Winefield, & Furber, 2015b, Ma et al., 2017 leading to increased stress, sleep difficulties, and poor concentration, which may impact on siblings' functioning at school. Thus, while the current state of evidence using a dimensional approach has highlighted some areas of risk for siblings, improvements and advancements in dimensional measures will likely allow more specific conclusions to be formed in the future. ...
Article
A previous review on the prevalence of psychopathology in siblings of children with mental health problems (MHPs) suggested that these siblings are at increased risk of a broad range of psychopathologies. No disorder-specific risk could be identified. It may be that a different approach to understanding mental health is needed. The following paper aimed to explore if using a dimensional approach could provide greater clarity and insight into the mental health of these siblings by conducting a similar systematic review using dimensional data on the psychosocial functioning of siblings of children with MHPs. An electronic search of publications from 1990 to 2011 identified 29 articles. The findings show that while mean sibling scores on internalising problems, externalising problems, social problems were in the normal range compared to standardised norms, siblings of children with MHPs scored poorer than control children and a greater proportion of siblings scored in the borderline/clinical range compared to children in the general population. Particular areas of functional impairments identified were delinquent behaviour, somatic complaints, anxious/depressed behaviour, and social problems. Effect sizes were moderate to large. Findings on symptom scores with categorical underpinnings were inconsistent. Implications for the debate between dimensional and categorical approaches are discussed and guidelines for future research are outlined. Implications for clinical treatment for siblings are highlighted.
... Iwakabe and Gazzola described the main goals of metasynthesis as theory building and development, and the systematic identification of shared concepts and themes. Ma et al. (2015) evaluated the utility of metasynthesis in qualitative research. They identified the potential for new insights and interpretations of the data that were not available to the original researchers: for example, by reducing the bias of small studies, identifying consistencies and variations across studies, and recognizing the role of contextual factors (e.g., gender, culture) in individual studies. ...
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Objective: We tested qualitative metasynthesis of a series of Hermeneutic Single Case Efficacy Design (HSCED) studies as a method for comparing within-session processes that may explain good and poor therapeutic outcome. Method: We selected eight HSCED studies according to change in clients’ scores on the Strathclyde Inventory (SI), a brief self-report instrument used to measure outcome in person-centered psychotherapy. Four of the case studies investigated the experience of clients whose pre–post change in SI scores showed improvement by the end of therapy, and the other four focused on clients whose change in SI scores indicated deterioration. We conducted a qualitative metasynthesis, adopting a generic descriptive-interpretive approach to analyze and compare the data generated by the HSCED studies. Results: In contrast to improvers, deteriorators appeared to be less ready to engage in therapeutic work at the beginning of therapy, and found the process more difficult; their therapists were less able to respond to these difficulties in a responsive, empathic manner; deteriorators were less able to cope successfully with changes of therapist and, eventually, gave up on therapy. Conclusion: We found that our qualitative metasynthesis of a series of HSCED studies produced a plausible explanation for the contrasting outcomes that occurred.
... The two systematic reviews of well-known qualitative research on the well-being of children and adolescents, however valuable they are, do not allow progress on the indicated need, since they are focused on specific populations and life experiences. The first one focuses on the health and well-being of young children in their transition to school (Fane et al. 2016) and the second one focuses on siblings of children with mental health problems (Ma et al. 2015). ...
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Within the framework of the increasing academic valuation of the use of qualitative methodologies for the study of the well-being of children and adolescents, a systematic review of the available empirical production was developed through the “Qualitative Metasynthesis” methodology. The purpose of the study was to analyze and describe, jointly and integratively, the main common and shared aspects of the available knowledge on the dimensions that, according to the children and adolescent’s understandings, are significant for their well-being. During the second semester of the year 2018, the SCOPUS and Web of Science databases were reviewed, identifying a total of 76 articles of which 13 met the inclusion criteria and were analyzed following the methodology of constant comparison, interpretation of results and conceptual reinterpretation proposed by Sandelowski and Barroso (2007). The results brought about the delimitation and description of five categories: “Positive notion of oneself”; “Good treatment and support relations”; “Recognition”; “Significant activities”; and “Contextual aspects”. The obtained results contribute to the systematization of the knowledge about well-being provided from qualitative methodologies, thus contributing to the development of indicators for the study of well-being with information on domains and significant areas for children and adolescents.
