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Background:
Systematic Review

Functioning of Neurotypical Siblings of Individuals with Autism Spectrum Disorder: A Systematic Review

by
Brenda Cervellione
*,
Calogero Iacolino
,
Alessia Bottari
,
Chiara Vona
,
Martina Leuzzi
and
Giovambattista Presti
Department of Human & Social Sciences, Kore University of Enna, Cittadella Universitaria, 94100 Enna, Italy
*
Author to whom correspondence should be addressed.
Psychiatry Int. 2025, 6(2), 52; https://doi.org/10.3390/psychiatryint6020052
Submission received: 16 February 2025 / Revised: 19 March 2025 / Accepted: 25 April 2025 / Published: 6 May 2025
Browse Figure
Versions Notes

Abstract

:
Neurotypical (NT) siblings of individuals with Autism Spectrum Disorder (ASD) experience complex emotional, psychological, behavioral, and social challenges. Understanding the factors that influence their well-being is essential for developing tailored interventions. This systematic review examines the psychological and social functioning of NT siblings and identifies protective and risk factors that impact their adaptation. A systematic search was conducted across EBSCO, PubMed, and Google Scholar, covering studies published between 2013 and 2024. Inclusion criteria focused on research investigating NT siblings’ emotional, psychological, behavioral, and social well-being. Thirty studies met the inclusion criteria and were synthesized narratively. Findings reveal heterogeneous experiences among NT siblings, ranging from increased empathy and resilience to heightened anxiety, depression, and social difficulties. The quality of sibling relationships and social support systems plays a pivotal role in moderating these outcomes. NT siblings represent a vulnerable group requiring family-centered interventions. Future research should adopt longitudinal and multi-informant approaches to explore long-term effects and culturally sensitive support strategies.

1. Introduction

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition characterized by challenges in social communication, repetitive behaviors, and restricted interests, affecting approximately 1 in 54 children globally [1]. While extensive research has focused on the challenges and interventions for individuals with ASD, less attention has been given to the broader family context, particularly the impact of ASD on neurotypical (NT) siblings [2]. Given that siblings are often the longest-lasting relationships in a person’s life, understanding their role and experiences within ASD families is crucial for developing family-centered interventions.
NT siblings of children with ASD frequently experience emotional, psychological, behavioral, and social challenges that can significantly influence their well-being [3]. Studies indicate that they may be at an increased risk of internalizing symptoms (e.g., anxiety, depression) as well as externalizing difficulties (e.g., aggression, attention problems) [4,5]. However, research also highlights positive adaptations, including enhanced empathy, resilience, and caregiving skills [6]. These heterogeneous outcomes suggest that certain protective and risk factors mediate the impact of ASD on NT siblings, yet there is still no consensus on which factors are most influential [7].
At the same time, ASD is highly heterogeneous, with symptoms varying widely among individuals. While some autistic individuals exhibit pronounced social inhibition, difficulty responding appropriately to social interactions, and challenges adapting to different communicative contexts, others may display excessive disinhibition, such as approaching or hugging strangers [8]. Repetitive and restrictive behaviors, including stereotypies such as echolalia or hand-flapping, are also common, alongside cognitive and behavioral rigidity [1]. Additionally, atypical sensory profiles are frequently reported, with hypersensitivity or hyposensitivity to stimuli such as loud noises, temperature, or physical touch [9]. These sensory and behavioral traits, combined with frequent comorbidities and increased caregiving demands, contribute to the broader impact of ASD on family dynamics [10].
From a systemic perspective, the family is a network of bidirectional relationships (e.g., marital, parental, sibling bonds) that must adapt and reorganize when faced with new challenges to restore equilibrium [11,12]. The presence of a child with ASD significantly influences these interactions, requiring adjustments that may place additional emotional and psychological strain on NT siblings. Given their frequent interactions, siblings play a pivotal role in emotional and social development, often navigating both supportive and conflictual dynamics within the family [13,14]. These relationships, which are neither elective nor easily modifiable [13], represent early opportunities for individuals to develop essential social skills such as cooperation, competition, and mutual support. However, in ASD families, the distinct needs of the autistic sibling may shape these experiences in unique ways [15,16].

1.1. Addressing the Gaps in the Literature

Despite the growing body of research on NT siblings, several gaps remain. First, most studies focus on how ASD affects NT siblings, but little attention has been given to how autistic individuals perceive and experience sibling relationships. The double empathy problem theory [17] suggests that both NT and autistic individuals struggle to understand each other’s perspectives, leading to bidirectional misinterpretations. While NT siblings may find it challenging to adapt to their autistic sibling’s unique behaviors, autistic individuals may also experience difficulties engaging in reciprocal interactions due to sensory sensitivities, executive functioning challenges, and communication differences [9]. Understanding this reciprocal dynamic is essential for developing effective family interventions.
Second, it remains unclear whether the psychological challenges observed in NT siblings are specific to ASD families or part of broader family stress dynamics. Some research suggests that siblings of children with other chronic conditions (e.g., intellectual disabilities, ADHD, or medical illnesses) also experience emotional distress, raising the question of whether NT siblings in ASD families face unique stressors or share common risks with other caregiving siblings [18,19]. This review aims to clarify these distinctions while also considering the systemic nature of family dynamics.

