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Parental Differential Treatment of Children with CF and Their Healthy Siblings

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Title:
Parental Differential Treatment of Children with CF and Their Healthy Siblings
Creator:
MARCIEL, KRISTEN K. ( Author, Primary )
Copyright Date:
2008

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Subjects / Keywords:
Adolescents ( jstor )
Age groups ( jstor )
Child development ( jstor )
Child psychology ( jstor )
Chronic conditions ( jstor )
Diseases ( jstor )
Fibrosis ( jstor )
Parents ( jstor )
Patient care ( jstor )
Siblings ( jstor )

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University of Florida
Holding Location:
University of Florida
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Copyright Kristen K. Marciel. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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11/30/2004

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PARENTAL DIFFERENTIAL TREATMENT OF CHILDREN WITH CYSTIC FIBROSIS AND THEIR HEALTHY SIBLINGS By KRISTEN K. MARCIEL A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2004

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Copyright 2004 by Kristen K. Marciel

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This document is dedicated to my mother, for her influence and support in our shared goal of helping families with a child with CF.

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ACKNOWLEDGMENTS Thanks go to Dr. Alexandra Quittner for her mentorship through the development of this project and the writing of the manuscript. iv

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TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................iv LIST OF TABLES .............................................................................................................vi LIST OF FIGURES ..........................................................................................................vii ABSTRACT .....................................................................................................................viii INTRODUCTION ...............................................................................................................1 METHOD ............................................................................................................................9 Participants ...................................................................................................................9 Procedures ...................................................................................................................10 Measures .....................................................................................................................11 Statistical Analyses .....................................................................................................12 RESULTS..........................................................................................................................14 PDT across Developmental Age.................................................................................14 PDT across Development excluding Medical Care....................................................15 PDT comparing Younger versus Older Siblings Pairs...............................................17 PDT comparing Male versus Female Healthy Siblings..............................................17 PDT during Specific Activities...................................................................................18 PDT and Disease Severity..........................................................................................20 Mood...........................................................................................................................20 Short-term Stability of PDT........................................................................................21 DISCUSSION....................................................................................................................30 Limitations of the Study.............................................................................................34 Future Directions........................................................................................................35 LIST OF REFERENCES...................................................................................................37 BIOGRAPHICAL SKETCH.............................................................................................40 v

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LIST OF TABLES Table page 1. Primary Caregiver Demographic Data for Specific Aim 1 (N = 81).............................22 2. Child Demographic Data for Specific Aim 1 (N = 81)..................................................23 3. Primary Caregiver Demographic Data for Specific Aim 2 (n = 15).............................24 4. Child Demographic Data for Specific Aim 2 (n = 15)..................................................24 5. Means and SDs for PDT –Individual Time in Minutes (N = 81)..................................24 6. Means and SDs for PDT – Individual Time as a Percentage of Waking Time.............25 7. Means and SDs for PDT –Individual Time in Minutes, excluding Medical Care.........25 8. Means and SDs for PDT – Individual Time as a Percentage,........................................25 9. Means and SDs for PDT– Individual Time for Younger vs. Older Sibling Pairs.........26 10. Means and SDs for PDT – Individual Time for Male vs. Female Healthy.................26 11. Means and SDs for PDT – Individual Time in Minutes in Basic Child Care..............27 12. Means and SDs for PDT – Individual Time in Minutes in Medical Care...................27 13. Means and SDs for PDT – Individual Time in Minutes in Mealtimes (N = 81).........27 14. Means and SDs for PDT – Individual Time in Minutes in Recreation (N = 81).........27 15. Means and SDs for Ratings of Mood (n = 57).............................................................28 16. Correlations of Individual Time over Six Months.......................................................28 17. Means and SDs for PDT – Individual Time over Six onths (n = 15)..........................28 vi

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LIST OF FIGURES Figure page 1. PDT across Developmental Age....................................................................................29 2. PDT across Development excluding Medical Care.......................................................29 vii

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Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science PARENTAL DIFFERENTIAL TREATMENT OF CHILDREN WITH CYSTIC FIBROSIS AND THEIR HEALTHY SIBLINGS By Kristen K. Marciel May 2004 Chair: Alexandra L. Quittner Major Department: Clinical and Health Psychology Sibling relationships are an important influence on a child’s development. Siblings of a child with a chronic illness may be at increased risk for receiving less attention from their parents, which may lead to negative outcomes. The primary objectives of this study were to assess parental differential treatment (PDT) in children with cystic fibrosis (CF) and their healthy siblings across three developmental stages and to determine the short-term stability of PDT over a period of six months. Participants included 81 parents of children with CF and at least one healthy sibling. A subset of 15 families was selected for the second aim. PDT was measured using daily dairies of the parents’ activities over a 24-hour period. Results revealed that parents spent more time overall with the child with CF when that child was in the preschool-age range. Additionally, parents spent more time with the child with CF in specific activities, such as medical care, mealtimes, and recreation. In a subset of families, results indicated that PDT exhibits short-term viii

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stability across three time points. These results provide a better understanding of the construct of PDT, which may inform research on interventions for healthy siblings in families with a younger child with a chronic illness. Future research should further examine the healthy sibling’s response to PDT. ix

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INTRODUCTION Sibling relationships are one of the most important, long-term relationships children have, and serve as important models for future interactions with peers (Dunn & McGuire, 1992; Furman & Buhrmester, 1985). The sibling relationship is part of a unique family context in which many children develop. However, siblings are studied comparatively less than other populations (Williams, 1997). Although siblings have approximately half of their genetic make-up in common, they often share few personality traits (rs = .15-.25) (Daniels & Plomin, 1985). This indicates that the environment in which siblings are raised may exert differential effects. The family unit has been studied in terms of how “children become differentiated from one another in personality, interests, social motives, and social skills” (Maccoby, 1984, p. 318). Thus, the differences in siblings’ environments, or intrafamilial variables, are of great importance (Feinberg, Neiderhiser, Simmens, Reiss, & Hetherington, 2000). Maccoby (1984) suggested that siblings play an important role in the psychological development of children, such as the development of self-esteem. Although some studies have focused on interfamilial variables when studying a child’s environment, there has been a growing interest in research on intrafamilial variables, such as the amount of attention a parent pays to each child and the effects of birth order (Daniels & Plomin, 1985). An extensive normative developmental literature indicates that parents treat their children differentially in terms of the time, attention, and affection, directing more attention towards younger versus older siblings (Brody, McCoy, 1

