Examining Positive Family Interactions and Psychosocial Risks In Healthy Siblings of Children with Special Healthcare Needs

Background and Purpose
Approximately one in three multi-child U.S. households includes at least one child with special healthcare needs (CSHCN), yet the mental health of healthy siblings remains underexamined. Prior research documents elevated depression and anxiety among well siblings, but no nationally representative study has tested whether positive family interactions (PFIs) moderate these risks across developmental stages. Grounded in a risk-resilience framework, this study asked: (1) Are healthy children with a sibling with SHCN at elevated risk for depression and/or anxiety compared to peers with only healthy siblings? (2) Do PFIs moderate this association across developmental age groups?

Methods
This cross-sectional study used the 2023 National Survey of Children's Health (NSCH). The analytic sample included N = 25,759 well children aged 0-17 with at least one sibling: 15.4% had a sibling with SHCN and 84.6% had only well siblings. Children were stratified into early childhood (0-5), middle childhood (6-11), and adolescence (12-17). The sample was 49.9% male, 78.1% White, and 14.5% Hispanic. Mental health outcomes were parent-reported lifetime diagnoses of depression and anxiety (binary). Age-specific PFI composites were derived from NSCH items capturing shared family meals, reading/storytelling, meaningful conversations, and caregiver event attendance. Chi-square tests with odds ratios and Cramer's V compared mental health prevalence by sibling health status within each age group. Independent-samples t-tests assessed PFI group differences. Moderation was tested via logistic regression using Hayes' PROCESS macro, adjusting for caregiver education and poverty status.

Results
Well children with a sibling with SHCN had significantly higher odds of depression and anxiety across all age groups (all p < .001). Depression ORs ranged from OR = 8.2 (ages 0-5; 0.3% vs. 0.0%) to OR = 4.3 (ages 6-11; 0.9% vs. 0.2%) to OR = 2.1 (ages 12-17; 6.1% vs. 3.0%). Anxiety ORs ranged from OR = 2.8 (1.5% vs. 0.5%) to OR = 1.6 (6.5% vs. 4.2%) to OR = 1.8 (13.4% vs. 7.8%). PFI scores were high in both groups; a small but significant deficit emerged only in early childhood (M = 6.54 vs. 6.82). PFIs did not buffer depression or anxiety in early or middle childhood. In adolescence, PFIs were associated with reduced depression odds (OR ≈ 0.73), but the significant PFI × sibling health interaction (B = 0.07, p = .003) indicated this protection was weaker for adolescents with an SHCN sibling. No PFI moderation was detected for anxiety.

Conclusions and Implications
Healthy siblings of CSHCN represent a vulnerable subgroup whose elevated mental health risks are not meaningfully buffered by positive family routines alone. Practitioners should implement universal psychosocial screening for well siblings and offer interventions addressing illness-related stress, role strain, and parental availability. Policymakers should fund sibling-inclusive supports such as psychoeducation and caregiver respite to ensure no child is overlooked. Future research should examine illness severity and coping mechanisms as intervention targets, particularly during adolescence. Rigorous, inclusive inquiry into the full family system advances the democratic principle that every child's wellbeing matters.