Assessment of Peer Victimization and Mental Disorders Among Siblings of Individuals with Autism Spectrum Disorders

The purpose of this study was to investigate the presence of peer victimization, mood disorders (Major Depressive Disorder, Dysthymic Disorder) and anxiety disorder (Generalized Anxiety Disorder) among siblings of individuals diagnosed with Autism Spectrum Disorders (ASD). A web based survey was used to collect data on siblings of individuals on the spectrum. A sample of 10 females was finalized for the purpose of analyses. The mean age of the participants was 25.9 years (SD=9.21). The sample of 10 suggested a high proportion of respondents with scores above the cutoff point on the overt victimization and relational victimization scales suggest that siblings experienced high levels of victimization. From the sample, 70% met the diagnostic criteria for Major Depressive Disorder. In addition, 40% of the sample met the diagnostic criteria for Generalized Anxiety Disorder. Siblings reported high levels of support from family. Discussion related to future research, assessment and treatment are presented.


Introduction
Autism Spectrum Disorder (ASD) rates have steadily increased in the past decade. It is estimated that 1 out of 68 children are identified with autism, incidence that has increased meaningfully in the last decade [1] (CDD, 2014). The symptoms of ASD vary from mild to severe in individuals diagnosed with the disorder. Individuals diagnosed with ASD, display enduring neurodevelopment deficiencies that affect conduct, social communications, and the encumbrance caring for them is especially heavy when the child is presenting with emotional, behavioral and communication problems or include other comorbid issues [2] that may influence day-to-day functioning and independence [3]. The developmental challenges that individuals on the spectrum are faced will cause them to rely heavily on the support of their relatives, especially their parents [4]. Many individuals with ASDs have distinctive features that might impact family members, including parents, siblings, and extended family members [5]. According to [6] research related to ASD and the impact the diagnosis has on family members focused primarily on parents as the sub-unit within the family and very little attention was provided to the cognitive, behavioral and emotional impact the diagnosis of autism has on siblings of individuals on the spectrum.

Stigma and Peer Victimization
Investigation of relatives of individuals diagnosed with disabilities suggested that the families of these individuals' experience "Courtesy Stigma" [7]. In this process, member of the family experience stigmatization because of their relationship with the stigmatized person rather than through their individual characteristics [7]. Mor and Berkson [8] suggested that individuals develop impressions of others who are influenced by the bodily features and nonverbal behaviors of others around them. Furthermore, people frequently use movement signals of others when making impressions of others, and an individual's reactions and perceptions to physical cues serves as a foundation for the construction of stereotypes and for social interactions [8]. Individuals diagnosed with ASD may present with body rocking which is one of the more common repetitive behaviors. Mor and Berkson [8] noted that people make more undesirable trait inferences about people who engage in body rocking than they do about individuals who do not act in that manner. Current data indicate that bullying and peer victimization are associated with severe emotional and behavioral problems [9]. Victimization exists when individuals are exposed frequently to a harmful action by others [10]. Individuals who were victimized by their peers were more vulnerable to developing psychological symptoms of depression and anxiety [9]. Although there is a large body of literature on bullies and victims, there is no current published data that investigated peer victimization among siblings of individuals on the ASD. The aims of the following study was to examine levels of peer victimization, presence of mood disorder and the presence of anxiety disorder in a sample of siblings of individuals diagnosed with ASD. Orsmond and Seltzer [11] indicated that adults who have a sibling on the ASD may be responsible for the wellbeing of their sibling once their parents are unable to care for them. Parents of individuals on the spectrum are exposed to high levels of stress and presenting with lower levels of marital satisfaction [12]. Throughout their lives, siblings of individuals on the spectrum may be exposed to various conditions within their environment which increase their vulnerability to develop mental health issues [6]. Much of the current and available literature on siblings of individuals diagnosed with ASD or siblings of individuals with other disabilities presented with inconsistent and inconclusive findings in the area [13]. In review of the literature in the area of ASD impact on siblings' mental health it is suggested that growing up with a sibling with disability can have an impact on social and emotional adjustment of family members [14]. (Table 1) summarize the majority of these findings. In relation to social competence and peer relationship it was noted that there are is no agreement on how ASD influence the abovementioned domains in the lives of siblings [15]. Overall, there is no sufficient data to support the notion that siblings of individuals on the spectrum are at higher risk for developing any mental health issues. Nevertheless, there is some evidence suggesting that females of siblings with autism are at greater risk for developing anxiety related disorders. Anxiety related disorders are the most common in childhood and can contribute to changes in academic performance as well as cognitive and social development [16]. There are several methodological challenges discussed in the literature on siblings of individuals diagnosed with ASD. The first is related to life stages of the siblings [17]. The life stage is associated with a developmental stage. Individuals who are in childhood will respond differently to the presence of a sibling with ASD compared with an adolescent. Hankin,[18] noted that depression rises dramatically during adolescence and that the 1-year prevalence rates of clinical depression increase from 3% to 18% between the ages of 15 and 18 years, and 25 to 40% of adolescents report having a depressed mood. The second issue is related to differences in participants' demographics [13]. The demographic factors include family size and sibling age. The third matter that presented challenges in obtaining accurate data on siblings of individuals on the spectrum is connected to specific methodological issues [6]. Small samples, non-probability and convenience samples have contributed to the limited ability to generalize the findings. Variance in the standardized measures and tools used in the research may also contribute to variations in the results available. The abovementioned challenges offer an opportunity to continue the investigation of the impact the diagnosis of ASD has on siblings. • Meta-analytic research found a significant but small effect for having a sibling with mental retardation on a typically functioning sibling. • All studies utilized were peerreviewed articles to assure adequate information.