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2 & Stoneman, 1992). In a study of school-age children with a younger sibling, Kowal and Kramer (1997) found that one-third of the target children in the sample reported the occurrence of PDT, and that three-fourths of those children felt this PDT was reasonable and fair. Often times, parents give more attention to younger children because their needs are greater. Changes in PDT over development are relatively unidentified; thus, the current study compares the magnitude of PDT at three developmental time points. However, PDT that extends beyond a typical level has been associated with poorer adjustment, greater conflict between siblings, and more negative perceptions of the sibling and parent-child relationship (Brody et al., 1992; Dunn & McGuire, 1992). Brody, McCoy, and Stoneman (1992) suggested a cyclic model of PDT and negative parent-child relationships. Specifically, they found that parents demonstrated greater differential attention when there was a greater difference in negative emotionality between children and that the magnitude of differential attention resulted in greater negative emotionality for the children. Little is known, however, about the stability of PDT as inferred by a cyclic model. Quittner and colleagues (1992) noted that PDT, as measured by the phone diary, exhibited stability over a one-week period (r = .55, p < .05). The current study seeks to determine the short-term stability of PDT across a six-month period. Parental differential treatment occurs in all families to a varying degree. However, differential treatment may occur to a greater degree in families with a child with a chronic illness (Quittner & Opipari, 1994). This increase in the magnitude of PDT may have a negative impact on the healthy sibling (Silver & Frohlinger-Graham, 2000). Due to receiving less attention from their parents, healthy siblings often feel jealous and ignored and may develop emotional and behavioral problems (Davies, 1993). In a study by

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3 Derouin and Jessee (1996), 40% of siblings of children with CF said that they were “the most unhappy family member” (p. 142). Most studies examining siblings of a child with a chronic illness have focused on adjustment of the healthy sibling, specifically assessing internalizing and externalizing behavior problems (Cuskelly, 1999; McHale, Updegraff, Jackson-Newsom, Tucker, & Crouter, 2000). As a result, many of these children “act out.” For example, in a review paper on siblings of children with asthma, cancer, cystic fibrosis, and other illnesses, Williams (1997) found elevated rates of externalizing problems, such as aggression with peers and delinquency. A meta-analysis of outcomes for siblings of children with a chronic illness revealed that siblings are more likely to have internalizing versus externalizing behavior problems (Sharpe & Rossiter, 2002). Female siblings of children with chronic illnesses, such as epilepsy, asthma, sickle cell disease, and others, reported more clinically significant levels of internalizing problems than female siblings of children without a chronic illness; however, this difference was not statistically significant (Silver & Frohlinger-Graham, 2000). Older female siblings of males with a chronic illness reported significantly more feelings of anxiety and hostility than older female siblings of females with chronic illnesses (Silver & Frohlinger-Graham, 2000). These feelings may be related to resentment of being asked to help with household and caretaking activities (Lobato, Faust, & Spirito, 1988). However, reviews reported the internalizing symptoms of siblings of children with a variety of chronic conditions and thus, they did not control for potential differences resulting from the type of illness. Additionally, older female healthy siblings comprised the sample, without examining the outcomes for older male healthy siblings. Interestingly, a study by Feinberg and colleagues (2000) found that girls reported similar levels of PDT to boys. Thus, the current study adds to the literature by examining

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4 the magnitude of PDT in a specific chronic illness context for both male and female healthy siblings, which may inform previous outcome literature. While the focus of prior research has been on the negative outcomes of having a sibling with a chronic illness, a few studies have suggested there may be positive outcomes as well. Female siblings of children with a chronic illness have reported higher levels of interpersonal sensitivity than female siblings of children without a chronic illness (Silver & Frohlinger-Graham, 2000). Older female siblings of children with chronic illnesses might feel that helping around the house and with their siblings is necessary due to the illness. Other positive outcomes include a greater feeling of maturity and responsibility (Snethen & Broome, 2001). Siblings may have an increased feeling of closeness to the child with a chronic illness through assisting with medical treatments. Cystic fibrosis (CF) is an interesting disease in which to study PDT due to the time-consuming treatment regimen. Currently, CF affects over 20,000 people living in the United States (Cystic Fibrosis Foundation [CFF], 2002). It is a chronic illness with a shortened life expectancy of 33.4 years (CFF, 2002). It results from inheritance of recessive genes from both parents. People with CF are predominantly Caucasian (95.3%) and are typically diagnosed at approximately six months of age (CFF, 2002). CF affects multiple organ systems but in particular causes mucus to build up in the lungs and is often associated with pancreatic insufficiency (Orenstein, 1997). Lung function, as measured by forced expired volume (FEV 1 % predicted), slowly declines over age at a rate of approximately two percent each year from age 6 to 24, and declines more gradually thereafter (CFF, 2002). Thus, the leading cause of morbidity and mortality in CF is progressive lung disease.

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5 Given the multiple systems affected by CF, the medical regimen is complex and time-consuming and typically includes antibiotic treatments, enzyme replacement, chest physiotherapy, and boosting calorie intake (Eiser, Zoritch, Hiller, Havermans, & Billig, 1995; Orenstein, 1997). This daily medical regimen can be difficult to fit into a family’s schedule because it can take up to two hours per day (Eiser et al., 1995). These stressors can be difficult for each member of the family and prior studies of family adjustment to CF indicate there is increased depression in parents soon after diagnosis, increased strain on the marital relationships, and decreased opportunities for family recreation (Quittner, Opipari, Regoli, Jacobsen, & Eigen, 1992; Quittner et al., 1998). One sibling reported that “we don’t get to do things as family because someone has to stay home to do [the ill child’s] pats” (Derouin & Jessee, 1996, p. 142). In a qualitative study by Derouin and Jessee (1996), 60% of the healthy siblings of a child with CF reported that they experienced PDT in favor of the child with CF. Quittner and Opipari (1994) found that parents spent more time with their younger child who had CF than their older healthy siblings, particularly in activities related to play and mealtimes, even after removing time spent in medical care. A follow-up study with older children (Opipari, 1996) also indicated greater PDT in families of children with versus without CF, with poorer emotional and psychological adjustment reported by older, healthy siblings. It has been suggested that children with CF require more attention from their parents to manage their disease, particularly when an infection is present (Foster, Bryon, & Eiser, 1998). However, disease severity, as measured by lung function, was not related to maternal well-being in a study by Foster and colleagues (1998). Although disease severity did not influence mother’s well-being, it is expected that disease severity

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6 will influence differential treatment, due to the increased time needed for medical treatments when the disease is more severe. Foster et al. (2001) found that the target child received more attention during exacerbations, according to parent, patient, and sibling report. Parents, patients, and siblings attributed this PDT to CF even when the child with CF was in adolescence (Foster et al., 2001). While most studies of PDT have focused on a single age group, this study provides a developmental perspective of PDT across preschool, school-age, and adolescent age groups. The measurement of PDT has presented a methodological challenge which has been addressed in number of ways. Most studies of siblings of children with chronic illnesses have been qualitative or anecdotal in nature, collecting descriptions of PDT from parents and children (Lobato et al., 1988). That study only used a parent report measure of their perspective of PDT. It was suggested that children’s perception of care might differ from their parent’s perception. Previous research indicates that few studies have collected data by sibling report (Cuskelly, 1999). In a qualitative study, sibling report of PDT was collected using a phone interview (Derouin & Jessee, 1996). Quantitative measures provided additional information regarding the extent of perceived PDT. Daniels & Plomin (1985) developed a measure entitled the Sibling Inventory of Differential Experience (SIDE) in order to quantitatively examine siblings’ experiences. The SIDE includes scales of PDT called the Differential Parental Affection and Differential Parental Control. This measure provides a subjective view of siblings’ perception of PDT. Davies (1993) found no differences, according to parent report, in the amount of parental care of the healthy sibling in families with a child with CF compared to families with two healthy children; however, healthy siblings commented on experiencing PDT. Thus, parent and