1.2. Objectives of This Review

Given these gaps, this systematic review aims to
-
Synthesize existing research on the emotional, psychological, and social functioning of NT siblings of children with ASD.
-
Identify protective and risk factors that shape their adaptation, considering individual and family-level influences.
-
Examine the reciprocal nature of sibling interactions, integrating the experiences of both NT and autistic siblings.
-
Compare the challenges faced by NT siblings in ASD families to those in families with other developmental conditions, clarifying the uniqueness of ASD-related sibling experiences.
-
Provide practical insights for clinical and educational interventions, emphasizing family-centered approaches to support both NT and autistic siblings.
By adopting a neurodiversity-informed approach, this review seeks to move beyond a deficit-focused perspective and instead highlight the complex interplay of family dynamics, sibling adaptation, and reciprocal social challenges. These insights will contribute to the development of more inclusive intervention strategies, benefiting not only NT siblings but also their autistic family members.

2. Materials and Methods

2.1. Search Strategy

A systematic search was conducted between November 2023 and May 2024 using the EBSCO database (Psychology and Behavioral Sciences Collection, APA PsycArticles, Education Research Complete, MEDLINE Complete, CINAHL Complete), PubMed, and Google Scholar to identify relevant studies on the emotional, psychological, behavioral, and social functioning of neurotypical siblings of individuals with Autism Spectrum Disorder (ASD).
These databases were selected for their broad coverage of peer-reviewed literature, ensuring access to high-quality studies relevant to the field. The search was conducted systematically to ensure the inclusion of all relevant peer-reviewed articles within the specified timeframe.
The search strategy used a combination of Medical Subject Headings (MeSH) terms and keywords related to siblings and Autism Spectrum Disorder (ASD). The main search terms included the following terms:
(“autism spectrum disorder” OR “ASD”) AND (“sibling” OR “brother” OR “sister” OR “family” OR “neurotypical sibling” OR “parental stress” OR “maternal depression”).
Boolean operators (AND/OR) were applied to refine the results. Additionally, backward and forward citation tracking was performed by reviewing the reference lists of selected studies to ensure comprehensive coverage.

2.2. Inclusion and Exclusion Criteria

Studies were selected based on the following eligibility criteria:
Inclusion criteria:
-
Empirical studies (quantitative or qualitative) examining the psychological, emotional, behavioral, and social functioning of neurotypical (NT) siblings of individuals with ASD.
-
Articles published in peer-reviewed journals between 2013 and 2024.
-
Studies written in English.
-
Research using validated assessment tools for sibling well-being and family dynamics.
Exclusion criteria:
-
Studies focusing only on parental perspectives, without assessing sibling outcomes.
-
Case reports, theoretical papers, or conference abstracts.
-
Studies lacking clear methodological descriptions or conducted on non-representative small samples.

2.3. Study Selection Process

The study selection followed a three-stage process:
-
Title and abstract screening—Two independent reviewers (B.C., A.B.) assessed the relevance of each study based on the predefined criteria.
-
Full-text evaluation—Eligible articles were retrieved and further assessed for methodological rigor.
-
Final selection—Discrepancies in study selection were resolved through a systematic consensus process to ensure objectivity.
-
Each stage was independently conducted by four reviewers (B.C., A.B., C.I., G.M.L.P.) to reduce bias and improve the reliability of study selection.
The PRISMA flow diagram (Figure 1) [20] has been updated to reflect the total number of studies identified at each stage, ensuring complete transparency in the selection process. Further details regarding the search strategy and reporting standards are available in Table S1 (Supplementary Materials).
To ensure consistency, all reviewers followed a predefined selection protocol, and disagreements were resolved through joint review sessions. The methodological rigor of each study was evaluated based on predefined selection criteria, and any concerns were addressed in team discussions before inclusion.

2.4. Inter-Rater Reliability

The study selection process was conducted independently by six authors (B.C., C.I., A.B., C.V., M.L., G.P.). Any disagreements were resolved through discussion and consensus to ensure accuracy. Given the qualitative nature of the synthesis, a formal inter-rater reliability statistic (e.g., ICC or Cohen’s Kappa) was not calculated, as agreement was reached through systematic author verification. This methodology aligns with standard practices in systematic reviews where qualitative evaluation is prioritized over statistical reliability metrics.
This approach ensured a rigorous and transparent study selection process, maintaining methodological consistency across all review stages.