Siblings of Individuals on the ASD
Limitations: • Meta-analysis is limited due to the limited number and quality of associated studies. • Cannot establish if there are relationships between adjustment problems and having a sibling with mental retardation. Pilowsky et al., 2007 [23] Kohler, 1999 [24] Study Design: Cross -Sectional Sample: • Twenty-five families of children with autism or PDD. Measures: • Parents asked to identify that type of services their children received over a period of 6 months. • Families provided information about the accessibility of the services they have received over the 6 month period. • Parents asked a series of five questions.
• Parents were asked about the methods each service provided used to see if there was a link around the needs of a their children.
• Families of children with PDD or autism have needs that much be fulfilled by a large amount of services. • Families did meet with a variety of services. • Two items utilized from the Satisfaction with Sibling Relationship Scale to assess sibling satisfaction with parental differential treatment.
• Persistence was an important predictor of quality relationships between typically developing siblings and children with autism. • Temperament buffering was found to occur when one sibling has a difficult temperament and the other does not. • High persistence allows negotiation of spending mutually pleasing time with SIB-ASD.
• Study was strong because it analyzed the parents' and siblings' perspectives on the sibling relationship. Limitations: • Findings involving the temperaments of children with ASD were less significant than the temperaments of their siblings Gamliel et al., 2007 [28] Study Design: Cross -Sectional Sample:

• Survey of Clinical and/or Educational
Services.
• Most participants of the group SIBS-A developed well in terms of language and cognition. • Findings of similarities and differences between SIBS-A and SIBS-TD were similar to findings for older siblings.
Limitations: • Relatively low sample size for the group SIBS-A. • Unknown if larger groups of SIBS-A would replicate the data that was received from this study. • Ethical issues must be taken into consideration, because participants who were experiencing language delays at 14 months were functioning fine at 54 months. • No difference in the rate of autism spectrum diagnoses among the groups. • Majority of children found to be of normal functioning. • Siblings age was associated with more positive emotional description of the proband. • Probands verbal ability was related to adjustment in both the autism group and the mental retardation group. • Larger families accounted for a greater delay in socialization skills • Surprisingly siblings of children with autism are well adjusted.
Limitations: • Small sample size could have affected the statistical power of the analysis. Macks et al., 2007 [30] Study Design: Cross -Sectional Sample: • Fifty-one siblings of children with autism • Thirty-five sibling of non-disabled children.