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7 child report may differ. On the other hand, objective measures allow for the measurement of the actual, rather than perceived, occurrence of PDT. Brody and colleagues (1992) observed parent-child interactions during a play task with a small toy. In this case, PDT was defined as the positive or negative quality of the play. They found that mothers were more negative and controlling toward younger siblings, when those children displayed more negative emotionality (Brody et al., 1992). A study by Quittner & Opipari (1994) used a 24-hour recall protocol to elicit the amount of time the parent spent with each child, measuring the component of attention. This objective measure was correlated with parent report measures of PDT for families with only healthy children. However, parents of a child with CF reported spending equal time with each child, when the magnitude of PDT in favor of the child with CF was, in fact, significantly greater. Thus, the current study uses only this objective measure of time to define PDT in terms of attention toward each child. The design of the study included three developmental age groups based on the age of the child with CF. Children were categorized into three groups based on developmental age: infancy through kindergarten (i.e. 1 to 6 years), first through sixth grade (i.e. 7 to 12 years), and junior to senior high school (i.e. 13 to 17 years). This study had two primary aims: (1) to examine the extent PDT across developmental stages (preschool-age, school-age, & adolescence), and (2) to examine the stability of PDT over a six-month period. Given the demands of caring for a child with CF, it is hypothesized that parents will spend more time with the child with CF versus the healthy sibling across all developmental periods. Specifically, it is expected that: (1) PDT will decrease over development, with preschool-age children receiving more PDT than school-age and

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8 adolescent children with CF, and (2) that PDT will decrease in older age groups over development, even when time spent in medical care is subtracted from the total amount of individual time. Exploratory hypotheses included the following: (3) PDT will be greater for older than younger healthy siblings, (4) the magnitude of PDT will be greater for female healthy siblings than male healthy siblings, (5) PDT will decrease in older age groups in specific activities, such as basic child care, medical care, mealtimes, and recreation, (6) PDT will increase as lung function decreases, and (7) parents’ ratings of mood will be more positive when spending time with the child with CF versus the healthy sibling. The second major aim is to determine, in a subset of families, whether PDT will remain stable across three time points over a period of six months.

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METHOD Participants The current study included 81 families with a child with CF. Data were collected as part of two larger NIH-funded trials to promote adherence to medical treatments. Participants were recruited from six CF centers in the Midwest and Southeast. Inclusion criteria were as follows: (a) child with CF had been diagnosed for at least one year, (b) child with CF was within ages 1 to 11 years in one trial and 10 to 17 years in the other trial, (c) family had at least one sibling without a diagnosis of CF, and (d) parent provided consent for participation. Exclusion criteria for the adolescent adherence trial included severe psychiatric difficulties and mental retardation. Families were recruited during their routine outpatient CF clinic visits. Once parents provided consent to participate in the larger trial, assessments were conducted during clinic visits which occurred every three months. Phone diary data were collected between each clinic assessment. The sibling who was closest in age was selected as the comparison child, as suggested by previous research (Derouin & Jessee, 1996; Foster et al., 1998). For Specific Aim 1, participants were 81 parents of children with CF, ages 1.6 to 18 (M = 10.31 years; SD = 4.51 years), and their healthy siblings, ages 0 to 25 (M = 10.25 years; SD = 5.18). Average lung function, as measured by forced expiration volume predicted (FEV 1 % predicted), was 83.48% (SD = 22.72%) for children with CF, which placed the sample in the mild range of disease severity. The gender of the child with CF was evenly balanced, with 55.6% male, and the gender of healthy siblings was also evenly distributed 9

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10 with 49.4% male. Parents were predominantly married (80.2%), Caucasian (91.4%), middle class, and mostly mothers (88.9%). Families were placed into one of three age groups, (i.e. Developmental Age), according to the age of the child with CF: infancy to kindergarten (i.e. preschool-age cohort), first to sixth grade (i.e. school-age), and junior to senior high school (i.e. adolescent). Thus, 23 children were in the preschool age group (ages 1.64 to 6.84), 31 children were in the school-age group (ages 7.22 to 12.98), and 27 children were in the adolescent age group (ages 13.08 to 17.52). Additional demographic information is available in Tables 1 and 2. For Specific Aim 2, participants were 15 children with CF, ages 1.64 to 11.91 (M = 5.81; SD = 3.84), their healthy siblings, ages 4 to 18 (M = 7.8; SD = 3.93), and their parents. Families were selected based on their completion of diaries at the baseline, three-month, and six-month assessments. Average lung function, as measured by forced expiration volume predicted (FEV 1 % predicted), of the child with CF was 84% (SD = 32.43%), which placed the sample in the mild range of disease severity. Additional demographic information is provided in Tables 3 and 4. Procedures This study was conducted as part of two larger studies on adherence to medical regimens in CF, which were approved by the Institutional Review Boards associated with each site. Parents whose children met criteria for the study were provided with information by mail and from the nurse coordinator. Participants were offered $10 for each phone diary completed, as well as an additional $10 if all three phone diaries were completed. Demographic, medical information, and measures of adherence were collected for the larger study. The current study focused on data obtained via the Daily Phone Diary

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11 (DPD; Quittner & Opipari, 1994), a computerized diary measure that was administered via telephone. Parents, who were the primary caregivers, were called three times consecutively on one weekend day and two weekdays. These data were then collapsed by activity and averaged across the three days. Measures Demographic questionnaires. Demographic information was collected on a 24 item questionnaire. Parents responded to questions about themselves, such as their relationship to the child, age, marital status, work status, education, race, and household income. They also provided information about the child, including age, grade in school, medical history, and availability of health insurance. Parents also provided general information on others in the home, including their ages, relationships, and diagnoses. Daily Phone Diaries. At baseline, we assessed PDT using a 24-hour recall program, the DPD (Quittner & Opipari, 1994). The DPD has been used to measure parental differential treatment, marital role strain, adherence to medical regimens, and time spent in various activities and with specific family members (Quittner et al., 1992; Quittner & Opipari, 1994; Quittner et al., 1998). Research assistants called parents on the phone and asked them to recall all activities lasting five minutes or longer, their companions during the activity, and ratings of their mood, on a five point Likert-type scale ranging from very positive (5) to very negative (1). The DPD program is computerized and the data is automatically entered into the computer. The DPD supplied the following categories of activities: basic child care, medical care, mealtimes, house hold tasks, recreation, self-care, work, research activities, and sleep. The duration of each activity was rounded to the nearest five-minute increment. The phone diary has demonstrated good test-retest reliability over a three week period (rs = .61-.71, ps < .01)