3. Results

Characteristics of Included Studies

A total of 30 studies that met the eligibility criteria were included in this literature review (Figure 1).
The selected studies were conducted in different geographical regions and explored the adaptive and maladaptive behaviors [21] manifested by TD siblings within complex family contexts, as well as the social impact of living with a sibling with ASD. The studies included in this review referenced different research designs. The studies were analyzed qualitatively, and the results were synthesized to provide an overview of the current status of adaptive and maladaptive behaviors manifested [18] by TD siblings within complex family contexts. A synopsis of these studies is presented in Table 1.

4. Discussion

This systematic review aimed to explore the emotional, psychological, behavioral, and social functioning of neurotypical (NT) siblings of individuals with Autism Spectrum Disorder (ASD). By synthesizing 30 studies, this review provides a comprehensive overview of NT siblings’ lived experiences, highlighting the factors influencing their well-being, the protective and risk variables, and the effectiveness of targeted interventions.
A growing body of literature suggests that NT siblings develop both adaptive and maladaptive responses to their family context [47,48,51]. Some NT siblings demonstrate greater resilience, empathy, and adaptability, while others report elevated stress, social isolation, and emotional burden [29,32]. The heterogeneity of these outcomes underscores the complex interplay between individual, familial, and social factors shaping the experiences of NT siblings.

4.1. Summary of Findings: A Complex and Multifaceted Reality

(1)
The Emotional and Psychological Impact on NT Siblings
Many NT siblings report mixed emotions when interacting with their ASD sibling [21]. The emotional experience is often ambivalent, characterized by feelings of love and connection but also stress, frustration, and social embarrassment [45]. Studies by Tudor et al. [22] and Chan and Lai [32] highlight how maternal stress and depression significantly influence NT siblings’ emotional functioning, often predicting higher internalizing symptoms such as anxiety and depression.
The development of coping strategies is a critical factor. While some NT siblings engage in active coping mechanisms (e.g., emotional regulation, peer support), others resort to maladaptive strategies [51], such as emotional suppression or avoidance [26]. Recent research suggests that emotional distress in NT siblings is influenced not only by family dynamics but also by external social factors such as stigma and lack of awareness among peers [50]. A critical protective factor identified in multiple studies is parental emotional availability [24]. NT siblings who receive consistent parental support report higher psychological well-being and better emotional self-regulation.
(2)
The Social and Behavioral Functioning of NT Siblings
Social functioning is another domain where NT siblings exhibit high variability. Peer relationships are often impacted by the presence of an ASD sibling [49]. Some NT siblings experience social withdrawal and loneliness, as they feel misunderstood by their peers [5,41]. Others develop enhanced social skills and empathy, particularly when exposed to supportive social environments [48].
One of the most critical aspects emerging from recent literature is the impact of birth order on social adaptation [30]. NT siblings born after an ASD sibling report higher levels of caregiving responsibilities and stress, whereas older NT siblings tend to show higher levels of resilience and adaptability [38]. These findings suggest that age, maturity, and family dynamics play a crucial role in shaping NT siblings’ experiences. Furthermore, Baena et al. [50] found that cohabiting NT siblings often develop unique relational strategies to cope with daily stressors associated with living with an ASD sibling, emphasizing the role of informal support systems.
Another key factor is stigma and perceived social exclusion. Studies by Quatrosi et al. [43] and Braconnier et al. [38] found that NT siblings often struggle to explain their ASD sibling’s behavior to peers, leading to feelings of embarrassment, isolation, or bullying experiences. Recent evidence suggests that interventions promoting ASD literacy in schools can significantly reduce these negative experiences, fostering better peer relationships and emotional security for NT siblings [50]. In contrast, when schools and communities provide structured educational programs on ASD awareness, NT siblings report higher levels of self-confidence and peer acceptance [23].
(3)
Protective Factors and the Role of Social Support
One of the most consistent findings across studies is the importance of social support as a buffer against psychological distress [27,41]. NT siblings with strong social networks (friends, extended family, school support) demonstrate greater resilience and lower levels of anxiety and depression. Conversely, siblings with low perceived social support are at higher risk of loneliness and emotional maladjustment [25].
Some interventions have shown promising results in enhancing social support and reducing emotional distress. For example, psychoeducational sibling programs [23] and structured family interventions [24] significantly improve NT siblings’ emotional well-being and coping mechanisms. Recent findings highlight that informal support networks, such as extended family and community support, can be equally effective in mitigating distress, especially in collectivist cultures [50].

4.2. Strengths of the Review

This review integrates a wide range of methodologies, including qualitative studies, longitudinal research, and meta-analyses. The inclusion of studies from different cultural backgrounds (e.g., [32,50]) provides a cross-cultural perspective on NT sibling experiences. Additionally, the use of validated psychometric tools (e.g., Negative Adjustment Scale, [46]) enhances the reliability of the findings. By incorporating recent studies on the lived experiences of NT siblings [50], this review offers a broader perspective on the daily challenges and adaptation mechanisms these individuals develop.