... This critique is increasingly addressed through the use of the synthesis of related qualitative studies through a systematic approach to collecting, analysing and interpreting their results (Lachal et al., 2017). Metasynthesis is an interpretative process, which can provide new insights not found in primary studies (Ma et al., 2015). To the authors' knowledge, no metasynthesis of qualitative research into WRAP training has been published. ...
Article
Purpose The purpose of this systematic review was to address two questions: what is the qualitative evidence for the effects of the Wellness Recovery Action Plan (WRAP) training, as perceived by adults with mental health difficulties using it? What is the quality of qualitative literature evaluating WRAP? Design/methodology/approach Five electronic reference databases and the EThOS database for unpublished research were systematically searched, as well as two pertinent journals. Study quality was assessed using Critical Appraisal Skills Programme criteria and results analysed using thematic synthesis. Findings Of 73 studies, 12 qualitative papers met inclusion criteria and were generally good quality. Analyses demonstrated expected findings, such as increased understanding and active management of mental health in the context of group processes. Results also highlighted that WRAP training promoted acceptance and improved communication with professionals. Peer delivery of WRAP was highly valued, with contrasting perceptions of peers and professionals evident. Some cultural considerations were raised by participants from ethnic minorities. Research limitations/implications WRAP training participation has positive self-perceived effects beyond those captured by measures of recovery. Broader implications are suggested regarding earlier access to WRAP, professional support and communication between professionals and service users. Recommendations for further research include the relationship between social support and illness self-management and peer-delivered acceptance-based approaches. Multiple time-point qualitative studies could offer insights into WRAP training processes and whether changes are sustained. Originality/value As the first review of qualitative evidence regarding WRAP training, value is offered both through increased understanding of outcomes and also guidance for future research.
... Researchers undertake qualitative meta-analyses to develop novel interpretations that may provide a more in-depth understanding of a topic than what can be surmised by reading the primary literature (e.g., Ma et al. 2015). The main advantage of this methodology is that there is no need to analyse the entire body of literature, rather, when selected findings are contextualised appropriately, this approach can offer new insight into a topic (Schreiber et al. 1997;Levitt 2018). ...
Thesis
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Global reports stress the importance of developing the construction industry to address productivity-related issues and challenges with urbanization. McKinsey concluded that the construction industry could be more efficient by using and managing resources to address low productivity. With an expected intensified urbanization and rapidly changing global economic landscape, pressure has been put on the current rate of housing production. Therefore, industrialization has been promoted as making industries sustainable, with increased resource-use efficiency and greater adoption of innovation that focuses on industrial processes. Technology companies have started to take an interest in the construction market as they see a potential in industrialization and scalability of house-building and have made large investments in construction companies that use prefabricated or modular manufacturing techniques to build houses. Although industrialized house-building (IHB) companies have been the subjects of wide-ranging research, research into how to utilize IHB can be important and interesting, not only to address the low productivity in the industry but also to examine increased resource-use efficiency and explain how to benefit from the global interest in investing in IHB companies. Therefore, an increased understanding of IHB companies from a resource-based perspective, as illustrated from a Swedish perspective, is considered to be of importance for further development of the building industry. The contribution of this thesis is a synthesis of four different constructs (entrepreneurial orientation, dynamic capability, path dependency, and technology transfer), discussed in three academic papers, that characterize and further the understanding of how an IHB company use and manages its resources. Findings shows that, on a corporate level, the IHB company managed resources in many different ways and it did so to secure the business. It took different approaches towards how it use and manage resources. From a theoretical perspective, entrepreneurial orientation has a more proactive, long-term, and strategic focus on using and managing