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12 and inter-rater reliability of more than 90% (Quittner & Opipari, 1994; Quittner & Espelage, 1997 as cited in Quittner et al., 1998). The DPD allowed PDT to be analyzed by examining the amount of time the parent spent with each child individually, as well as providing other types of information, such as type of activity and parents’ ratings of their mood. For this study, the following variables were examined: (1) the amount of the time the parent spent with each child (Individual Time), (2) the percent time the parent spent with each child as a function of Individual Time divided by total waking hours (Percentage of Individual Time), (3) the specific activities in which they participated (Basic Child Care, Medical Care, Mealtimes, Recreation), and (4) the quality of the time during each activity (Mood). Throughout the paper, Target Child refers to the child with CF. When comparing individual time with the child with CF versus healthy sibling, the term Group refers to the disease status of the child (CF versus healthy). Pulmonary Function Tests. Forced expired volume (FEV 1 % predicted) has been used as a primary indicator of lung function in CF (Orenstein, 1997). As more obstruction accumulates in the lungs, less volume of air is able to be expired. Normal lung function is categorized as 90% and above; mild disease severity is categorized as 70-89%, moderate as 40-69%, and severe as 39% and below (CFF, 2002). Statistical Analyses Descriptive statistics are provided in Tables 5 through 13. Mixed model ANOVAs were used to examine the first and second hypotheses, which stated that parents would spend more time with the child with CF versus their healthy sibling, and that the magnitude of PDT would decrease across developmental stages. These analyses resulted in power ranging from .798 to .968. One-way ANOVAs were also conducted on

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13 change scores calculated on the Individual Time variable with the child with CF minus the Individual Time with the healthy sibling. These tests yielded similar power; thus, only the mixed model ANOVAs and similar results will be reported. T-tests were then used to compare PDT for younger versus older and male versus female healthy siblings. For t-test analyses of PDT, change scores were calculated as Individual Time with the child with CF minus Individual Time with the healthy sibling. Mixed model ANOVAs were used to compare Individual Time spent with the child with CF to the Individual Time spent with the healthy sibling in the following specific activities: Basic Child Care, Medical Care, Mealtimes, and Recreation. Pulmonary functioning data was available for a subset of children (n = 54), thus, a correlation was used to assess the relationship between FEV 1 and PDT using the change score data. A mixed model ANOVA was used to compare ratings of Mood during Individual Time spent with the child with CF versus the healthy sibling across developmental cohorts. Finally, short-term stability of PDT was examined using a repeated measures ANOVA to determine whether PDT changed significantly across Time, from baseline to the three and six month assessments. Significance was defined as p < .05.

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RESULTS PDT across Developmental Age The amount of time spent individually with the child with CF was expected to decrease across developmental stages, with less Individual Time spent with older versus younger children with this disease. In contrast, Individual Time spent with the healthy sibling was not expected to change across developmental stages. Thus, parental differential treatment, defined as the difference in number of minutes spent with the child with CF versus the healthy sibling, was expected to decrease as the Target Child’s age increased. A mixed model ANOVA revealed a main effect for Group (F(1, 78) = 45.35, p < .001, 2 = .37), indicating that parents spent more Individual Time with the child with CF versus his or her healthy sibling (see Table 5). This analysis also yielded a main effect for Developmental Age (F(2, 78) = 5.88, p < .01, 2 = .13), indicating that parents spent more time with children in the preschool-age cohort versus the school-age and adolescent cohorts. A significant Group x Developmental Age interaction was also obtained (F(2,78) = 8.54, p < .001, 2 = .18), and simple contrasts showed that the preschool-age cohort experienced significantly more PDT in favor of the child with CF compared to the school-age (p < .05) and the adolescent groups (p < .001). Note that the school-age and adolescent groups did not differ significantly from one another. Inspection of the means and standard deviations supported the hypothesis, with Individual Time with the child with CF decreasing across developmental cohorts (see Table 5). Parents of children with CF in the preschool-age group spent 97 more minutes 14

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15 on average with the child with CF than their healthy sibling. In the school-age and adolescent cohorts, parents spent, on average, 56 and 12 more minutes with the child with CF versus the healthy sibling, respectively (see Figure 1). Note also that 25.9% of healthy siblings received no time alone with the parent during the entire day. In order to provide an additional perspective on PDT, Percentage of Time was calculated by dividing the Individual Time with each child by the total number of minutes in a day during which the parent was awake. The main effect for Group was still significant (F(1,78) = 40.08, p < .001, 2 = .34), indicating that parents spent more Individual Time with the child with CF versus his or her healthy sibling. As expected, a main effect for Developmental Age was also found (F(2,78) = 7.31, p < .001, 2 = .16). Again, the results of a mixed model ANOVA indicated a significant Group x Developmental Age interaction (F(2,78) = 7.96, p < .001, 2 = .17). Simple contrasts produced the same pattern as before, with the preschool-age group experiencing significantly more PDT compared to the school-age and adolescent groups (p < .01 and p < .001, respectively). Parents in the preschool-age cohort spent approximately 10% more time with the child with CF than the healthy sibling, which decreased to 6% and 1% in the school-age and adolescent cohorts, respectively (see Table 6). PDT across Development excluding Medical Care Given the number of medical treatments required to care for a child with CF, it seemed important to determine the magnitude of PDT across development after partialling out time spent in Medical Care activities. Thus, time spent in Medical Care was subtracted from Individual Time spent with each child. Similar to the previous results, a mixed model ANOVA resulted in a main effect for Group (F(1,78) = 14.47, p <

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16 .001, 2 = .16), suggesting that parents spent a greater percentage of Individual Time with the child with CF versus their healthy sibling even when time devoted to medical care was partialled out (see Table 7). A main effect for Developmental Age, however, was not obtained. A significant Group x Developmental Age interaction was found (F(2,78) = 4.87, p < .01, 2 = .11), indicating that the pattern of decreasing PDT over development was similar to the pattern found when time spent in Medical Care activities was included. Simple contrasts also supported this finding, with the preschool-age cohort experiencing more PDT than the adolescent group (p < .05; see Figure 2). Parents spent approximately 51 more minutes on average with the child with CF in the preschool-age cohort versus the healthy sibling and 30 more minutes with the target child in the school-age cohort; in contrast, parents in the adolescent cohort spent 3 more minutes on average with the healthy sibling versus the child with CF when Medical Care time was excluded (see Table 7). Similar analyses with Percentage of Time excluding Medical Care produced comparable results with a significant main effect for Group (F(1,78) = 12.38, p < .001, 2 = .14), a non-significant main effect for Developmental Age (although it approached significance, p = .052), and a significant Group x Developmental Age interaction (F(2,78) = 4.42, p < .05, 2 = .1). Simple contrasts again showed the preschool-age cohort experiencing the most PDT in comparison to the adolescent cohort (p < .05). Specifically, parents in the preschool-age cohort spent 8.4% of their day with the child with CF compared to 3.4% of their day with the healthy sibling (see Table 8). This pattern reversed in the adolescent cohort, with parents spending 3.67% of their day with the healthy sibling compared to only 3.19% of their day with the child with CF.