4.3. Limitations

Despite its contributions, this review has several limitations. Many studies rely on cross-sectional designs, preventing causal inferences [31]. Future research should employ longitudinal designs to track NT siblings’ developmental trajectories over time.
Additionally, self-reported data may introduce response bias, as NT siblings might underreport their emotional distress due to family loyalty [38]. Further studies should incorporate mixed-method approaches, combining qualitative insights with standardized psychological assessments to gain a more comprehensive understanding of NT siblings’ experiences [50]. Future research should also include multi-informant designs, incorporating parental and clinician assessments to improve the reliability of findings.
Another critical limitation of this review pertains to the variability in methodological rigor across the included studies. Longitudinal studies leveraging large-scale national databases (e.g., [27,35]) offer the most robust evidence regarding the developmental and psychological risks faced by neurotypical siblings, providing comprehensive, long-term insights based on representative samples. Similarly, meta-analyses (e.g., [30]) enhance the reliability of findings by synthesizing data across multiple studies, thereby strengthening conclusions regarding the psychological outcomes of NT siblings.
Conversely, a significant proportion of the studies included in this review are cross-sectional (e.g., [22,28]) or qualitative in nature (e.g., [21,24]), limiting their generalizability due to small sample sizes, cultural specificity, and potential biases associated with self-reported data.
A formal risk-of-bias assessment was not conducted in this review, as it primarily synthesizes qualitative and heterogeneous quantitative studies rather than aggregating effect sizes in a meta-analytic framework. For similar reasons, conducting a meta-analysis was not feasible due to the substantial heterogeneity in study designs, sample characteristics, and outcome measures. The included studies vary significantly in methodological rigor, with some relying on longitudinal national registry data while others utilize small cross-sectional self-reported measures. This methodological variability prevents direct statistical aggregation and limits the ability to generate pooled effect sizes.
Future research should aim to standardize study methodologies and measurement tools to enable more rigorous meta-analytical approaches. By reducing heterogeneity in study design and reporting, future systematic reviews could offer a stronger quantitative synthesis, providing a clearer understanding of the psychological and social impact on neurotypical siblings of individuals with ASD.
In line with best practices for narrative systematic reviews, we have adopted a structured approach to evaluating study quality based on key methodological indicators, including sample size, study design, use of validated measurement tools, and potential sources of bias inherent in self-reported data or cultural specificity (e.g., [27,35]).
Longitudinal studies with large, representative samples and objective health records (e.g., [27,35]) provide the most robust evidence regarding neurotypical siblings’ psychological risks. Conversely, cross-sectional studies (e.g., [22,28]) and qualitative research (e.g., [21,24]) offer valuable insights but require cautious interpretation due to their inherent methodological limitations. Furthermore, experimental interventions (e.g., [22]) demonstrate promising results; however, the absence of long-term follow-up restricts the ability to determine the sustainability of these effects over time.
By adopting this structured evaluation framework, this review enhances transparency in the interpretation of findings while maintaining the flexibility required to synthesize diverse study methodologies. Future research should integrate standardized risk-of-bias assessments where applicable, particularly in systematic reviews incorporating meta-analytical techniques.
Recognizing these methodological differences, this review underscores the necessity for future research to prioritize large-scale, longitudinal, and multi-informant studies to establish a more empirically grounded understanding of NT siblings’ psychosocial outcomes. At the same time, qualitative methodologies remain indispensable for capturing the nuanced, lived experiences of NT siblings, contributing to the development of tailored, family-centered intervention strategies.

4.4. Clinical and Educational Implications

(1)
Family-Centered Interventions
Clinical interventions should address the needs of the entire family system [23]. Family-based therapies that include NT siblings, ASD siblings, and parents have shown positive effects on overall family functioning [32]. Moreover, culturally adapted interventions may be necessary to ensure that sibling support programs are relevant and effective across diverse populations [50].
(2)
School-Based Interventions
Educational settings play a crucial role in shaping NT siblings’ social experiences. School-based programs that promote ASD awareness and peer education can reduce stigma and improve social integration [43]. Recent studies emphasize that school interventions should not only target peers but also teachers, as their awareness and attitudes significantly impact NT siblings’ experiences in the classroom [50].
(3)
Psychological Support and Resilience Training
Programs such as SibChat [35] provide NT siblings with structured spaces to express their emotions, develop coping strategies, and build resilience. Integrating digital interventions, such as online psychoeducational programs, has shown promise in increasing accessibility to support resources for NT siblings, especially in geographically isolated areas [50].

