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Parentification of adult siblings of individuals with autism spectrum disorder: Distress, sibling relationship attitudes, and the role of social support

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Background Typically developing (TD) siblings of individuals with autism spectrum disorder (ASD) often fulfil caregiving roles as children or adults (i.e., parentification, which can be either parent-focused or sibling-focused). Method This study examines how parentification interacts with social support when predicting distress and sibling relationship attitudes in 60 TD adult siblings of individuals with ASD. Results Perceived social support served as a moderator. Specifically, TD adult siblings who experienced high parent-focused parentification during childhood and low current social support were most likely to report high distress. TD siblings who reported low sibling-focused parentification during childhood and low current social support were most likely to report less positive attitudes about their relationships with their siblings with ASD. Conclusions Current findings suggest that perceived social support may serve as a potential point of intervention for reducing distress and improving sibling relationship attitudes among adult TD siblings of those with ASD.
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Running head: PARENTIFICATION AND SOCIAL SUPPORT 1
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Parentification of Adult Siblings of Individuals with Autism Spectrum Disorder: Distress,
Sibling Relationship Attitudes, and the Role of Social Support
Theodore S. Tomeny
The University of Alabama
Tammy D. Barry
Washington State University
Elizabeth C. Fair
The University of Southern Mississippi
This work was not supported by any funding agencies and the authors have no conflicts of
interest to report.
CITATION:
Tomeny, T. S., Barry, T. D., Fair, E. C. (2016). Parentification of adult siblings of individuals
with autism spectrum disorder: Distress, sibling relationship attitudes, and the role of
social support. Journal of Intellectual and Developmental Disability. Online Preprint.
doi: 10.3109/13668250.2016.1248376
Link to article: http://dx.doi.org/10.3109/13668250.2016.1248376
PARENTIFICATION AND SOCIAL SUPPORT 2
Abstract
Background: Typically-developing (TD) siblings of individuals with autism spectrum disorder
(ASD) often fulfill caregiving roles as children or adults (i.e., parentification, which can be either
parent-focused or sibling-focused). Method: This study examines how parentification interacts
with social support when predicting distress and sibling relationship attitudes in 60 TD adult
siblings of individuals with ASD. Results: Perceived social support served as a moderator.
Specifically, TD adult siblings who experienced high parent-focused parentification during
childhood and low current social support were most likely to report high distress. TD siblings
who reported low sibling-focused parentification during childhood and low current social
support were most likely to report less positive attitudes about their relationships with their
siblings with ASD. Conclusions: Current findings suggest that perceived social support may
serve as a potential point of intervention for reducing distress and improving sibling relationship
attitudes among adult TD siblings of those with ASD.
Keywords: autism spectrum disorder, parentification, social support, siblings, adults
PARENTIFICATION AND SOCIAL SUPPORT 3
Parentification of Adult Siblings of Individuals with Autism Spectrum Disorder: Distress,
Sibling Relationship Attitudes, and the Role of Social Support
According to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition
(DSM-5), individuals with autism spectrum disorder (ASD) exhibit social communication
difficulties characterized by impairments in social-emotional reciprocity, nonverbal
communication, and social relationships (American Psychiatric Association, 2013). Moreover,
these individuals display restricted interests or repetitive behaviors that may include stereotyped
speech, obsessions, adherence to routines, and sensory sensitivities (American Psychiatric
Association, 2013). In addition to primary symptoms, those with ASD often exhibit a number of
problematic associated features, such as intellectual disability, aggression, temper tantrums, self-
injurious behavior, sleep and feeding problems, anxiety, and depression, among others
(Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Ming, Brimacombe, Chaaban,
Zimmerman-Bier & Wagner, 2008). Due to the pervasiveness of these symptoms and the impact
they have on overall family functioning, the relationships between typically-developing siblings
(TD) and their brothers and sisters with ASD often differ from “typical” sibling relationships.
For example, when one sibling has a disability, TD siblings frequently assume caregiving roles
during childhood (Hooper, 2012). Moreover, these roles often continue into adulthood,
especially when parents are no longer able to care for their child with a disability (Egan &
Walsh, 2001). Due to the longevity of sibling relationships and the bi-directional impacts on
siblings’ emotional, social, and behavioral functioning throughout life, research examining these
sibling relationships is critical.
Family Environment and Parentification
PARENTIFICATION AND SOCIAL SUPPORT 4
Family environments that include a child with ASD are often characterized by higher
than typical levels of parental stress (for a review, see Hayes & Watson, 2013). As noted earlier,
associated symptoms of ASD often coincide with the primary symptoms. These challenging
symptoms likely result in further stress in the family environment (Hastings & Brown, 2002).
As part of a qualitative study, Tozer, Atkin, and Wenham (2013) interviewed adult siblings of
individuals with ASD, who reported that, as children, they felt an obligation to relieve some of
their parent’s stress by caring for their brother or sister with ASD. Research has shown that
many TD siblings do in fact take on an inordinate number of caregiving roles within the home
(Hooper, Doehler, Wallace, & Hannah, 2011). This phenomenon of children assuming a high
level of caregiving behaviors that are typically performed by adults is described as
parentification, and this often occurs in families that include a child with a disability or
debilitating illness (Hooper, Doehler et al., 2011). Parentification can involve providing
emotional support to the brother, sister, or parent, or it can involve completing household tasks
or caring for the physical needs of their brother, sister, or parent. Parentification can be sibling-
focused (the caregiving role is directed toward a brother or sister) or parent-focused (the
caregiving role is directed toward a parent; Hooper, Doehler et al., 2011).