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17 PDT comparing Younger versus Older Siblings Pairs In order to examine the influence of birth order on PDT, an exploratory hypothesis tested the magnitude of PDT in the healthy siblings were older versus younger than the target child. Thus, change scores were calculated as the difference between Individual Time spent with the child with CF compared to the healthy sibling, so that positive change scores suggested PDT in favor of the child with CF. Next, change scores for younger healthy siblings were compared to those of older healthy siblings in each Developmental Age cohort using t-tests. None of the t-tests were significant. Although there were only a few younger siblings in the preschool-age cohort, younger (n = 4) and older healthy siblings (n = 19) both received less Individual Time with the parent, between 20 and 26 minutes, compared to the child with CF who spent an average of 123 minutes with the parent. The data in the school-age and adolescent cohorts were even more convincing. In the school-age cohort, older (n = 15) and younger siblings (n = 16) received only about 21 minutes alone with the parent while the child with CF received over 76 minutes of Individual Time on average. Similarly, older (n = 9) and younger siblings (n = 18) in the adolescent cohort received only between 31 and 35 minutes alone with the parent while the child with CF received over 45 minutes on average (see Table 9). PDT comparing Male versus Female Healthy Siblings Several studies have suggested that PDT occurs differentially depending on the gender of the healthy sibling. Similar to the analyses comparing older versus younger healthy siblings, t-tests were conducted to compare PDT (in terms of change scores between Individual Time spent with the child with CF minus the healthy sibling) directed toward male versus female healthy siblings. Consistent with previous literature, female

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18 healthy siblings experienced more PDT than male healthy siblings; however, the differences were not statistically significant. It is interesting to note that in the adolescent cohort, male healthy siblings received 4.55 minutes more time on average than the child with CF, while female healthy siblings received 23.07 minutes less time on average (see Table 10). Although not statistically significant, this suggests that parents spend the least amount of time with female healthy siblings. PDT during Specific Activities Next, analyses were conducted to identify the specific activities in which PDT took place. A mixed model ANOVA was utilized to examine the Individual Time spent with each child in Basic Child Care. A main effect for Group was not found (F(1,78) = 3.44, p = .067, 2 = .042), suggesting that Individual Time spent with the target child and healthy sibling did not significantly differ. This analysis revealed a main effect for Developmental Age (F(2,78) = 5.38, p < .01, 2 = .12), suggesting that Individual Time spent in Basic Child Care decreased across developmental cohorts. Additionally, a significant Group x Developmental Age interaction was found (F(2,78) = 5.87, p < .01, 2 = .13). Simple contrasts revealed that the preschool-age cohort experienced significantly more PDT in Basic Child Care activities compared to the school-age and adolescent cohorts (p < .01, p < .05, respectively), which reflects the preschool-age target child’s need for additional supervision and care. In the preschool cohort the target child received 24 more minutes on average as opposed to the adolescent cohort, in which the healthy sibling received an average of 8 more minutes of attention (see Table 11). In addition, 34.6% of healthy siblings received no Individual Time with parents in Basic Child Care activities.

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19 Because CF requires a demanding and time-consuming medical regimen, PDT was expected to occur especially during Medical Care activities. As expected, a mixed model ANOVA yielded a main effect for Group (F(1,78) = 63.42, p < .001, 2 = .45), indicating that parents spent more Individual Time with the child with CF during Medical Care activities than the healthy sibling. The main effect for Developmental Age was also significant (F(2,78) = 6.29, p < .01, 2 = .14) with Individual Time spent in Medical Care activities decreasing across developmental cohorts. Not surprisingly a significant Group x Developmental Age interaction was found (F(2,78) = 6.08, p < .01, 2 = .14). These results were due, in part, to the fact that parents spent very little Individual Time in Medical Care activities with healthy siblings (see Table 12). Due to the increased nutritional challenges of CF, Mealtimes was another activity during which PDT was expected. A mixed model ANOVA revealed a significant main effect for Group (F(1,78) = 7.2, p < .01, 2 = .08), suggesting that parents spent more Individual Time with the child with CF versus the healthy siblings in Mealtime activities. Specifically, parents spent 12 minutes more with the child with CF in the preschool cohort, 4 minutes more in the school-age cohort, and less than 1 minute more in the adolescent cohort, on average (see Table 13); however, the differences in PDT were not statistically different across Developmental Age cohorts. Thus, neither a main effect of Developmental Age nor an interaction between Group and Age was found. Because it was hypothesized that PDT in optional activities, such as Recreation, may have a greater impact on the emotional adjustment of the healthy sibling, time spent in this activity was examined. A mixed model ANOVA revealed a significant main effect for Group (F(1,78) = 9.26, p < .01, 2 = .11), indicating that parents spent more

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20 Individual Time with the target child versus healthy siblings in Recreation activities. For example, parents spent 8 minutes more on average with the child with CF compared to the healthy sibling (see Table 14). However, it is critical to note that 86.4% of healthy siblings received absolutely no time with the primary caregiver in Recreation activities. Neither a main effect of Developmental Age nor an interaction between Group and Age was found. PDT and Disease Severity The severity of CF can fluctuate because of pulmonary exacerbations, and children with more severe disease wil have to increase the time spent on medical care. Thus, an association between PDT and disease severity was expected. A correlation between FEV 1 and PDT was conducted with a subsample for whom these data were available (n = 54), revealing a small, non-significant relationship (r = -.192, p = .163). Mood Previous literature has suggested that parents may rate their mood more negatively during activities with the healthy sibling because they feel conflicted in directing their time between the healthy and chronically ill siblings (Quittner & Opipari, 1994). Thus, a mixed model ANOVA was conducted to determine the rating of Mood based on the disease status and age of the child. No significant main effects were found for either variable (Group: F(1,54) = 1.28, p = .26, 2 = ..02; Developmental Age: F(2,54) = .08, p = .92, 2 = .003). This result was not surprising given that there was little variability in average mood ratings which ranged from 2 to 5 for the child with CF and healthy sibling (M = 3.8, SD = .51 and M = 3.71, SD = .59, respectively; see Table 15).

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21 Short-term Stability of PDT The second aim of this study was to examine the short-term stability of the construct of PDT in a subset of families. Thus, a repeated measures ANOVA was conducted with 15 families who completed diaries at all three time points: baseline, 3-months, and 6-months (n = 15). In order to compare the magnitude of PDT across these time points, change scores were calculated based on Individual Time with the target child minus Individual Time with the healthy sibling. PDT across the three time points were highly correlated, ranging from r = .35 (p = .21) to r = .46 (p = .08) for the child with CF, and r = .25 (p = .38) to r = .53 (p < .05) for the healthy sibling (see Table 16). In addition, a repeated measures ANOVA yielded a non-significant effect for Time (F(1,14) = .05; p = .83, 2 = .003), suggesting that PDT was relatively stable in these families (see Table 17).

