مزایای شمولیت خواهر و برادر در درمان اختلالات طیف اوتیسم

Having a brother or sister with an autism spectrum disorder (ASD) can significantly impact the life of a typically developing sibling. These relationships are generally characterized by less frequent and nurturing interactions than are evident in sibling constellations with neurotypical children or children with other developmental disabilities. One way to address this issue is to teach typically developing siblings skills to participate in a brother or sister's treatment. Including siblings in behavioral interventions is documented to be beneficial to both children, and is associated with generalization of skills for the sibling with ASD. Here we review this body of literature, present case examples from clinical practice, and make treatment recommendations for utilizing sibling-mediated behavioral approaches. The brothers and sisters of children with autism have the potential to be very important in the lives of their siblings, both during childhood and as adults. One of the major challenges many children with autism spectrum disorders (ASD) face is learning how to interact with and play with other children. Oftentimes they may ignore their typically developing siblings and have little interest in being with them. Efforts by the sibling to engage the child with ASD in play may be met by ignoring, tantrums, or aggression. Siblings, by contrast, often yearn for a playmate, are frustrated by the lack of response of the child on the spectrum, and may be frightened by their intensity of effort to avoid engagement. For example, some of our own videotapes of sibling pairs before treatment show a child with ASD yelling and turning his back on his sister, while she sits by looking sad. The posttreatment tapes portray a different picture, with both children playing together and exhibiting more positive affect (e.g., Celiberti & Harris, 1993). Overall, there is a relative dearth of literature directly linking involvement of a sibling in treatment to positive outcomes for that sibling. The mixed nature of current data makes it impossible to draw strong conclusions regarding the causal effects of a teaching role on a sibling's well-being. However, research does suggest that including siblings in treatment positively impacts the sibling's satisfaction with the relationship, heightens responsivity for children with ASD, and increases engagement for both children (e.g., Celiberti and Harris, 1993 and El-Ghoroury and Romanczyk, 1999). Likewise, with notable exceptions (i.e., Jones and Schwartz, 2004 and Tsao and Odom, 2006), there is little research to support the preferential use of siblings over other potential interventionists. Although siblings have been well-documented as effective teachers, their involvement has not yet been directly linked to better outcomes for the child with ASD. Considering the status of the field, it is premature to attempt to tout differential benefits of sibling interventionists as a treatment option. However, the established benefits regarding skill acquisition for the child with ASD as well as self-efficacy and confidence on behalf of the sibling encourage the continued exploration of this approach. Therefore, we will review the current state of the research within the framework of sibling involvement as a complementary and supportive treatment, rather than a replacement for other intervention options. It is common for typically developing siblings to play with and enjoy each other, as well as sometimes to engage in expected conflict and sibling rivalry. In families in which one child has ASD, this ratio tends to favor the negative aspects of the relationship, and the good times are often absent. When children with ASD learn how to play with their typically developing siblings, resulting benefits can extend to the entire family (e.g., Celiberti and Harris, 1993 and Grindle et al., 2009). For example, sharing playful interactions may serve to strengthen the sibling bond by offering a pleasurable activity that engages both children and makes being together a positive experience. Just as therapists and parents learn to pair themselves with reinforcing events, a sibling can also provide a rich schedule of reinforcement that makes him or her a highly reinforcing person with whom to play. In addition, appropriate interactions between siblings, such as initiating social greetings or play, may serve to broaden the play and social repertoires of the child on the autism spectrum and allow him to generalize these skills from his sibling to peers at school and in the community. Positive social interactions benefit not only the child with ASD, but also the neurotypical sibling. A typically developing brother or sister who learns how to engage a sibling with autism in play or other activities may develop a sense of effectiveness and ease in interacting with him (Grindle et al., 2009). Regular interaction may also allow the typically developing sibling to discover the admirable qualities in a brother or sister with an ASD, and to feel closer to the sibling than in the past. This deepening bond frequently occurs in families with two or more typically developing children and can be replicated in families that include a child with ASD as well. Children are not the only ones who benefit from this improved quality of interaction; when siblings can effectively play together, life becomes a little easier for parents. It allows them more free time for doing household chores or relaxing for a few minutes, and they can take pleasure in watching their children enjoy each other. The entire family can also build on these social and play skills to share mutually enjoyable activities, such as taking walks, riding bikes, or going camping. One approach to fostering improved sibling interactions is to include a typically developing sibling in an aspect of his brother or sister's treatment (Grindle et al., 2009). The integration of a sibling into a behavioral intervention serves the dual purpose of increasing the contact between children, while teaching the child with ASD the necessary tools to successfully sustain these interactions in the future.