Outcomes of “parentified” siblings appear mixed. For example, a moderate amount of
parentification may lead to positive outcomes such as increased responsibility, and even higher
than typical levels of parentification can lead to other positive outcomes (e.g., increased maturity
and family closeness), as is often seen in immigrant families or families from multi-cultural
backgrounds (Jurkovic et al., 2004). Similarly, sisters of children with ASD have reported
positive feelings about caring for their brother or sister with autism (Cridland, Jones, Stoyles,
Caputi, & Magee, 2015). However, high levels of parentification have also been associated with
PARENTIFICATION AND SOCIAL SUPPORT 5
negative outcomes such as feelings of rejection or psychopathology, including anxiety disorders,
personality disorders, and eating disorders, that persist into adulthood (Hooper, 2012; Hooper,
DeCoster, White, & Voltz, 2011; Hooper, Doehler et al., 2011). Some TD siblings of individuals
with ASD report having felt guilt in adulthood when they left home to begin their own lives,
along with continued struggles related to balancing commitments to their disabled brother or
sister with other aspects of their lives (e.g., their own children, their careers; Tozer et al., 2013).
Tomeny, Barry, Fair, and Riley (under review) found that parent-focused parentification
predicted distress in TD adult siblings, whereas sibling-focused parentification predicted more
positive attitudes about the sibling relationship. Consistent with previous research, Tomeny et al.
(under review) suggested that perhaps parent-focused parentification is generally unfavorable
due to the significant role-reversal, but sibling-focused parentification can be beneficial given
that it is linked with positive interactions, such as shared experiences (e.g., Whiteman, McHale,
& Crouter, 2007), problem-solving (e.g., Smith & Ross, 2007), and constructive activities (e.g.,
Tucker, McHale, & Crouter, 2008) among siblings. Thus, outcomes of parentified siblings may
vary according to the recipient of their parentification, in addition to the level of parentification
experienced. Based on previous research (e.g., Seltzer, Orsmond, & Esbensen, 2009), it is clear
that the effects of sibling demographics (such as age, gender, race, number of individuals in the
household when the TD sibling was a child, sibling birth order, and age discrepancy between
siblings) also should be taken into account when considering how parentification relates to either
TD sibling distress or relationship quality. The current study was designed considering these
possible influences.
Sibling Relationship Quality
PARENTIFICATION AND SOCIAL SUPPORT 6
Research exploring the overall quality of the sibling relationship when one sibling has
ASD is mixed (Orsmond & Seltzer, 2007). For example, the aforementioned behavior problems
often exhibited by children with ASD can negatively impact sibling relationships. These problem
behaviors often make it difficult for siblings to participate in activities and/or spend time
together, and this may reduce the quality of the sibling relationship (Orsmond, Kuo, & Seltzer,
2009). However, these sibling relationships can also have positive characteristics and be of high
quality. For example, Rivers and Stoneman (2003) found that TD siblings reported feeling
satisfied overall with their sibling relationship. Moreover, in a study conducted by Kaminsky
and Dewey (2001), TD siblings reported higher levels of admiration for and less fighting with
their brother or sister with ASD, even under conditions of lower levels of closeness and prosocial
behavior when compared to a control group.
Social Support
Social support is an important factor that may help to alleviate some of the stress and
challenges that are present in families of children with ASD. By reducing the impact of some of
these difficulties, social support may thereby help improve mental health, sibling relationship
quality, and general outcomes. Social support is a broad term that includes emotional support,
tangible support, information, advice, and positive social interactions provided from one person
or agency to another person (Bromley, Hare, Davison, & Emerson, 2004; Crnic, Greenberg,
Ragozin, Robinson, & Basham, 1983; Lee, Lee, & August, 2011; Vaughan, Foshee, & Ennett,
2010; White & Hastings, 2004). Social support may benefit individuals independently and lead
to positive outcomes even when stressors or challenging situations are not present, or social
support may act as a buffer by protecting individuals from possible negative effects of stressful
or difficult situations (Armstrong, Birnie-Leftcovitch, & Ungar, 2005). For example, a study
PARENTIFICATION AND SOCIAL SUPPORT 7
conducted by Wolf, Fisman, Ellison, and Freeman (1998) found that TD siblings of children with
ASD or Down’s syndrome who also experienced higher levels of social support had lower levels
of maladjustment. A qualitative study conducted by Atkin and Tozer (2014) examined the
influence of social support (e.g., service providers) on TD adult siblings. These siblings reported
benefits of third-party assistance for their disabled brother or sister, although they also stressed
the importance of being involved in decision-making for their brothers or sisters with disabilities
and of being personally supported and valued by service providers. Receiving emotional social
support and having access to tangible support for their brother or sister was described as
important (Atkin & Tozer, 2014), and it is possible that these supportive factors may serve to
protect against negative outcomes for adult siblings.
Purpose and Hypotheses
The purpose of the current study was to examine social support as a possible protective
factor for TD adult siblings of individuals with ASD. As previously mentioned, the literature on
outcomes associated with parentification is mixed. That is, a history of parentification can be
associated with either negative (Hooper, 2012; Hooper, DeCoster et al., 2011; Hooper, Doehler
et al., 2011) or positive (Jurkovic et al., 2004; Tomeny et al., under review) outcomes, depending
on the context and type of parentification being examined (i.e., parent-focused parentification is
linked to negative outcomes, whereas sibling-focused parentification is linked to positive
outcomes).