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Table 1. Primary Caregiver Demographic Data for Specific Aim 1 (N = 81) Preschool age group (n = 23) School age group (n = 31) Adolescent age group (n = 27) n M SD Range % n M SD Range % n M SD Range % Caregiver age 23 35.74 8.18 24.16-61.42 31 39.07 5.68 24.58-47.49 27 38.99 4.1 29.72-46.72 Mother 16 34.14 6.42 24.16-46.03 69.6 30 38.97 5.74 24.5847.49 96.8 26 38.85 4.12 29.72-46.72 96.3 Father 6 35.74 5.52 27.17-42.68 26.1 1 us 42.11 3.2 1 42.53 3.7 Grandparent 1 61.42 4.3 Race Caucasian 21 91.3 27 87.1 26 96.3 African-American 1 3.2 Hispanic 2 8.7 Marital stat Married 22 95.7 23 74.2 20 74.1 Separated 1 4.3 2 6.5 Divorced 5 16.1 7 25.9 Single 1 3.2 22

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Table 2. Child Demographic Data for Specific Aim 1 (N = 81) Preschool age group (n = 23) School age group (n = 31) Adolescent age group (n = 27) n M SD Range % n M SD Range % n M SD Range % Child age 23 4.19 1.83 1.646.84 31 10.93 1.74 7.2212.98 27 14.82 1.24 13.0817.52 Child Gender Girls 12 52.2 12 38.7 12 44.4 Boys 11 47.8 19 61.3 15 55.6 FEV 1 % Predicted 7 86.29% 37.49 36-127 30.43 27 79.93% 22.33 36-123 87.1 20 87.3% 16.66 52-121 74.07 Sibling age 23 6.49 3.6 0-17 31 11.34 4.66 2-20 27 12.19 5.34 3-25 Sibling Gender Girls 11 47.8 14 45.2 16 59.3 Boys 12 52.2 17 54.8 11 40.7 23

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24 Table 3. Primary Caregiver Demographic Data for Specific Aim 2 (n = 15) n M SD Range % Caregiver age 14 38.08 8.9 24.16-61.42 Mother 10 36.29 6.77 24.16-45.18 73.3 Father 3 36.28 3.88 33.18-40.63 20 Grandparent 1 61.42 6.7 Race Caucasian 13 86.7 African-American 1 6.7 Hispanic 1 6.7 Marital status Married 14 93.3 Separated Divorced 1 6.7 Single/never married Table 4. Child Demographic Data for Specific Aim 2 (n = 15) n M SD Range % Child age 15 5.81 3.84 1.64-11.91 Child Gender Girls 7 46.7 Boys 8 53.3 FEV 1 %Predicted 6 84 32.43 36-119 40 Sibling age 15 7.8 3.93 4-18 Sibling Gender Girls 8 53.3 Boys 7 46.7 Table 5. Means and SDs for PDT –Individual Time in Minutes (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 122.49 84.72 23 25.46 20.16 School-age 31 76.74 75.23 31 20.82 23.09 Adolescent 27 45.93 33.01 27 34.1 32.71

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25 Table 6. Means and SDs for PDT – Individual Time as a Percentage of Waking Time (N = 81) Child with CF Health y Siblin g Developmental Age n M SD n M SD Preschool 23 13.71% 9.64 23 3.46% 4.49 School-age 31 8.32% 8.4 31 2.14% 2.4 Adolescent 27 4.69% 3.33 27 3.67% 3.53 Table 7. Means and SDs for PDT –Individual Time in Minutes, excluding Medical Car e (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 75.7 72.14 23 25.02 19.71 School-age 31 52.38 57.46 31 20.45 22.31 Adolescent 27 31.14 29.45 27 34.1 32.71 Table 8. Means and SDs for PDT – Individual Time as a Percentage, excluding Medical Care (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 8.4% 8.4 23 3.4% 4.46 School-age 31 5.74% 6.49 31 2.11% 2.33 Adolescent 27 3.19% 3.06 27 3.67% 3.53

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Table 9. Means and SDs for PDT– Individual Time for Younger vs. Older Sibling Pairs (N = 81) Child with CF Younger Healthy Sibling Older Healthy Sibling Developmental Age n M SD n M SD n M SD Preschool 23 122.49 84.72 4 20.42 29.07 19 26.52 18.68 School-age 31 76.74 75.23 16 20.76 22.27 15 20.89 24.71 Adolescent 27 45.93 33.01 18 35.28 31.28 9 31.76 37.27 Table 10. Means and SDs for PDT – Individual Time for Male vs. Female Healthy Siblings (N = 81) Child with CF Male Healthy Sibling Female Healthy Sibling Developmental Age n M SD n M SD n M SD Preschool 23 122.49 84.72 12 23.51 16.91 11 27.58 23.88 School-age 31 76.74 75.23 17 20.96 25.24 14 20.65 21.11 Adolescent 27 45.93 33.01 11 41.59 36.78 16 28.96 29.72 26

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27 Table 11. Means and SDs for PDT – Individual Time in Minutes in Basic Child Care (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 40.89 45.2 23 17.14 16.51 School-age 31 15.11 16.73 31 11.15 14.86 Adolescent 27 13.4 18.39 27 20.93 25.17 Table 12. Means and SDs for PDT – Individual Time in Minutes in Medical Care (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 46.32 30.24 23 0.43 2.09 School-age 31 25.08 37.84 31 0.38 2.1 Adolescent 27 14.78 25.38 27 0.00 0.00 Table 13. Means and SDs for PDT – Individual Time in Minutes in Mealtimes (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 12.99 28.63 23 0.67 1.98 School-age 31 6.41 9.45 31 1.99 7.48 Adolescent 27 3.73 8.46 27 3.52 10.45 Table 14. Means and SDs for PDT – Individual Time in Minutes in Recreation (N = 81) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 23 12.25 23.16 23 3.86 11.51 School-age 31 13.71 22.78 31 2.63 7.57 Adolescent 27 8.02 16.29 27 3.77 13.11

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28 Table 15. Means and SDs for Ratings of Mood (n = 57) Child with CF Healthy Sibling Developmental Age n M SD n M SD Preschool 20 3.71 .44 20 3.75 .58 School-age 19 3.88 .38 19 3.7 .65 Adolescent 18 3.83 .69 18 3.69 .56 Table 16. Correlations of Individual Time over Six Months 1 2 3 4 5 6 Families (n = 15) 1. Child with CF – Baseline – .46 .35 .1 .41 .05 2. Child with CF – 3 months – .4 .06 .29 .31 3. Child with CF – 6 months – -.23 -.15 -.08 4. Healthy Sibling – Baseline – .25 .45 5. Healthy Sibling – 3 months – .53* 6. Healthy Sibling – 6 months – *Note that the correlation is significant at p < .05. Table 17. Means and SDs for PDT – Individual Time over Six onths (n = 15) Child with CF Healthy Sibling n M SD n M SD Baseline 15 141.39 87.49 15 25.42 24.99 3 months 15 143 75.34 15 24.33 26.78 6 months 15 158.22 88.67 15 27.78 33.95