5. Conclusions

This review highlights that NT siblings experience a wide range of emotional, psychological, and social challenges, but social support, resilience training, and psychoeducational interventions can significantly improve their well-being. Findings suggest that NT siblings face distinct psychological vulnerabilities, including heightened anxiety and depression, but also display remarkable adaptability and resilience in response to their family context [50]. This duality underscores the necessity of targeted interventions that address both risk factors and protective elements in NT siblings’ development.
The inclusion of recent literature [41,50] reinforces the notion that NT siblings’ experiences are highly contextual and shaped by cultural, educational, and family-specific variables. For instance, studies indicate that birth order, gender, and the severity of ASD symptoms in the affected sibling significantly influence NT siblings’ psychological well-being and coping strategies [49]. Additionally, cultural differences in family expectations and support structures play a crucial role in shaping NT siblings’ adaptation [43].
Future research should focus on longitudinal studies, multi-informant approaches, and culturally diverse samples to develop tailored interventions. Particularly, longitudinal designs could help identify developmental trajectories in NT siblings, providing insights into the long-term psychological consequences of growing up with an ASD sibling [24]. Furthermore, expanding research on the role of social stigma in NT siblings’ peer interactions and academic functioning could offer valuable directions for intervention strategies.
Expanding research on digital mental health interventions for NT siblings could further enhance support accessibility and effectiveness [50]. Innovative programs, such as telehealth psychoeducational interventions and digital peer-support groups, have demonstrated preliminary success in mitigating stress and fostering resilience among NT siblings, particularly those in geographically isolated areas or communities with limited ASD-specific resources [32].
By adopting a family-centered, neurodiversity-informed framework, clinicians and educators can foster positive sibling relationships and family cohesion. Interventions should integrate a multi-level approach, incorporating school-based ASD awareness programs, structured sibling support groups, and individualized psychological interventions for NT siblings displaying emotional distress [44].

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/psychiatryint6020052/s1, Table S1: The PRISMA Checklist.

Author Contributions

Conceptualization, B.C. and A.B., methodology, B.C. and A.B.; investigation, B.C. and A.B.; data curation, B.C. and A.B.; writing—original draft preparation, B.C. and A.B.; writing—review and editing, B.C. and A.B.; supervision, M.L., C.V., C.I. and G.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This systematic review is exempt from ethics approval because we are collecting and synthesizing data from previous studies in which ethical approval has already been obtained by the trial investigators at their respective local sites.