The overall aim of the current study was to answer the question: Are there combinations
of social support and specific types of parentification (parent-focused or sibling-focused) that are
associated with better adjustment (lower distress, more positive sibling relationship attitudes) for
adult TD siblings of an individual with ASD? Based on previous research, it was hypothesized
PARENTIFICATION AND SOCIAL SUPPORT 8
that, among TD siblings of individuals with ASD, perceived levels of social support would
moderate the relation between (a) parent-focused parentification and distress; (b) parent-focused
parentification and sibling relationship attitudes; (c) sibling-focused parentification and distress;
and (d) sibling-focused parentification and sibling relationship attitudes. Specifically, it was
expected that social support would lessen any positive relation between parentification and
distress and bolster any positive relation between parentification and sibling relationship
attitudes. Examining each outcome separately for parent-focused versus sibling-focused
parentification answered the question of whether any conditional relations varied based on type
of parentification. Finally, relations of sibling demographics (age, gender, race, number of
individuals in the household when the TD sibling was a child, sibling birth order, and age
discrepancy between siblings) with TD sibling distress and relationship quality were assessed
and significant demographic covariates were controlled in tests of the hypotheses.
PARENTIFICATION AND SOCIAL SUPPORT 9
Method
Research Design
The current study examined the hypotheses among TD adult siblings of individuals with
ASD, who completed self-report measures of parentification (retrospective report), social
support, sibling relationship attitudes, and distress (i.e., depression, anxiety, and stress) through a
secure online survey. All variables were dimensional and analyzed via moderated multiple
regression analyses to test for significant two-way interactions.
Participants
Sixty TD adult siblings of individuals with ASD participated by providing data about
themselves and their brother or sister with ASD. TD siblings ranged in age from 18 to 68 (M =
29.65, SD = 13.17), and 85% were female. The brothers and sisters with ASD ranged in age
from 10 to 74 (M = 26, SD = 12.77), and 18% were female. Seventy-eight percent of respondents
were older than their brother or sister with ASD and five years was the average absolute value of
sibling age differences. TD siblings reported the specific diagnosis that had been given to their
brother or sister with ASD (i.e., diagnoses were not independently confirmed). The sample’s
racial distribution was as follows: 88.3% Caucasian, 5% Hispanic, 3% Asian, 2% African-
American, and 2% other. Thirty-five percent of TD siblings reported being married, 42%
described themselves as never married or living alone, and 23% reported making over $100,000
annually. Other descriptive information about the sample is presented in Table 1.
Insert Table 1 about here
Measures
Demographic and Diagnostic Questionnaire. Each participating TD sibling completed
a demographic and diagnostic questionnaire that requested various demographic details about
PARENTIFICATION AND SOCIAL SUPPORT 10
themselves and their brother or sister with ASD. TD siblings provided information about their
brother or sister, including specific diagnosis, care received, and other demographic and
diagnostic information (e.g., age, gender, race, marital status, diagnosis type, who diagnosed
him/her, age of diagnosis, types of services received, living situation). Beyond basic
demographic details, TD siblings were also asked to provide information about their households
and their interactions with their brother or sister with ASD (e.g., number of people living in the
home, household income, level of education, marital status, amount of care provided to their
brother or sister with ASD). Finally, TD siblings were asked to report details of their childhood
families (e.g., number of people living in childhood home).
Parentification Inventory. The Parentification Inventory (PI) is a 22-item retrospective,
self-report measure of parent- and sibling-focused parentification (Hooper, 2009). The PI is
designed to assess an individual’s views of roles and responsibilities usually reserved for adult
caregivers that they carried out during childhood. TD siblings were asked to consider their
childhood family experiences and rate their agreement on a 5-point Likert scale (1= Never True
to 5 = Always True; higher scores indicate higher levels of parentification). The PI produces a
Total score and three subscale scores derived via factor analyses completed by Hooper, Doehler
et al. (2011) that measure Parent-focused Parentification (12 items), Sibling-focused
Parentification (7 items), and Benefits of Parentification (3 items). Example items from the
parent-focused scale include: “I served the role of referee for my family,” and “I was the first
person family members turned to when there was a family disagreement.” Examples from the
sibling-focused scale include: “I was expected to comfort my sibling(s) when they were sad or
having emotional difficulties,” and “I was responsible for helping my siblings (brother/sister)
complete their homework.” Subscale scores represent the mean score of the items on each
PARENTIFICATION AND SOCIAL SUPPORT 11
respective scale per procedures outlined by Hooper (2009). Psychometric examination of the PI
has revealed sufficient internal reliability and convergent validity with similar measures of
parentification, and divergent validity with appropriate measures of mental and physical health
(Hooper & Doehler, 2012). For the current sample, Cronbach’s alpha for each of the PI subscales
ranged from .64 to .88.
Interpersonal Support Evaluation List. The Interpersonal Support Evaluation List
(ISEL) is a 40-item self-report measure of perceived availability of social support for adults that
is counterbalanced for desirability (Cohen, Mermelstein, Kamarck, & Hoberman, 1985).
Respondents rate their agreement on a 4-point Likert scale from 0 (Definitely False) to 3
(Definitely True). The ISEL produces four subscales corresponding to four functions of support:
Tangible (availability of material aid), Appraisal (availability of having someone to talk to about
problems), Self-esteem (positively comparing oneself to others), and Belonging (availability of
others with whom to partake in activities). The ISEL also produces a total Overall Support scale,
which served to measure sibling perceptions of general support for the current study. Example
items from the ISEL include: “When I feel lonely, there are several people that I can talk to,” and
“If I were sick, I could easily find someone to help me with my daily chores.” The ISEL has
displayed internal consistency, test-retest reliability, and divergent validity (when compared to
measures of psychopathology; Cohen et al.). The current sample yielded a Cronbach’s alpha
coefficient of .96 for the Overall Support scale, indicating excellent internal consistency.