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29 020406080100120140PreschoolSchool AgeAdolescentDevelopmental AgeIndividual Time in minute s Child with CF Sibling Figure 1. PDT across Developmental Age 020406080100120PreschoolSchool AgeAdolescentDevelopmental AgeIndividual Time in minute s Child with CF Sibling Figure 2. PDT across Development excluding Medical Care

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DISCUSSION This study found strong support for the hypothesis that parental differential treatment occurred in favor of the child with CF, regardless of whether time alone with the parent was examined in minutes or in percent time of the caregivers’ day. These results are consistent with previous research which compared differential treatment in families with a child with CF to age-matched control families (Quittner & Opipari, 1994; Opipari, 1996). Given the demands of caring for a child with CF, parents are obligated to spend more time assisting the child with medical treatments. However, parents spent more time with the target child, even when time spent in medical treatments was partialled out. Although differential treatment occurred in favor of the target child across cohorts, developmental age was a key factor in the magnitude of differential time reported by caregivers. This is the first study to examine the magnitude of differential treatment at different points in development and the results clearly indicated that more time was directed toward children with CF who were in the preschool-age cohort, compared to those in the school-age and adolescent cohorts. These results differ from the findings of Opipari (1996), who found that even school-age children with CF received more time and attention than healthy older siblings in comparison to age-matched healthy sibling dyads. Recent advancements in management of CF may play a role in this discrepancy. Nearly ten years ago it was necessary for parents to assist their children in airway clearance, which could mean twenty to thirty minutes of manual percussion two to 30

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31 three times per day. Currently, families have options for airway clearance that allow the child to independently perform airway clearance, such as vests and Flutter devices (Jaffe & Bush, 2001). In order to better understand the key influences on differential treatment, this study examined birth order, gender of the healthy sibling, and the specific activities in which differential treatment took place. First there was no evidence that birth order affected differential treatment across the sample. Although there were too few younger healthy siblings in the preschool cohort, data for younger and older healthy siblings in the school-age and adolescent cohorts indicated that differential treatment occurred in favor of the child with CF regardless of whether his or her sibling was older or younger. This suggests that differential treatment did not occur solely as a result of the demands of caring for a younger versus older child, but rather supports the notion that differential treatment results from time related to both disease management and other factors related to having a child with CF. Next, there was no evidence that gender of the healthy sibling influenced the magnitude of differential attention. Although female healthy siblings, compared to male siblings, received fewer minutes of time alone with the parent, this difference was not statistically significant. This fits with the result of Feinberg et al. (2000) which found that girls did not report more differential treatment than boys, in families with out a child with a chronic illness. Finally, it is important to consider whether differential treatment occurs in obligatory activities, such as caring for a young child or performing medical treatments, or in voluntary activities, such as playtime and recreation. As expected, parents spent

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32 more time with younger children in basic child care activities, particularly when the child had CF. However, this finding does not necessarily suggest that parents are not spending adequate time with healthy siblings in basic child care activities. Davies (1993) found that healthy siblings of children with CF and siblings in families without a child with CF received similar amounts of dependent care activities, according to both mother report and an objective measure. As expected in the current study, parents spent more time alone with the target child in medical care activities across all developmental cohorts. McHale and colleagues (2000) suggested that siblings underestimate differential treatment when they believe it is reasonable. This type of obligatory activity may be easier for the healthy sibling to view as reasonable and fair. Thus, parents also spent more time with the child with CF during meals, regardless of his or her age, which is likely related to the nutritional recommendations for calorie intake. Because mealtimes are an important family activity, this differential time may have significant implications for healthy siblings. Foster et al. (1998) suggested that strain during mealtimes may have ramifications for all members of the family, including siblings “who perhaps do not receive the same dietary ‘perks,’” and the stress for mothers who must accommodate the needs of all their children (p. 52). Finally, the exploratory analysis of differential treatment during recreation time may have the most interesting implications for families. In this study, parents spent more time in voluntary, play activities with the child with CF than the healthy sibling. In these activities, there is the possibility that the healthy sibling may see this differential treatment as unfair which could lead to increased risk of jealousy and poorer adjustment. Opipari (1996) found that a greater magnitude of differential treatment was related to poorer emotional and behavioral adjustment in the healthy

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33 sibling. However in this study, the absolute difference in these minutes was relatively small. It is important to note, on the other hand, that the majority of healthy siblings received absolutely no time alone with the parent in recreational activities. An exploratory analysis did not find a relationship between disease severity and differential treatment. Because the typical medical regimen for CF can take up to two hours per day, the additional treatments for children with more severe disease may not add significantly to the time spent on daily treatments. This lack of relationship could also be due to the slow decline of lung function across this age period, which is only an average rate of two percentage points each year until the mid-20s (CFF, 2002). Note also that this study did not examine differential attention during times of pulmonary exacerbations which could require hospitalizations. Similarly there was no evidence that cavegivers’ mood ratings related to time spent with either the chronically ill or healthy child. This contrasts with the findings of Quittner & Opipari (1994) in which mothers rated their mood more positively during activities with the child with CF compared to the healthy sibling. Since the publication of that study, treatments for CF have improved and this has increased life-expectancy for individuals with CF. In addition, the current sample included older children who had been diagnosed for a longer period of time. Thus, parents may have had more time to adjust to having a child with a diagnosis of CF. This study sought to examine the short-term stability of differential treatment over a period of six months across a wide range of ages. In a subset of families for whom three diary assessments were available, the extent of differential treatment appeared quite stable.

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34 Thus, families who reported less differential treatment at baseline continued to exhibit this pattern at all three time points. Similarly, caregivers who treated their children more differentially continued to do so, which may place these healthy siblings more at risk for negative outcomes. Receiving consistently less time and attention from the primary caregiver may lead the healthy sibling to feel less important than the child with CF. Limitations of the Study Most importantly, this study lacked measures of the quality of the sibling relationship as well as measures of the psychological and social adjustment of the healthy siblings. Thus, this study does not allow inferences to be about the consequences of differential treatment for this sample of healthy siblings. However, previous research has consistently shown that increased differential treatment is related to poorer relationship quality and psychological adjustment (e.g., Opipari, 1996; McHale et al., 2000). Given the consistency of differential treatment found in this study, future research should carefully examine these variables. Cuskelly (1999) noted the importance of studying the benefits of growing up with a sibling with a chronic illness and this process has also received little attention in families raising a child with CF. The second major limitation of this study was the lack of a control group. Thus, this study cannot address normative developmental changes in differential treatment. Although greater differential treatment in favor of young children with CF in basic child care and medical care activities is expected, the magnitude of this differential treatment may or may not be normative. Previous research, however, has found that differential treatment occurs to a greater degree in families with a child with CF compared to control families (Quittner & Opipari, 1994; Opipari, 1996).