There is an extensive research literature on teaching peers to relate to their classmates with ASD in the classroom and on the playground (e.g., Garfinkle and Schwartz, 2002 and Morrison et al., 2001); that work is reviewed elsewhere in the present volume. There is also significant research on the psychological impact of growing up having a brother or sister on the autism spectrum (e.g., Hastings, 2003, Macks and Reeve, 2007 and McHale et al., 1986). For example, Knott, Lewis, and Williams (1995) found that sibling dyads in which one child was typically developing and the other had an ASD spent less time together than dyads in which both siblings were developing typically or in which one had a diagnosis of Down syndrome. The literature on the psychological adjustment of siblings of children with an ASD is mixed. Some studies suggest they function quite similar to children who grow up with a typically developing brother or sister (e.g., Hastings, 2003 and Macks and Reeve, 2007), while others report more negative outcomes for siblings of children on the autism spectrum (e.g., Giallo & Gavidia-Payne, 2006). One of the complexities of this research involves the Broader Autism Phenotype, that is the likelihood that a sibling of a child on the autism spectrum may also show some characteristics of the autism spectrum (Yirmiya & Ozonoff, 2007). The research on teaching siblings to relate to a brother or sister with ASD is relatively sparse. Early studies identified very limited target behaviors (e.g., Colletti and Harris, 1977 and Schreibman et al., 1983) or involved siblings who were much older than the child with autism (e.g., Lobato & Tlaker, 1985), and none involved teaching that most fundamental of childhood activities, play. By the 1990s researchers were starting to engage the elemental goal of helping neurotypical brothers and sisters teach their sibling with autism to play. One of these earliest studies by Celiberti and Harris (1993) taught the sisters of young boys with autism to engage their brothers in simple interactive play. The girls learned how to give simple instructions and prompts, to model behavior, and to praise their brothers for appropriate play. We discuss this work in greater detail below. Another study from the mid-90s showed that children with autism could learn social initiation skills with peers in preschool and transfer these skills to their sibling at home (Belchic & Harris, 1994). However, learning to play together need not be a one-way street. In many cases, targeting the skills of the child with ASD is a necessary prerequisite for involving siblings. To this end, children with ASD can learn play skills in structured settings, such as school, and then share them at home with a receptive sibling. In terms of differential benefits of sibling interventionists, two studies have compared the benefits of using typical peers versus siblings to teach children on the autism spectrum to label pictures (Jones & Schwartz, 2004) or engage in a social behavior (Tsao & Odom, 2006). In both studies peers and siblings were effective models of correct responding, although there was some variation among the sibling dyads. In the domain of pivotal social behavior, Ferraioli and Harris (2009) taught siblings of children with autism how to establish and shape joint attention. Joint attention (JA) is a complex social skill that involves the spontaneous coordination of attention between two people, for the purposes of sharing interest. It is one of the fundamental skills of social interaction and is almost always impaired in children with autism. Deficits in JA have been correlated with overall ASD severity (Turner, 2006). The literature also indicates that acquisition of JA skills in children with ASD is related to ancillary gains in other social abilities, including social initiations, positive affect, imitation, and expressive language (Jones et al., 2006 and Whalen et al., 2006).