Depression, Anxiety, and Stress Scale 21. The Depression, Anxiety, and Stress Scale 21
(DASS-21) is a 21-item self-report measure of distress in the forms of depression, anxiety, and
stress, a short-form of the longer, 42-item DASS (Lovibond & Lovibond, 1995). Respondents
rate how much the questionnaire items applied to them during the previous week on a scale from
PARENTIFICATION AND SOCIAL SUPPORT 12
0 (Did not apply to me at all) to 3 (Applied to me very much, or most of the time). The DASS
produces Depression, Anxiety, and Stress subscales and a Total scale. Scale scores are the sum
of scores multiplied by two to allow for comparisons to the 42-item version of the DASS
(Lovibond & Lovibond, 1995). Example items from the DASS include “I found it difficult to
relax,” and “I felt down-hearted and blue.” Examination of the DASS’s psychometric properties
suggests appropriate convergent validity, construct validity, and internal consistency (Henry &
Crawford, 2005; Lovibond & Lovibond, 1995). The Total scale was of interest for the current
study as a measure of general distress in TD siblings. Cronbach’s alphas for the DASS subscale
scores for the current sample ranged from .84 to .91, indicating good internal consistency.
Lifespan Sibling Relationship Scale. The Lifespan Sibling Relationship Scale (LSRS;
Riggio 2000) is a 48-item self-report measure of sibling relationship attitudes completed by
adults. Respondents report on current and retrospective attitudes about their sibling
relationships. The participants in the current study were asked to consider their brother or sister
with ASD when completing this measure. Respondents rate their agreement with items on a 5-
point Likert scale from 1 (Strongly disagree) to 5 (Strongly agree) with higher scores suggesting
more positive attitudes about the sibling relationship. The LSRS is composed of 6 subscales and
a Total score. The LSRS Total score served as a measure of overall sibling relationship attitudes
for the current study. Example items include “My sibling makes me happy,” “My sibling
bothered me a lot when we were children,” and “I am proud of my siblings.” The LSRS has been
shown to display appropriate internal reliability and convergent and divergent validity, and this
validity has been shown to remain stable with respondents across the adult age span (Riggio,
2000). LSRS subscales produced Cronbach’s alphas ranging from .78 to .92 for the current
sample, indicating good internal reliability.
PARENTIFICATION AND SOCIAL SUPPORT 13
Procedure
Data for the current study were collected following approval from the University
Institutional Review Board of the authors’ affiliation at the time of data collection (The
University of Southern Mississippi; IRB protocol #13060401) and were included as part of the
protocol for a larger study. TD sibling participants were recruited via email advertisements to
autism support group listservs, particularly those targeting families of adults with ASD, and
through a referral sampling technique. After TD siblings agreed to participate, they were sent a
link to a secure survey website via Qualtrics (Qualtrics, Provo UT) containing the measures and
detailed instructions for completing the questionnaires. After providing consent, TD siblings
completed the Demographic and Diagnostic Questionnaire, the PI, the LSRS, the DASS, and the
ISEL. Completion of these measures took less than 30 minutes per participant on average. TD
siblings were asked to consider their brother or sister with ASD when completing surveys that
requested any information about the sibling relationship. Participants could choose to exit the
survey and discontinue the study at any time, but only participants who completed all measures
for the current study were included. Of all siblings who accessed the study survey, the
completion response rate was 73%. Participants could skip specific items; the procedures for
handling missing data are described in the Statistical Analyses section below. Participants were
entered into a drawing for one of ten $10 gift cards from a national retailer. The random drawing
was conducted and gift cards were awarded after the completion of the study.
Statistical Analyses
Preliminary analyses. Less than 0.3% of data was missing at the item-level and the
mean of the items on respective scales were imputed to replace this missing data according to
Harrell (2001). Descriptive statistics were completed for all variables of interest, and correlation
PARENTIFICATION AND SOCIAL SUPPORT 14
analyses were conducted to examine the interrelations among variables of interest. Demographic
variables identified as possible control variables (i.e., TD sibling age, TD sibling gender, TD
sibling race, number of individuals in the household when the TD sibling was a child, TD sibling
birth order, and absolute value of age discrepancy between siblings) based on their relation to TD
sibling outcomes in the literature (e.g., Seltzer et al., 2009) were correlated with the variables of
interest in the current study to determine covariates for subsequent regression analyses.
Hypothesis testing. Study hypotheses were then examined using a series of four
moderated multiple regression analyses (interactions between social support and each type of
parentification [parent- and sibling-focused] predicting TD sibling distress and sibling
relationship attitudes). Moderator and predictor variables were centered prior to creating each
interaction term to reduce multicollinearity and aid in interpreting plotted interactions. With TD
sibling distress as the criterion variable, covariates were entered in Step 1, social support and
parent-focused or sibling-focused parentification were entered in Step 2, and the interaction term
was entered in Step 3. With sibling relationship attitudes as the criterion variable, covariates
were entered in Step 1, social support and parent-focused or sibling-focused parentification were
entered in Step 2, and the interaction term was entered in Step 3.