Data Availability Statement

This systematic review used already published data. The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Psychiatryint 06 00052 g001
Figure 1. Flow Chart PRISMA 2020 [20].
Figure 1. Flow Chart PRISMA 2020 [20].
Psychiatryint 06 00052 g001
Table 1. Summary of included studies examining the psychological, emotional, behavioral, and social functioning of neurotypical siblings of individuals with ASD.
Table 1. Summary of included studies examining the psychological, emotional, behavioral, and social functioning of neurotypical siblings of individuals with ASD.
Author-YearObjectiveType of StudySampleMethodsMain ResultsClinical ImplicationsLimits
Chu et al., 2023 [21]Exploring the lived experiences and perceptions of adolescents with siblings with ASD in Malaysia.Qualitative study with semi-structured interviews.Adolescents with typical development who have a sibling/sister with ASD (n = n.s.)Semi-structured interviews followed by thematic analysis to explore communication difficulties and emotional coping strategies.Communication difficulties with ASD siblings; mixed emotions; emotional self-regulation as a coping strategy; closer relationships.It indicates the need for specific supports for these adolescents, useful for professionals such as speech therapists and other health professions.Sample limited to Malaysia; results may not be generalizable to other cultural contexts.
Tudor, Rankin, and Lerner, 2018 [22]To examine the clinical needs and functioning of neurotypical siblings of youth with ASD.Quantitative study with path analysis.239 mothers of young people (6–17 years old) with at least one child with ASD and another neurotypical child.Standardized online measures of family factors and TD sibling outcomes, with path analysis to identify key predictors.Only 6–23% of siblings were identified in the clinical range for emotional, behavioral or social functioning. Maternal depression and sibling relationship quality were identified as key pathways for sibling functioning.The findings may guide the development of targeted interventions to improve the functioning of neurotypical siblings in families with ASD.Based on self-reported data from mothers, which could introduce bias; sample limited to households with Internet access.
Brouzos, Vassilopoulos, and Tassi, 2017 [23]To examine the effectiveness of an 8-week psychoeducational group program for siblings of children with ASD.Experimental study with control group.38 siblings of children with ASD, aged 6–15 years.Self-report questionnaires administered before and after intervention; experimental (n = 22) and control (n = 16) groups.Significant increase in knowledge about ASD and reduction in adjustment difficulties and emotional/behavioral problems in the experimental group.The results support the use of psychoeducational groups to improve the psychological adjustment of siblings of children with ASD.Relatively small sample; lack of long-term follow-up to verify sustainability of results.
Wright and Benigno, 2019 [24]Exploring sibling involvement in the development and implementation of interventions for children with ASD through the framework of family systems theory (FST).Theoretical review and analysis of clinical practices.Not specified.Review of the basic principles of FST, followed by a review of the state of research on sibling relationships in ASD and the role of siblings in interventions.Factors such as developmental level, communication status, and areas of strength and challenge are crucial in promoting positive sibling involvement and optimal family functioning.Stresses the need to develop family-centered intervention programs that consider the unique characteristics of each household to optimize outcomes.The theoretical nature of the article limits the availability of direct empirical data; further research is needed to validate the conclusions.
Guidotti et al., 2021 [25]Investigating the experience of neurotypical siblings of children with ASD by combining quantitative and qualitative methodologies.Mixed study with explanatory sequential drawing.44 neurotypical siblings of children with ASD, ages 6–17 years.Inventory of fraternal relationships to assess warmth, rivalry and conflict; participant drawings analyzed with Pictorial Assessment of Interpersonal Relationships.Neurotypical siblings show affection, but males show more conflict than females. Drawings indicate more cohesion in harmonious situations and more distance in conflicts; adolescents show more annoyance, shame and embarrassment than children.The combined use of quantitative and qualitative tools, such as drawing, is useful in gaining a detailed understanding of neurotypical siblings’ experiences, informing more personalized interventions.Relatively small sample; generalizability may be limited, and qualitative analysis may be subject to subjective interpretation.
Koukouriki, Soulis, and Andreoulakis. (2021) [26]To investigate associations between depressive symptoms of neurotypical siblings of children with ASD and parental mental health, perceived social support, and demographic factors.Quantitative correlational study.85 neurotypical siblings of children with ASD and their parents in Greece.Self-administered questionnaires to assess depressive symptoms (Children’s Depression Inventory), parental mental health (General Health Questionnaire-28) and perceived social support (Multidimensional Scale of Perceived Social Support).Neurotypical siblings show higher levels of depressive symptoms than normative data. Depressive symptoms are significantly associated with parental anxiety and perceived social support, but social support does not attenuate the association between parental anxiety and depressive symptoms in siblings.It highlights the need for family-centered interventions that take into account both the psychological status of parents and neurotypical siblings, not limiting only to social support.Sample limited to Greece; results may not be generalizable to other cultural populations; use of self-administered questionnaires may introduce response bias.
Lin et al. (2021)
[27]		To examine the risks of mental and developmental disorders in unaffected siblings of individuals with ASD.Longitudinal study based on national database.1304 unaffected siblings of ASD probands and 13,040 controls matched for age, sex, and family structure in Taiwan.Use of Taiwan’s National Health Insurance Research Database to follow participants from 1996 or birth through 2011. Identification of developmental delays, language disorders, ADHD, anxiety disorders, unipolar depression, and disruptive behavior disorders.Unaffected siblings of individuals with ASD have a higher risk of developing developmental delays, intellectual disability, ADHD, anxiety disorders, unipolar depression, and disruptive behavior disorders than controls.It emphasizes the importance of monitoring the development and mental health of unaffected siblings of individuals with ASD, suggesting the need for specific clinical and public attention.Study limited to Taiwan, which may limit the generalizability of the results; mechanisms underlying the observed associations were not explored.