Measures: • Children's Depression Inventory-Short
From (CDI-S) • Behavior Assessment System for Children-Parent Rating Scales (BASC-PRS) • Siblings of children with autism had a more positive self-report than siblings of nondisabled children. • Psychosocial and emotional adjustment was more prevalent for siblings of children with autism than siblings of nondisabled children.
• Future studies should involve multiple respondents and examine, in depth, other demographic characteristics.
• Siblings are likely to be the closest to children with autism than any other individual present. Trajkovski et al., 2008 [31] Study Design: Cross -Sectional Sample: • Thirty-five participants with autism • Twenty-one of their siblings Measures: • Ten mL of venous blood was drawn from each donor. • No autistic children were receiving medication at the time of the blood drawing.
• Analysis of the blood results revealed significant higher levels of plasma concentrations • Family Crisis Oriented Personal Evaluation Scale (F-COPES).
• Typical developing siblings were positive in their ratings in regards to their relationships with their siblings diagnosed with autism. • No significant findings that related sibling measures with demographic characteristics. • When marital stress increased the quality of the sibling relationships declined.
• Strength was derived from the use of the siblings as the source of information about the sibling relationships. • Study supports and extends research in the field of sibling relationships. • Further research would be needed to clarify the direction of effect of the associations present in this study. Cassel et al., 2007 [33] Study Design: Cross -Sectional Sample: • Thirty-one infants with older siblings with ASD. Measures: • All infants participated with a parent in the FFSF.

• FFSF was coded by coders certified in the
Facial Action Coding System (FACS).
• Infant siblings of children with ASD have an increased risk to develop ASD or deficits of the broad phenotype. • At 6 months ASD-sibs smiled for a lower portion of time during the FFSF than did children of TD-sibs with their parents. showed significantly more behavioral problem than the control group. • Sisters of children between the ages of 12-16 had a better selfconcept.
Limitation: Small nonprobability sample Yirmiya et al., 2007 [38]  • Each young adult with a sibling with disabilities had chosen to work in a helping industry, they also felt that living with a child with disabilities help them be more responsible but they also felt guilt, isolation, and embarrassment Limitation: • Small sample Gold et al., 1993 [42]

Study Design
This was a web-based survey, exploring levels of peer victimization and DSM-IV-TR diagnosis of siblings of individuals diagnosed with an Autism Spectrum Disorder (ASD). Siblings of individuals with ASD were contacted by the Interactive Autism Network (IAN) and were asked to participate in an online survey. A total of 25 siblings participated in the study. In final analysis ten of the participants were eligible for inclusion. The online questionnaires were completed by the participants in the study using the Qualtrics online survey system. The design had backward directionality and retrospective timing.
The strength of this study was the fact that the design allowed for collecting data from a much larger sample than would have been possible if interviews were conducted at a lower cost and in a briefer time period. The weaknesses of the design were that it did not include a control group and information was subject to recall bias.

Sampling Plan
The sample included siblings of an individual diagnosed with ASD and are registered with the Interactive Autism Network (IAN). An inclusion criterion for the study was a sibling who grew up or currently residing in a household where their sibling is a child on the spectrum. Information about the study was sent to individuals who met the above inclusion criteria via IAN. The Interactive Autism Network (IAN) is an innovative online project bringing together tens of thousands of people affected by autism spectrum disorders and hundreds of researchers in a search for answers. A non-probability sampling, using a purposive sampling technique was used to collect data.