Results
Preliminary analyses. Descriptive statistics and interrelations of the variables of interest
determined via bivariate correlation analyses are listed in Table 2. Skewness was within
acceptable limits, with some positive skew for the distress variable (DASS total), consistent with
what has been found in previous research using this clinical measure with a community sample,
both for the long form (Crawford & Henry, 2003) and the short form as used in the current study
(Henry & Crawford, 2005). An examination of the relations of the outcomes with the predictor
PARENTIFICATION AND SOCIAL SUPPORT 15
and moderator variables in Table 2 shows that parent-focused parentification was significantly
positively correlated with TD sibling distress, whereas sibling-focused parentification was
significantly positively correlated with sibling relationship attitudes. Social support was
significantly negatively correlated with TD sibling distress and significantly positively correlated
with sibling relationship attitudes. Table 2 also indicates that the two types of parentification
were significantly positively correlated with one another and that TD sibling distress and sibling
relationship attitudes were significantly negatively correlated with one another.
The interrelations between demographic variables and the variables of interest in the
current study also are presented in Table 2. As shown in the table, TD sibling birth order was
significantly negatively correlated with sibling-focused parentification in that TD siblings with
an earlier birth order in the family had more sibling-focused parentification. TD sibling race was
significantly negatively correlated with sibling relationship attitudes, showing that White
participants had lower levels of positive sibling relationship attitudes. Finally, sibling age
discrepancy was significantly positively correlated with social support and sibling relationship
attitudes, indicating that greater absolute values of the age discrepancy between siblings were
associated with higher levels of social support and more positive sibling relationship attitudes.
Although five correlations were conducted with each demographic variable, alpha was kept at p
< .05 to maintain the most conservative approach to covariate selection (i.e., select more
covariates) rather than apply a correction due to multiple analyses, which would result in
potentially less covariates. This choice to be more inclusive seemed most appropriate given that
each demographic variable was initially assessed due to theoretical relations to TD sibling
outcomes that have been supported in previous research.
PARENTIFICATION AND SOCIAL SUPPORT 16
Based on these analyses, sibling age discrepancy was entered as a control variable for all
moderated multiple regression analyses, given its significant relation with the hypothesized
moderator. In addition, TD sibling birth order was entered as a control variable for analyses
involving sibling-focused parentification (given their significant interrelation). Finally, TD
sibling race was entered as a control variable for analyses involving sibling relationship attitudes
(given their significant interrelation). Thus, each subsequent regression analysis had one to three
covariates, depending on the variables included in the analyses.
Insert Table 2 about here
Hypothesis testing. First, the interaction between TD sibling social support and parent-
focused parentification when predicting TD sibling distress and sibling relationship attitudes (as
separate criterion variables) was examined using two moderated multiple regression analyses as
outlined in the Statistical Analyses section above. For the distress variable, Model 1 (control
variables) was not significant. Model 2 (main effects) accounted for a significant amount of
additional variance, R2 = .32, F(2, 56) = 13.66, p < .001. Specifically, social support accounted
for unique variance in the model, B = -.56, SE = .13, p < .001. Model 3 (interaction) also
accounted for a significant amount of additional variance, R2 = .05, F(1, 55) = 4.68, p = .03
(interaction term, B = -.44, SE = .20, p = .03; Table 3). A plot of the interaction indicated that
distress was highest among TD siblings who experienced relatively higher levels of parent-
focused parentification but who had relatively lower levels of social support (Figure 1).
For the sibling relationship attitudes variable, Model 1 (control variables) was significant,
R2 = .13, F(2, 57) = 4.06, p = .02; however, neither control variable was a significant unique
predictor in the model. Model 2 (main effects) accounted for a significant amount of additional
variance, R2 = .12, F(2, 55) = 4.49, p = .02. TD sibling race accounted for unique variance in
PARENTIFICATION AND SOCIAL SUPPORT 17
this model, B = -30.35, SE = 13.26, p = .03, as did parent-focused parentification, B = 16.13, SE
= 7.26, p = .03, and social support, B = .61, SE = .24, p = .01. However, Model 3 (interaction)
did not account for significant additional variance, R2 = .0009, F(1, 54) = .06, p = .81 (Table 3).
Insert Table 3 and Figure 1 about here
Second, the interaction between TD sibling social support and sibling-focused
parentification when predicting TD sibling distress and sibling relationship attitudes (as separate
criterion variables) was examined using two moderated multiple regression analyses as outlined
in the Statistical Analyses section above. For the distress variable, Model 1 (control variables)
was not significant. Model 2 (main effects) accounted for a significant amount of additional
variance, R2 = .26, F(2, 55) = 10.73, p < .001. Specifically, social support accounted for unique
variance in the model, B = -.60, SE = .14, p < .001. However, Model 3 (interaction) did not
account for significant additional variance, R2 = .02, F(1, 54) = 1.32, p = .26 (Table 4).
For the sibling relationship attitudes variable, Model 1 (control variables) was significant,
R2 = .21, F(3, 56) = 4.87, p = .004. Both TD sibling birth order, B = -11.06, SE = 4.59, p = .02,
and TD sibling race, B = -32.15, SE = 13.78, p = .02, were significant unique predictors in this
model. Model 2 (main effects) accounted for a significant amount of additional variance, R2 =
.14, F(2, 54) = 5.76, p = .01. TD sibling race accounted for unique variance in this model, B = -
30.44, SE = 12.82, p = .02, as did sibling-focused parentification, B = 19.09, SE = 6.46, p = .01.
