Patient Presentation
A 3-year-old male came to clinic for his health supervision visit. The mother described that the 3-year-old was always bothering his 5-year-old brother and they would have lots of verbal fights which were becoming more physical. The mother says a typical situation was one where the 3-year-old wanted to play with his brother, but the brother was doing something else. He usually tried to convince his brother to play, then slowly moved into the 5-year-olds personal space, then took the 5-year-old’s possessions. The 5-year-old’s usual response was to ignore the brother’s negotiating, verbally warn the brother to leave his space, and then yell loudly for a parent or hit the brother when the possessions were taken. The mother wasn’t sure what to do and was worried because the 3-year-old seemed to be getting more aggressive. The social history was negative including mental illness and domestic violence.
The pertinent physical exam showed a healthy male with growth parameters in the 10-50%. His examination was normal. The diagnosis of normal sibling rivalry but with recent escalation was made. The mother was counseled in understanding that it is normal for the younger sibling to want to play with the older sibling but both have different developmental needs with the 3-year-old just learning cooperative play and the 5-year-old’s being very good at it. The mother was encouraged to help the older son find ways they could play together (“You play with the horses and I’ll play with the other animals on the farm”), to continue to ignore when appropriate and to walk away or find an adult when needed to help with the conflict. For the younger child, she was encouraged to monitor him and to redirect him earlier in the process if possible. For example, once the 3-year-old starts to enter the 5-year-olds physical space she could verbally redirect him to another activity in the same area. Also helping both children understand their physical boundaries and possessions, such as “Those are your brother’s toys and he is playing with them now. You can play with your toys.”
Discussion
Sibling rivalry is a common problem. It often occurs around the time of birth of a second child. There can be aggression towards the sibling and/or developmental regression in the child.
Older children can “…regularly wage war, physically and psychologically, within the home.” While this can worry and irritate parents, the inter-sibling confrontations also offer the opportunity to learn conflict resolution, adaption, sharing and can also evolve the relationship “…into one of extraordinary closeness and depth.”
Factors that can help in understanding the problem include:
- Temperament – how does the child react in general to the world
- Development – what is the child’s cognitive understanding of the world
- Parental favoritism/descriptions of the child – while there may not be overt favoritism, the words a parents uses to describe a child are important including typecasting or stereotyping. There may also be special needs that a sibling necessarily has that must be met by the parents and therefore are seen as favoritism such as a child with special health care needs.
- Perception – how the child views the other sibling(s) and parents
- Privacy – is there private space for the child to go, to store belongings or to have private time with parents?
- Analysis of typical fights – a “blow-by-blow” description of the last event may bring insight into provocations, conflict resolution strategies used, parental interventions, etc. which may identify typical enhancing and mitigating factors in the conflicts.
Learning Point
Help for sibling rivalry includes:
- Encourage parental understanding of the situation
- Encourage child understanding of the situation – having children begin to understand that fair is not necessarily equal in a family as everyone needs something different
- Teach conflict resolution – including sharing and taking turns, ignoring the behavior, talking it out, walking away from the situation, or getting an adult (or someone else) to help are excellent strategies.
- Parental modeling of what they would like the child to do is powerful. Advising parents to talk and not hit (e.g. talk it out) or to put themselves in time out (e.g. walking away).
- It is also helpful for a parent to tell the child what behaviors are appropriate. For example it is okay to be angry with their sibling and they could hit a pillow or bounce a ball, but not hit the sibling or throw the pillow or ball at the sibling.
- Praise that is truthful – Praise for behavior that the parent wants to encourage can be good. “I thought the way you ignored your sister who kept asking you about XXX was good. She finally got bored and walked away.”
For most families these treatments can help them through many sibling rivalry conflicts. However, there are many situations that persist beyond the normal time frame, or are intensified beyond the normal circumstances. For example, a 2 year old who bites a younger sibling once would probably be considered normal sibling rivalry. But a 10 year old who continually bites a sibling probably is not. This may be a child who is physically abusing his or her sibling and is perpetrating sibling violence. Sibling violence can be physical, psychological, emotional or sexual, as is other types of domestic violence. Many health care providers and family members do not recognize such acts as sibling violence because they are perpetrated between children and youth. But if perpetrated between adults such acts would be considered illegal. Such acts are often dismissed as “just being kids,” “roughhousing,” or “boys will be boys.” Behavioral and psychological treatment is needed to help these children and families and stop the violence.
Questions for Further Discussion
1. What history questions would help you to determine if interpersonal conflict is normal sibling rivalry or sibling violence?
2. What local resources are available to help treat sibling violence?
Related Cases
- Disease: Sibling Rivalry | Adoption | Family Issue
- Symptom/Presentation: Behavior Problems
- Specialty: Child Abuse and Neglect | General Pediatrics | Psychiatry and Psychology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Family Issues.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Phillips DA, Phillips KH, Grupp K, Trigg LJ. Sibling Violence Silenced, Rivalry, Competition, Wrestling, Playing, Roughhousing, Benign. Advances in Nursing Science. 2009:32;e1-e16.
Needlman A. Sibling Rivalry in Behavioral and Developmental Pediatrics. Park and Zuckerman eds. Little Brown and Co. Boston, MA. 1995:384-86.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 