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35 In addition, for some analyses, the sample size was small and did not permit robust tests of differences in differential treatment between younger and older, and male and female healthy siblings. Further, the cross-sectional design of this study provided a snap shot of differential treatment across developmental cohorts, and was not able to identify longitudinal patterns of differential treatment. Thus, some age differences could be attributed to interfamilial differences. While the preliminary results of this study indicated that differential treatment is a stable construct, a longitudinal study is needed to understand the point in development where a shift in differential treatment is likely to take place. Finally, this study focused on only one major component of differential treatment, parental attention. Other components, discipline and affection, may also be important to consider. Future Directions The diary methodology employed in this study yielded important results as evidenced by the consistent findings between this and prior studies. Additionally, the diary data was able to demonstrate short-term stability of differential treatment at three time points over six months. Thus, the daily phone diary is a promising tool to further investigate the associations between how parents spend their time and the siblings’ perceptions of differential treatment. Both objective and subjective measures of differential treatment should be used when examining the effects of differential treatment on outcome variables, such as the psychological and social adjustment of the sibling and ratings of the quality of the sibling relationship. Findings from such studies may also inform the design of interventions for siblings growing up in a chronic illness context. While it may be a challenge to alter actual differential treatment, given the demands of

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36 CF medical regimens, siblings’ perceptions of differential treatment may be a better target for future interventions. Although some studies have examined outcomes of siblings of children with chronic illnesses, future studies can utilize this developmental framework to examine the implications of differential treatment on all members of the family throughout development. Additionally, the short-term stability of differential treatment provides an additional perspective when interpreting the relationship between differential treatment and adjustment of the healthy sibling. Although limited research has focused on the healthy siblings of children with chronic illnesses, Fanos (n.d.) has established a center devoted to supporting siblings in these families. This research group has developed a family counseling program designed to address the emotional and psychological needs of the sibling within this family context. This program emphasizes the importance of the healthy sibling. Future studies should evaluative the effectiveness of this type of program.

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LIST OF REFERENCES Brody, G., McCoy, J., & Stoneman, Z. (1992). Parental differential treatment of siblings and sibling differences in negative emotionality. Journal of Marriage and the Family, 54, 643-651. Cuskelly, M. (1999). Adjustment of siblings of children with a disability: Methodological issues. International Journal for the Advancement of Counselling, 21, 111-124. Cystic Fibrosis Foundation (CFF). (2002). Patient registry 2001 annual report. Bethesda, Maryland: Author. Daniels, D. & Plomin, R. (1985). Differential experience of siblings in the same family. Developmental Psychology, 21(5) 747-760. Davies, L. (1993). Comparison of dependent-care activities for well siblings of children with cystic fibrosis and well siblings in families without children with chronic illness. Issues in Comprehensive Pediatric Nursing, 16, 91-98. Derouin, D. & Jessee, P. (1996). Impact of a chronic illness in childhood siblings’ perceptions. Issues in Comprehensive Pediatric Nursing, 19, 135-147. Dunn, J. & McGuire, S. (1992). Sibling and peer relationships in childhood. Journal of Child Psychology & Psychiatry & Allied Disciplines, 33(1), 67-105. Eiser, C., Zoritch, B., Hiller, J., Havermans, T., & Billig, S. (1995). Routine stresses in caring for a child with cystic fibrosis. Journal of Psychosomatic Research, 39(5), 641-646. Fanos, J. (n.d.) The sibling center: Supporting well siblings of children with a medical condition. Retrieved March 18, 2004, from http://www.cpmc.org/services/sibcnt.html Feinberg, M. E., Neiderhiser, J. M., Simmens, S., Reiss, D., & Hetherington, E. M. (2000). Sibling comparison of differential parental treatment in adolescence: Gender, self-esteem, and emotionality as mediators of the parenting-adjustment association. Child Development, 71(6), 1611-1628. Foster, C.L., Bryon, M., & Eiser, C. (1998). Correlates of well-being in mothers of children and adolescents with cystic fibrosis. Child: Care, Health and Development, 24(1), 41-56. 37

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38 Foster, C., Eiser, C., Oades, P., Sheldon, C., Tripp, J., & Goldman, P. (2001). Treatment demands and differential treatment of patients with cystic fibrosis and their siblings: Patient, parent and sibling accounts. Child: Care, Health and Development, 27(4), 349-364. Furman, W. & Buhrmester, D. (1985). Children’s perceptions of the qualities of sibling relationships. Child Development, 56, 448-461. Jaffe, A. & Bush, A. (2001). Cystic fibrosis: Review of the decade. Monaldi Archives for Chest Disease, 56(3), 240-247. Kowal, A. & Kramer, L. (1997). Children’s understanding of parental differential treatment. Child Development, 68(1), 113-126. Lobato, D., Faust, D., & Spirito, A. (1988). Examining the effects of chronic disease and disability on children’s sibling relationships. Journal of Pediatric Psychology, 13(3), 389-407. Maccoby, E. E. (1984). Socialization and developmental change. Child Development, 55, 317-328. McHale, S. M., Updegraff, K. A., Jackson-Newsom, J., Tucker, C. J., & Crouter, A. C. (2000). When does parents’ differential treatment have negative implications for siblings? Social Development, 9(2), 149-172. Opipari, L. C. (1996). Parental differential treatment in two family contexts: Association with children’s sibling relationship, adjustment, and social networks (Doctoral Dissertation, Indiana University, 1996). Dissertation Abstracts International, 57, 2180. Orenstein, D. M. (1997). Cystic fibrosis: A guide for patient and family (2nd ed.). Philadelphia, PA: Lippincott-Raven. Quittner, A. L., Espelage, D. L., Opipari, L. C., Carter, B., Eid, N., & Eigen, H. (1998). Role strain in couples with and without a child with a chronic illness: Associations with martial satisfaction, intimacy, and daily mood. Health Psychology, 17(2), 112-124. Quittner, A. L., Opipari, L. C., Regoli, M. J., Jacobsen, J., & Eigen, H. (1992). The impact of caregiving and role strain on family life: Comparisons between mothers of children with cystic fibrosis and matched controls. Rehabilitation Psychology, 37(4), 275-290. Quittner, A. L., & Opipari, L. C. (1994). Differential treatment of siblings: Interview and diary analyses comparing two family contexts. Child Development, 65, 800-814.

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39 Sharpe, D. & Rossiter, L. (2002). Siblings of children with a chronic illness: A meta-analysis. Journal of Pediatric Psychology, 27(8), 699-710. Silver, E. J. & Frohlinger-Graham, M. J. (2000). Brief report: Psychological symptoms in healthy female siblings of adolescents with and without chronic conditions. Journal of Pediatric Psychology, 25(4), 279-284. Snethen, J. & Broome, M. (2001). Children in research: The experiences of siblings in research is a family affair. Journal of Family Nursing, 7(1), 92-110. Williams, P. D. (1997). Siblings and pediatric chronic illness: A review of the literature. International Journal of Nursing Studies, 34(4), 312-323.

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BIOGRAPHICAL SKETCH Kristen Marciel received her bachelor’s degree in child development at Vanderbilt University in 2001. She plans to receive her master’s degree in May 2004 and will pursue a doctoral degree in clinical and health psychology, specializing in pediatric psychology. Her primary research interest is the psychological adjustment of children with a chronic illness and their families. 40