Model 3 also accounted for a significant amount of additional variance, R2 = .05, F(1, 53) =
4.13, p = .047 (interaction term, B = -.65, SE = .32, p = .047; Table 4). A plot of the interaction
revealed that TD siblings who experienced relatively lower levels of sibling-focused
parentification and who also reported relatively lower levels of social support also had less
positive attitudes about the sibling relationship (Figure 2).
PARENTIFICATION AND SOCIAL SUPPORT 18
Insert Table 4 and Figure 2 about here
Discussion
The current study sought to examine interactions between parentification and social
support when predicting outcomes in TD adult siblings of individuals with ASD. It was
predicted that social support would interact with parent- and sibling-focused parentification
when predicting distress in TD siblings as well as sibling relationship attitudes as reported by TD
siblings.
Results for the hypotheses were mixed. When predicting distress in TD siblings, social
support served as a moderator such that those TD siblings who reported relatively higher levels
of parent-focused parentification and relatively lower levels of social support were more likely to
report higher levels of distress. In contrast, sibling-focused parentification did not interact with
social support when predicting distress, although a main effect of social support emerged such
that more social support was associated with less distress. Sibling-focused parentification
interacted with social support when predicting sibling relationship attitudes such that those who
reported relatively lower levels of sibling-focused parentification and relatively lower levels of
social support reported less positive attitudes about the relationship with their brother or sister
with ASD. Alternatively, parent-focused parentification did not interact with social support
when predicting sibling relationship attitudes. Main effects emerged for both parent-focused
parentification and social support, indicating positive relations with sibling relationship attitudes,
although parent-focused parentification and sibling relationship attitudes were unrelated at the
bivariate level.
These results support previous findings that sibling-focused parentification appears
related to more positive outcomes, whereas parent-focused parentification may be more strongly
PARENTIFICATION AND SOCIAL SUPPORT 19
associated with negative outcomes (Tomeny et al., under review). However, these results also
illustrate how social support can interact with both types of parentification when predicting
different outcomes. Specifically, post hoc plots of the interactions show that low levels of social
support may be a risk factor for higher levels of distress among TD siblings and/or less positive
sibling relationship attitudes in the context of high levels of parent-focused parentification or low
levels of sibling-focused parentification, respectively.
Traditionally, parentification has been conceptualized as a phenomenon associated
primarily with negative long-term outcomes, including severe mental health problems in
adulthood (Hooper, DeCoster et al., 2011). However, reactions to parentification are likely
varied and complex. For example, parentification appears to be a relatively common occurrence
among families of non-U.S. origin, and a review paper by Jurkovic et al. (2004) indicates that
parentification of Latino children is related to more responsibility, maturity, family closeness,
and feelings of competence. Moreover, studies suggest that supportive activities similar to those
that would occur during sibling-focused parentification may be important for the development of
positive sibling interactions and individual well-being (Stormshak, Bellanti, Bierman, & the
Conduct Problems Prevention Research Group, 1996; Tucker et al., 2008). As such, these
associations between parentification and positive outcomes appear to occur among siblings of
individuals with ASD, but only when parentification is focused on the brother or sister with ASD
(as opposed to parentification focused on parents; Tomeny et al., under review).
Sibling-focused parentification may serve to promote prosocial behavior between siblings
by providing the structure needed to overcome the social deficits associated with ASD.
Assuming that increased structure and levels of prosocial behavior improve the quality of sibling
interactions, this may lead to improved attitudes about the sibling relationship and decreased
PARENTIFICATION AND SOCIAL SUPPORT 20
distress among siblings. Given that early social interaction predicts later relationship success and
that the quality of sibling interactions remains relatively stable over time (Kramer & Kowal,
2005), it is possible that benefits of improvements in early sibling interactions/attitudes may last
well into adulthood. Alternatively, parent-focused parentification seems to follow the more
traditional pattern of being associated with increased distress in TD adult siblings.
Given the variability in outcomes of TD siblings of individuals with ASD, many have
called for research aimed at identifying possible risk- and protective-factors (e.g., Meadan,
Stoner, & Angell, 2010; Orsmond & Seltzer, 2007). Social support is a multi-faceted construct
that is often thought to protect against exposure to stressors and to serve to buffer the stress
response when exposure is unavoidable (Armstrong et al., 2005). The current results provide
support for social support’s protective role under conditions of parentification among the
population studied. High levels of parent-focused parentification in combination with low levels
of social support was associated with high levels of distress. Conversely, the combination of low
levels of sibling-focused parentification during childhood and low levels of social support was
associated with less positive attitudes about sibling relationships. Although clinicians have no
way to alter the history of the focus of parentification during childhood, concurrent levels of
social support in adults are often amenable to change. Thus, promotion of social support may
prove a valuable point of intervention for clinicians working with aging families of individuals
with ASD.
Limitations
The results of the current study should be considered in light of several limitations. The
sample is relatively small, and data were collected at a single time point in a manner that could
result in sampling bias. Specifically, participants in the current study represent a wide age-range,
PARENTIFICATION AND SOCIAL SUPPORT 21
which may confound their sibling experiences. However, analyses revealed that sibling age did
not correlate with any of the variables of interest and findings held when controlling for absolute
value of age discrepancy between siblings. In addition, data indicate that some respondents
likely lived at home with both their parents and their brother or sister with ASD, which may have
led to differing experiences with regard to the constructs of interest. Likewise, a large
percentage of respondents were female. Previous research has shown that sisters may be at
greater risk for negative outcomes (Orsmond & Seltzer, 2009) and that sisters’ roles in and
perceptions of caregiving may differ from those assumed by brothers (Burke, Taylor, Urbano, &
Hodapp, 2012; Cridland et al., 2015; Orsmond & Seltzer, 2000). Finally, participants in the
current study who responded to requests on listservs for support groups may not be
representative of the broader population.