resources (both tangible and intangible), looking at the ‘bigger picture’ more. Dynamic capability has a more reactive (addresses different aspects of change as it happens) and tactical focus on using and managing resources, looking at the small steps involved in sensing and seizing and reconfiguring of resources. Technology transfer can be seen as an active process, on an operational level, using and managing resources between parties. Entrepreneurial orientation enabled the case company to use and manage resources and competences continuously and also to sense, seize, and reconfigure cumulative resources over time, which resulted in an exponential build-up of dynamic capabilities. The way in which the company worked with developing corporate resources showed that continuous development of dynamic capabilities also influenced the industry path dependency, by working with fewer changes in processes caused by external factors. Later, by exponentially developing dynamic capabilities, and exploring lean to renew the corporate culture, the increased standardized work operationalized their accumulated resources. Through small steps of exploitation and exploration, and the reconfiguration of working methods, the company continuously improved operations, routinizing learning and the use of built-up resources. The way it worked by constantly sensing, seizing and reconfiguring its operations, addressed the assumption that companies grow in a path dependent way. This, in turn, has led to the potential of assigning resources through technology transfer of the IHB platform into another business.
... Researchers undertake qualitative meta-analyses to develop novel interpretations that may provide a more in-depth understanding of a topic than what can be surmised by reading the primary literature (e.g., Ma et al. 2015). The main advantage of this methodology is that there is no need to analyse the entire body of literature, rather, when selected findings are contextualised appropriately, this approach can offer new insight into a topic (Schreiber et al. 1997;Levitt 2018). ...
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The demand for affordable, high-quality homes and premises has increased as society has evolved. Construction companies have shown that an industrialised housebuilding (IHB) platform strategy is an effective way of meeting exacting customer requirements. We decided to apply a managerial perspective and consider the IHB platform as a technological solution when investigating technology transfer (TT) in a construction context. Drawing on a meta-analysis of the literature and a qualitative case study at an IHB company, this work examines how two construction companies participate in TT. The results show that the IHB platform strategy can help a company overcome uncertainties associated with the TT process. Furthermore, the platform strategy supports the transferability of IHB to different markets, which, in turn, provides unique opportunities for companies from other contexts to enter the construction market. Our findings also revealed that CEOs from three construction companies were not only interested in TT due to potential profit improvements, but also considered how the process could benefit their employees and the community. This may be a result that is specific to Nordic culture or insight into a unique characteristic of the broad construction industry. This study contributes knowledge to the scarce research field of TT in a construction context. It provides evidence for how further cases of TT may disrupt the construction industry in terms of new business models or companies from the diverse field entering the market.
... Qualitative meta-analyses have been advocated for their ability to develop novel interpretations that may extend deeper than those in the primary literature (e.g., Ma, Roberts, Winefield, & Furber, 2015). They do not need to analyze an entire literature, however, to develop and offer new understandings. ...
Article
Objective: This paper explains the function of qualitative meta-analyses and their methodological development. Recommendations have broad relevance but are framed with an eye toward their use in psychotherapy research. Rather than arguing for the adoption of any single meta-method, this paper advocates for considering how procedures can best be selected and adapted to enhance a meta-study's methodological integrity. Method: Through the paper, recommendations are provided to help researchers identify procedures that can best serve their studies' specific goals. Meta-analysts are encouraged to consider the methodological integrity of their studies in relation to central research processes, including identifying a set of primary research studies, transforming primary findings into initial units of data for a meta-analysis, developing categories or themes, and communicating findings. Conclusion: The paper provides guidance for researchers who desire to tailor meta-analytic methods to meet their particular goals while enhancing the rigor of their research.