Kantor et al., 2023 [28]Understanding the experiences of neurotypical siblings of people with autism spectrum disorder (ASD).Systematic review.Qualitative studies of neurotypical siblings of individuals with ASD, without limitations on age, sex, or background.Review conducted according to JBI methodology for qualitative reviews, with a three-step search strategy on various databases without period or language restrictions (but with English abstract/title).Neurotypical siblings’ experiences range from the positive (increased empathy, ability to cope with challenges) to the negative (increased risk of bullying). Many siblings do not receive adequate support to cope with challenges.Highlights the need to develop targeted interventions and supports for neurotypical siblings to improve their emotional and social well-being.Potential variation in quality of included studies; risk of bias in study selection; dependence on English abstracts/titles may exclude relevant studies in other languages.
Koukouriki, Athanasopoulou, and Andreoulakis, 2022 [29]Investigating feelings of loneliness and social dissatisfaction in neurotypical siblings of children with ASD.Quantitative correlational study.118 neurotypical siblings of children with ASD and 115 siblings of children with typical development.Administration of questionnaires to assess loneliness, social dissatisfaction and perceived social support by parents; use of multiple hierarchical regressions.Siblings of children with ASD reported higher levels of loneliness and social dissatisfaction than controls. Being first-born and perceived social support from parents are associated with lower feelings of loneliness.It suggests the need for specific interventions for younger siblings of children with ASD, beyond simple social support, to reduce feelings of loneliness and improve their well-being.Limited sample, potential generalizability reduced to other cultural contexts; study relies on self-reported measures, which may introduce bias.
Shivers, Jackson, and McGregor, 2019 [30]Meta-analytically aggregate effect sizes on outcomes of neurotypical siblings of individuals with ASD compared with comparison groups.Meta-analysis of quantitative studies.69 independent samples of neurotypical siblings of individuals with ASD.Inclusion of studies with neurotypical siblings (ASD-Sibs) older than 5 years reporting on emotional, psychological, behavioral, or social functioning; calculation of effect sizes.Neurotypical siblings of individuals with ASD have significantly more negative outcomes than the comparison groups, particularly with regard to internalizing behavior problems, psychological functioning, disability beliefs, and anxiety and depression symptoms.The results suggest the importance of including neurotypical siblings of individuals with ASD in family interventions and support strategies to mitigate the risks of negative outcomes.Aggregate results may hide significant individual differences; generalizability of results may be limited by the quality and variability of included studies.
Ben-Itzchak, Nachshon, and Zachor, 2019 [31]To examine how autism severity and social functioning are affected by the presence of older or younger siblings.Retrospective study.150 children with ASD (mean age = 4:0 ± 1:6) divided into three groups (without siblings, with older siblings, with younger siblings).Standardized neurological and behavioral assessments to examine autism severity and adaptive social skills; analysis of variance explained by social interactions and family characteristics.Children with ASD with older siblings show less severe social interaction deficits and better social skills than only children. There are no significant differences between children with younger siblings and the other groups.It emphasizes the importance of considering the positive role of older siblings in the development of social skills of children with ASD, suggesting that intervention programs could benefit from the involvement of older siblings.Retrospective study with potential limitations in generalization; does not explore specific mechanisms through which older siblings influence social development.
Tomeny, Barry, and Fair, 2017 [32]To examine how “parentification” (caregiving role assumed by neurotypical siblings) interacts with social support in predicting distress and relational attitudes among adult neurotypical siblings of individuals with ASD.Quantitative correlational study.60 adult neurotypical siblings of individuals with ASD.Measurement of perceived social support and parentification (focused on parents or siblings) during childhood; moderation analysis to assess the interaction between parentification and social support on distress and relational attitudes.Perceived social support moderates the effect of parentification on emotional distress: siblings with high parent-focused parentification and low current social support report more distress. Siblings with low sibling-focused parentification and low social support report less positive attitudes toward their siblings with ASD.Perceived social support could be a point of intervention to reduce distress and improve fraternal relationships in adult neurotypical siblings of individuals with ASD.Relatively small and specific sample; results may not be generalizable to other populations or cultural contexts; correlational design does not allow for causality.
Chan and Lai, 2016
[33]		Exploring the psychological adjustment of neurotypical siblings of children with ASD in Hong Kong.Quantitative correlational study.116 families with neurotypical siblings of children with ASD and learning disabilities.Parents completed questionnaires on siblings’ emotional and behavioral adjustment, mental well-being, quality of life, and family functioning. Siblings completed a questionnaire on their relationship with the autistic proband.Parental evaluations did not reveal a significant negative impact on the emotional and behavioral adjustment of neurotypical siblings, but concerns emerged regarding peer relationships and weak prosocial behaviors. Parental quality of life and family functioning were found to be significant predictors of sibling adjustment.Adopting a holistic approach to address the psychosocial needs of parents can facilitate the adjustment of neurotypical siblings, with a focus on peer relationships and prosocial behaviors.Study limited to a specific cultural context (Hong Kong); results may not be generalizable to other cultures; use of self-reported questionnaires may introduce response bias.
Raza et al., 2020
[34]		Examining social-emotional behavior in children at high risk (HR) of ASD and predicting symptoms and subsequent diagnosis of ASD.Longitudinal study with diagnostic assessments.HR children (siblings of children with ASD) and LR children (without family history of ASD).Social-emotional assessment at 18 months via Infant-Toddler Social-Emotional Assessment (ITSEA) and blind diagnostic assessment for ASD at 36 months.HR children later diagnosed with ASD showed greater impairment in social-emotional functioning than other HR and LR children. Differences in ITSEA domains and subdomains predicted symptoms and later ASD diagnosis.It emphasizes the importance of considering early social-emotional development in ASD risk assessment, suggesting that careful monitoring could improve early diagnosis and interventions.The limited accuracy of classification for ASD, with varying sensitivity and specificity values, suggests the need for further research to improve early screening tools.