The cross-sectional design of the current study meant that participants were instructed to
retrospectively report on occurrences during their childhood. Although errors in memory are
always possible, the techniques used in the current study to measure childhood parentification
are consistent with related studies (Burnett, Jones, Bliwise, & Ross, 2006; Fitzgerald, Schneider,
Salstrom, Zinzow, Jackson, & Fossel, 2008; Hooper, Doehler et al., 2011; Hooper & Doehler,
2012). Moreover, directionality and the temporal relations of the variables of interest cannot be
inferred from the cross-sectional design. Specifically, it may be that those TD siblings more
prone to positive attitudes about the sibling relationship are/were more likely to provide care for
their brother or sister with ASD. Additionally, ASD diagnoses were not independently verified
and data were collected from a single informant.
Directions for Future Research
PARENTIFICATION AND SOCIAL SUPPORT 22
Future research should seek to replicate the findings based on a larger sample that
includes more male TD siblings. A larger variety of sampling procedures, such as mailing or
calling TD adult siblings who are identified from clinics offering ASD services, may identify
participants who cannot be reached electronically and increase the variability in the sample.
Likewise, future research could seek to examine more closely the impact of sibling age or living
arrangement.
Longitudinal report from a larger, more diverse sample would offer additional
information about early family life and its potential impacts on sibling outcomes and family
functioning. Given the heterogeneity of the ASD population, future research would benefit from
a direct assessment of the individuals with ASD to confirm diagnoses and to gain more detailed
information about the sample of interest. Moreover, report from multiple informants (e.g.,
parents when possible, multiple siblings) would provide additional perspectives that would likely
prove valuable. Finally, in order to explain additional variance in TD sibling outcomes, future
research should focus on identifying alternative predictors in addition to the variables examined
in the current study.
Conclusions and Clinical Implications
As previously mentioned, past parentification cannot be undone. Moreover, TD children
in families with a child with ASD may be at particular risk for experiencing parentification due
to the variety of challenges and familial stressors (e.g., behavioral difficulties, financial
challenges) associated with raising a child with ASD. Fortunately, research indicates that
children likely benefit from development of self-identity via interventions meant to reduce
caregiving responsibilities and increase developmentally-appropriate activities and interests
(Jurkovic, 1997). The current study suggests that not all hope is lost should TD siblings fail to
PARENTIFICATION AND SOCIAL SUPPORT 23
receive such intervention in childhood. Furthermore, the current study underscores the
importance of clinicians considering evaluation of past parentification when working with TD
adult siblings of an individual with ASD, including considering types of parentification (parent-
focused versus sibling-focused). Although this study examined only a small number of factors
and the need for further research on other moderating and mediating variables remains, these
results highlight that increasing social support may serve as a possible point of intervention for
clinicians working with aging families of those with ASD.
PARENTIFICATION AND SOCIAL SUPPORT 24
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PARENTIFICATION AND SOCIAL SUPPORT 30
Table 1
Participant Characteristics
%
Sibling (% female)
85%
Brother/Sister with ASD (% female)
18%
TD Sibling Race
White
Hispanic
Asian
African-American
Other
88%
5%
3%
2%
2%
TD Sibling Marital Status
Married
Never married/living alone
35%
42%
TD Sibling Household Income (% over $100,000)
23%
Living Arrangements of Brother/Sister with ASD a
With respondent
With parents or other family member
Group home
Own home with an aide
Long-term residential facility
Alone
15%
58%
18%
3%
3%
3%
Distance from Brother/Sister with ASD
More than one hour’s driving time
In the same house
Less than one hour away
Less than 15 minutes away
43%
30%
22%
5%
Direct Care to Brother/Sister with ASD b
Direct care at least monthly
Direct care daily
40%
17%
Transportation to Brother/Sister with ASD
Transportation at least monthly
Transportation daily
38%
13%
Financial Assistance to Brother/Sister with ASD
Financial assistance at least monthly
Financial assistance daily
19%
12%
Errands for Brother/Sister with ASD
Errands at least monthly
Errands daily
38%
13%
a Some of the brothers and sisters with ASD likely lived in multiple settings given that living arrangement
percentages exceeded 100. However, it is also possible that respondents may have lived in the same home as their
brother or sister with ASD, which may have also been their parents’ home.
b assistance with activities of daily living (e.g., grooming, feeding, household chores)
PARENTIFICATION AND SOCIAL SUPPORT 31
Table 2
Correlations among Variables of Interest, Correlations between Variables of Interest and
Possible Covariates, and Descriptive Statistics
1.
2.
3.
4.
5.
--
.54***
-.22
.32*
.20
--
.10
.06
.44***
--
-.55***
.29*
--
-.27*
--
.08
.07
.05
-.20
.09
.06
-.05
.10
.02
.08
.06
-.05
.05
-.03
-.26*
.04
.23
.04
.15
-.02
-.07
-.29*
-.22
.22
-.24
.12
.21
.34**
-.15
.28*
2.18
2.61
83.74
26.12
149.69
.60
.65
19.52
21.87
35.49
.59
.75
-.76
1.67
-.45
.26
.71
1.74
1.67
3.60
1.00
1.43
12.00
0.00
62.00
2.18
4.57
117.00
112.00
212.00
Note. Gender coded 1 = female, 0 = male; Race coded 1 = White, 0 = Nonwhite.
a Demographics for the typically-developing (TD) sibling.
b Number of individuals in the household when the TD sibling was a child.
c Based on absolute value of age discrepancy between siblings.