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Consultation relies on story. This is true for researchers, for practitioners, and for clients. Given this fact, qualitative and mixed methods (QMM) research are particularly well suited to listening to the stories that compose the clinical practice of consultation in order to extend understanding and to support improvement and innovation. In this way, QMM is worthy of its growing credibility as a centerpiece of empirical inquiry. To initiate the series of articles collected for this special issue, this article extends consideration of readiness for the consultation process. By positioning consultation research as the consultee and QMM as the consultant, this brief discussion anchors in the metaphor of best consultation practice, as we understand it today.
Thesis
The purpose of this qualitative study was to explore how the European Standards for the accreditation of counseling training programs compare to CACREP standards and to each other. The differences and commonalities between standards have been defined through a meta-synthesis of integrated findings from a large body of inter-related qualitative studies and reinterpretation of the synthesized data. This qualitative meta-synthesis research was intended to contribute to the process of counseling globalization by exploring the unique cultural features and aspects of the European and the U.S. accrediting systems for counseling training programs. This research revealed 1) the commonly recognized areas that were accepted by both sides; 2) the areas that require further development in the European countries in order to successfully promote the counseling profession; 3) the areas that display unique characteristics based on cultural perceptions and historical backgrounds; and, 4) the areas that require CACREP to reconsider their standards regarding universal applicability. These specific qualities and needs of each analyzed professional counseling community were addressed with regards to the upcoming necessity to develop the unified global standards for counseling training and practice. The findings of this research may underpin the formation of the prospective unified standards for the global counseling training. The qualitative comparison of this meta-synthesis can be used for the discussion of how the worldwide professional counseling community can be effectively consolidated in the future.
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While it is well recognized that family relationships have a significant impact on child mental health and vice versa, little research has examined the impact of living with a child with mental health problems (MHPs) on family relationships for their siblings. This report aims to synthesize the existing literature and comment on the current state of evidence. An electronic search of publications from 1990 to 2011 was conducted and 22 studies were included. The findings show that families of children with MHPs have less positive (e.g. less supportive) and more negative (e.g. more conflictual, aggressive) sibling relationships and more negative parent-sibling relationships compared to control families. Exceptions were sibling relationships in families of children with conduct disorder (more positive) and anxiety disorders (not significantly different from controls). Limitations of the existing literature include the types of measures used and the use of single informants. Methodological guidelines for future studies are outlined.
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It is a stressful experience for parents and/or carers when their child is admitted to an in-patient unit because of severe mental illness.
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While the importance of looking at the entire family system in the context of child and adolescent mental health is well recognised, siblings of children with mental health problems (MHPs) are often overlooked. The existing literature on the mental health of these siblings needs to be reviewed. A systematic search located publications from 1990 to 2011 in four electronic databases. Thirty-nine relevant studies reported data on the prevalence of psychopathology in siblings of target children with MHPs. Siblings of target children had higher rates of at least one type of psychopathology than comparison children. Risk of psychopathology varied across the type of MHP in the target child. Other covariates included sibling age and gender and parental psychopathology. Significant variations and limitations in methodology were found in the existing literature. Methodological guidelines for future studies are outlined. Implications for clinicians, parents, and for future research are discussed.
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In this article, the authors outline methods for using fixed and random effects power analysis in the context of meta-analysis. Like statistical power analysis for primary studies, power analysis for meta-analysis can be done either prospectively or retrospectively and requires assumptions about parameters that are unknown. The authors provide some suggestions for thinking about these parameters, in particular for the random effects variance component. The authors also show how the typically uninformative retrospective power analysis can be made more informative. The authors then discuss the value of confidence intervals, show how they could be used in addition to or instead of retrospective power analysis, and also demonstrate that confidence intervals can convey information more effectively in some situations than power analyses alone. Finally, the authors take up the question ‘‘How many studies do you need to do a meta-analysis?’’ and show that, given the need for a conclusion, the answer is ‘‘two studies,’’ because all other synthesis techniques are less transparent and/or are less likely to be valid. For systematic reviewers who choose not to conduct a quantitative synthesis, the authors provide suggestions for both highlighting the current limitations in the research base and for displaying the characteristics and results of studies that were found to meet inclusion criteria.