Measures
Peer victimization was measured using the Social Experience Questionnaire [44]. This measure is a summated rating scale and had three subscales that measured Overt Victimization, Relational Victimization and Recipient of Prosocial Behaviors. Each of the subscales had 5 items and the total scale has 15 items. Examples of items in the Overt Victimization subscale are: "How often do you get hit by another kid at school? And "How often does another kid yell at you and call you mean names?" Examples of items in the Relational Victimization subscale are: "How often do other kids leave you out on purpose when it is time to play or do an activity? And "How often does a kid who is mad at you try to get back at you by not letting you be in their group anymore?" Examples of items in the Recipient and Prosocial Behavior subscale are: "How often does another kid try to cheer you up when you feel sad or upset? And "How often does another kid give you help when you need it?" Response categories ranged from 1 = never to 5 = all of the time. The theoretical range for the peer victimization scale was 15 to 75. Higher scores indicated more severe victimization. The cutoff scores for the overt victimization subscale are 3.9 and a 4.3 for the relational victimization subscale. Test-retest reliability over a four-week interval was .90 in a sample of 474 third through sixth grade children from four public schools in a moderately sized Midwestern town. Cronbach's alpha for the subscales was .76 for the Overt Victimization subscale, .86 for the Relational Victimization subscale and .76 for the Recipient of Prosocial Behaviors subscale [44].
Data on Major Depressive Disorder, Dysthymia and Generalized Anxiety Disorder were all obtained using the Patient Health Questionnaire (PHQ) [45]. The PHQ is a self-reporting measure that assesses mood, anxiety disorder, and other disorders in care patients. The PHQ was designed to quickly obtain data to determine whether or not it is probable that a respondent currently has an anxiety or depressive disorder. Level of social support was measured using the Multidimensional Scale of Perceived Social Support [46]. This scale consisted of 12 items that measured level of social support from three different sources: family, friends, and significant others. Four items, each of which was a statement for which degree of agreement or disagreement was required, assessed social support for each source. A higher score on the scale indicated greater levels of social support. Cronbach's alpha for the total scale was .88 and for the significant other, family subscale and friends subscales, the alphas were .91, .87 and .85 respectively. (Table 2) shows the socio-demographics characteristics of the sibling in the study. Only females completed the full data collection instrument which resulted in a 100% female gender sample. The average age of the sibling in the sample was 25.9 years (SD=9.21). About 50% of the sample were married or living with a partner and 90% were identified as Caucasians. Only 40% of the sample were employed and had an annual income of between 20,000 to 50,000 dollars per year. (Table 3) presents the diagnostic disorders of the sample. About 70% of the sample met the diagnostic criteria of DSM-IV-TR for Major Depressive Disorder and 40% of the sample met the diagnostic criteria for Generalized Anxiety Disorder. None of the participants met the diagnostic criteria for Dysthymia Disorder. As seen in (Table 4), the average number of depressive symptoms reported by participants were 5.6 (SD=1.9). Siblings reported on relatively high levels of peer victimization. Participants reported on a score of 5.8 (SD=1.23) on the scale of overt victimization and a score of 7.2(SD=2.25) on the sub scale for relational victimization. These results from the above subscales indicate that siblings of individuals diagnosed with ASD may experience peer victimization as the cutoff scores for the overt victimization subscale are 3.9 and a 4.3 for the relational victimization subscale. No additional significant findings were found in the sample when correlations were conducted (Table 5)

Clinical Implications
According to the findings presented in this study, peer victimization and mood disorder as well as anxiety related disorders can be prevalent among siblings of individuals on the spectrum. Consistent with previously reported data, females and siblings who grew up in a household with a child diagnosed with ASD may be at a higher risk for developing mental health related issues. Assessment and interventions with families who care for a child on the spectrum should include a component to evaluate and address any potential mental health issues presented by siblings. As mentioned earlier, parents can present with elevated levels of stress and exhibit mental health related issues as a result of caring for a child with ASD. Parent's stress and mental health issues alongside the diagnosis of autism can place the neurotypical sibling at risk for developing mental health issues.

Limitations and Strengths
Lack of research on the topic also presented limitation in available background and literature review for this study. One of the major limitations in this study was the small sample size. The representativeness of the study population limits generalizability only to individuals who were part of the IAN. Individuals who completed the survey online also did not answer all the questions which did not allow the use of the responses for analyses purposes as much of the data collected was in the format of scales and standardized measures. This study has numeral of methodological and theoretical strengths. The usage of standardized scales to assess mood and anxiety disorders assisted in obtaining a more precise report of the disorder. The use of a Web-based survey allowed for an inclusion of a larger geographical area for participant's recruitment.

Research Implications
The development of a risk assessment protocol and evaluation for siblings of individuals with ASD is requiring attention and future focus. For a population at risk for development of comorbid disorders as well as being peer victimized, a comprehensive evaluation of risk factors in research would assist in early identification and treatment services provided to siblings of individuals on the spectrum. Access to a larger community based sample may assist in providing a more accurate profile of siblings of individuals on the spectrum and will assist in the generalizability of findings. Research methodology should also consider using qualitative methods of analyses as these can provide an insight to the experiential reality of siblings of individuals on the spectrum.