***p < .001. **p < .01. *p < .05.!!
!!
PARENTIFICATION AND SOCIAL SUPPORT 32
Table 3
Summary Details of Moderated Multiple Regression Models Predicting Distress and Sibling
Relationship Attitudes in Typically-developing Siblings (Parent-focused Parentification)
Predictor Variables
Criterion Variables
Typically-developing
Sibling Distress
Sibling Relationship
Attitudes
Model 1
TD Sibling Race
--
-23.35 (13.82)
Sibling Age Discrepancy a
-.66 (.57)
1.75 (.90)
R2
.02
.13*
Model 2
TD Sibling Race
--
-30.35* (13.26)
Sibling Age Discrepancy a
-.01 (.52)
.61 (.94)
Parent-focused Parentification
7.86 (4.11)
16.13* (7.26)
Social Support
-.56*** (.13)
.61* (.24)
R2
.32***
.12*
Model 3
TD Sibling Race
--
-30.42* (13.38)
Sibling Age Discrepancy a
.13 (.51)
.64 (.95)
Parent-focused (PF) Parentification
7.38 (3.99)
16.03* (7.33)
Social Support
-.53*** (.13)
.62* (.24)
PF Parentification X Social Support
-.44* (.20)
-.09 (.37)
R2
.05*
.0009
Note. Identified covariates were entered in Model 1. Parent-focused parentification and perceived social support
were entered in Model 2, and the interaction between the two variables was entered in Model 3. Total R2 accounted
for by Model 1 and the change () in R2 for Models 2 and 3 are provided. Unstandardized regression coefficients
reported for each predictor with standard errors in parentheses. Race coded 1 = White, 0 = Nonwhite.
a Based on absolute value of age discrepancy between siblings.
***p < .001. **p < .01. *p < .05.
PARENTIFICATION AND SOCIAL SUPPORT 33
Table 4
Summary Details of Moderated Multiple Regression Models Predicting Distress and Sibling
Relationship Attitudes in Typically-developing Siblings (Sibling-focused Parentification)
Predictor Variables
Criterion Variables
Typically-Developing
Sibling Distress
Sibling Relationship
Attitudes
Model 1
TD Sibling Race
---
-32.15* (13.78)
TD Sibling Birth Order
4.88 (2.93)
-11.06* (4.59)
Sibling Age Discrepancy a
-.61 (.56)
1.53 (.87)
R2
.07
.21**
Model 2
TD Sibling Race
---
-30.44* (12.82)
TD Sibling Birth Order
3.33 (2.70)
-5.77 (4.52)
Sibling Age Discrepancy a
.05 (.53)
.58 (.87)
Sibling-focused Parentification
4.98 (3.98)
19.09** (6.46)
Social Support
-.60*** (.14)
.38 (.22)
R2
.26***
.14**
Model 3
TD Sibling Race
---
-25.14 (12.73)
TD Sibling Birth Order
2.42 (2.80)
-2.71 (4.64)
Sibling Age Discrepancy a
-.08 (.54)
1.01 (.87)
Sibling-focused (SF) Parentification
5.15 (3.97)
18.86** (6.28)
Social Support
-.56*** (.14)
.27 (.22)
SF Parentification X Social Support
.23 (.20)
-.65* (.32)
R2
.02
.05*
Note. Identified covariates were entered in Model 1. Sibling-focused parentification and perceived social support
were entered in Model 2, and the interaction between the two variables was entered in Model 3. Total R2 accounted
for by Model 1 and the change () in R2 for Models 2 and 3 are provided. Unstandardized regression coefficients
reported for each predictor with standard errors in parentheses. Race coded 1 = White, 0 = Nonwhite.
a Based on absolute value of age discrepancy between siblings.
***p < .001. **p < .01. *p < .05.
PARENTIFICATION AND SOCIAL SUPPORT 34
Figure 1. Interaction between parent-focused parentification and social support predicting
distress in typically-developing (TD) siblings. Analysis is controlling for sibling age discrepancy
(absolute value).
Figure 2. Interaction between sibling-focused parentification and social support predicting
sibling relationship attitudes in typically-developing (TD) siblings. Higher values of sibling
relationship attitudes indicate more positive relationship attitudes. Analysis is controlling for
sibling age discrepancy (absolute value), TD sibling birth order, and TD sibling race.
'JHVSF
'JHVSF
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... Kondisi ini perlu di maintenance agar dapat berdampak positif terhadap kondisi kesehatan psikososial sibling dan proses perkembangannya. Berbeda dengan penelitian yang dilakukan oleh Tomeny et al., (2017) yang menyebutkan bahwa terjadi disfungsi perilaku dan hubungan sosial yang rendah pada sibling anak dengan autis. Selaras dengan penelitian yang dilakukan Chan, Lai (2016) di Hongkong yang menunjukkan hasil bahwa sibling menunjukkan hubungan dengan teman sebaya dan perilaku prososial yang lemah. ...
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... These results are congruent with similar research documenting that social support, as perceived by the children themselves, predicted depressive symptoms in TD siblings of autistic individuals (Lovell & Wetherell, 2016), and that the frequency and importance of perceived social support is positively associated with emotional and behavioral difficulties reported by TD siblings (Tomeny et al., 2019). Other studies also reported an association between social support and better TD siblings' outcomes (Cebula, 2012;Hastings, 2003;Koukouriki & Soulis, 2020;Tomeny et al., 2017). ...
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