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Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
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Systematic review has developed as a specific methodology for searching for, appraising and synthesizing findings of primary studies, and has rapidly become a cornerstone of the evidence-based practice and policy movement. Qualitative research has traditionally been excluded from systematic reviews, and much effort is now being invested in resolving the daunting methodological and epistemological challenges associated with trying to move towards more inclusive forms of review. We describe our experiences, as a very diverse multidisciplinary group, in attempting to incorporate qualitative research in a systematic review of support for breastfeeding. We show how every stage of the review process, from asking the review question through to searching for and sampling the evidence, appraising the evidence and producing a synthesis, provoked profound questions about whether a review that includes qualitative research can remain consistent with the frame offered by current systematic review methodology. We conclude that more debate and dialogue between the different communities that wish to develop review methodology is needed, and that attempts to impose dominant views about the appropriate means of conducting reviews of qualitative research should be resisted so that innovation can be fostered.
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A growing body of evidence points to the importance of life stressors and social resources in adolescent functioning. This article describes the Life Stressors and Social Resources Inventory-Youth Form (LISRES-Y), which provides an integrated assessment of life stressors and social resources in eight domains: physical health, home/money, parent, sibling, extended family, school, friend, and boy/girlfriend. The indices were developed on data obtained from four groups of youth: depressed youth, youth with conduct disorder, youth with rheumatic disease, and healthy youth. As expected, depressed youth reported more acute and chronic stressors and fewer social resources than did healthy youth. In addition, the indices were predictably associated with individual differences in depressed mood, anxiety, behavior problems, and self-confidence. Negative life events, ongoing stressors in different domains, and stable social resources all contributed unique variance to the functioning criteria. The findings point to the value of an integrated measure of adolescent life context.
Book
The Cochrane Handbook for Systematic Reviews of Interventions (the Handbook) has undergone a substantial update, and Version 5 of the Handbook is now available online at www.cochrane-handbook.org and in RevMan 5. In addition, for the first time, the Handbook will soon be available as a printed volume, published by Wiley-Blackwell. We are anticipating release of this at the Colloquium in Freiburg. Version 5 of the Handbook describes the new methods available in RevMan 5, as well as containing extensive guidance on all aspects of Cochrane review methodology. It has a new structure, with 22 chapters divided into three parts. Part 1, relevant to all reviews, introduces Cochrane reviews, covering their planning and preparation, and their maintenance and updating, and ends with a guide to the contents of a Cochrane protocol and review. Part 2, relevant to all reviews, provides general methodological guidance on preparing reviews, covering question development, eligibility criteria, searching, collecting data, within-study bias (including completion of the Risk of Bias table), analysing data, reporting bias, presenting and interpreting results (including Summary of Findings tables). Part 3 addresses special topics that will be relevant to some, but not all, reviews, including particular considerations in addressing adverse effects, meta-analysis with non-standard study designs and using individual participant data. This part has new chapters on incorporating economic evaluations, non-randomized studies, qualitative research, patient-reported outcomes in reviews, prospective meta-analysis, reviews in health promotion and public health, and the new review type of overviews of reviews.
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Findings are reported regarding maternal experiences of their seriously emotionally disordered child both prior to and following a stay in a residential children's mental health treatment facility. Prior to placement, these parents had exhausted all nonresidential forms of intervention and, increasingly, became concerned not only for their identified child's welfare, but also for that of themselves and other siblings in the home. Regardless of whether their child's stay in residential treatment yielded positive or negative treatment outcomes, these parents unilaterally viewed the intensive short-term treatment of their child as an extremely valuable and necessary service. Parental recommendations for improvement in residential services include a reduced waitlist period, availability of services to children at a younger age, more parental education regarding effective child management strategies, and increased support for caregivers. The results are discussed as they relate to policy and practice for residential treatment providers.