Kuhlthau et al., 2023 [35]To examine the feasibility, acceptability, and preliminary effectiveness of a virtual resilience intervention for neurotypical adolescent siblings of children with ASD.Randomized controlled pilot study with waiting list.14–17-year-old neurotypical siblings of children with ASD.Modification of the Stress Management and Resiliency Training-Relaxation Response Resiliency Program for siblings of children with ASD. Eight weekly 60-min sessions via videoconference. Evaluation of stress management and resilience by independent sample t-tests and effect size calculations.The intervention group (IG) showed relative improvements over the control group (WLC) in stress management (d = 0.60) and resilience (d = 0.24). Most participants practiced relaxation exercises at least “a few times a week”.This pilot study suggests that the “SibChat” intervention could be an effective way to improve resilience and stress management skills in neurotypical siblings of adolescents with ASD, warranting further testing and program development.Small study size; preliminary results requiring confirmation through larger studies; long-term follow-up not evaluated, limiting understanding of sustainability of effects.
Jokiranta-Olkoniemi et al., 2016 [36]To examine the risk of psychiatric and neurodevelopmental disorders among siblings of individuals with ASD.Nested case-control study based on Finnish national registries.3578 cases with ASD and 11,775 controls with 6022 and 22,127 siblings, respectively.Analysis of data from the Finnish Prenatal Study of Autism and Autism Spectrum Disorders, which included children born between 1987 and 2005, diagnosed with ASD through 2007. Analysis of adjusted risk of disorders among siblings of probands with ASD compared with siblings of controls.Siblings of individuals with ASD have a significantly higher risk of developing psychiatric and neurodevelopmental disorders than controls. The highest risks were observed for disorders with childhood onset, such as attention-deficit/hyperactivity disorder (ADHD), learning and coordination disorders, and conduct and opposition disorders.The results suggest that there is familial clustering of psychiatric and neurodevelopmental disorders among siblings of individuals with ASD, indicating the need for monitoring and preventive interventions for this high-risk population.The study is limited to Finnish national registries, which may limit the generalizability of the results to other populations; moreover, the mechanisms underlying the observed clustering have not been explored.
Day et al., 2019
[37]		Understand the lived experiences of siblings who live or have lived with a sibling with ASD and how these experiences contribute to their support needs.Phenomenological study.Young adult siblings who lived with a sibling with ASD in Saskatchewan, Canada.In-depth qualitative interviews using a phenomenological approach to explore participants’ experiences and perceptions regarding their relationship with a sibling with ASD.The participants’ lived experiences revolved around two main themes: challenging experiences and positive experiences. These themes formed the essence of a “different, but no less important relationship” than other sibling relationships.The findings suggest the need to develop specific support groups for siblings of individuals with ASD, based on a thorough understanding of their lived experiences and unique needs.The study is limited to a specific geographic and cultural context (Saskatchewa, Canada); participants’ experiences may not be generalizable to other. populations or cultural contexts.
Longobardi et al., 2019 [38]To examine parents’ perceptions of sibling relationship quality and its association with neurotypical siblings’ behavioral and emotional characteristics.Quantitative correlational study.43 parents of children with ASD and neurotypical siblings.Measurement of siblings’ emotional and behavioral difficulties, sibling personality, and sibling relationships through questionnaires completed by parents.Behavioral difficulties such as emotional symptoms, conduct problems, hyperactivity/disattention, and problems in peer relationships are significantly associated with negative sibling relationships, characterized by rivalry, aggression, avoidance, and didactic behavior toward the sibling with ASD.Sibling-focused interventions should focus on improving negative sibling relationships to reduce the impact on the neurotypical sibling’s developmental difficulties by providing skills and approaches to improve these relationships.Small sample size, limited to a specific cultural context; results may not be generalizable to other populations.
Braconnier et al., 2018 [39]To examine parents’ and siblings’ perceptions of the positive and negative behaviors exhibited by neurotypical siblings and their siblings with ASD.Quantitative correlational study.Neurotypical siblings of individuals with ASD and their parents.Evaluation through self-administered questionnaires on positive and negative behaviors within the fraternal relationship, both from the perspective of parents and siblings themselves.Neurotypical siblings tend to evaluate the sibling relationship more positively than their parents. Neurotypical siblings exhibit more positive behaviors than their siblings with ASD, but they are also frequent recipients of aggression.The findings suggest that neurotypical siblings assume a caring role, highlighting the need for interventions that aim to support these dynamics and reduce emotional burden and conflict.Potential bias due to differences in parents’ and siblings’ perceptions; limited sample in terms of cultural diversity and size.
Kryzak and Jones, 2017 [40]Teaching social-communication and self-management skills to neurotypical siblings of children with ASD and evaluating the generalization of these skills.Study with multiple baseline probe design among sibling dyads.4 Neurotypical siblings of children with ASD.Behavioral skills training, including instruction, modeling, practice, and feedback for self-management of the social skills curriculum. Evaluation of generalization of social-communicative responses in novel contexts and over time.Neurotypical siblings independently mastered the social skills curriculum, with some generalization of learned skills to new contexts and over time. Comparison with typical peers provided some support for the social validity of the intervention results.The results support the use of self-management to promote generalization of social-communicative skills in neurotypical siblings, suggesting that explicit programming for generalization should be a key consideration in interventions.Small study size with a limited number of participants, which may limit the generalizability of the results; assessment of generalization was limited to specific contexts and defined time periods.
Garrido, Carballo, and Garcia-Retamero, 2020
[41]		To explore the factors that influence the impact of having an older sibling with ASD on different developmental domains and family quality of life (FQoL).Case-control study.78 unaffected siblings of children with ASD and children with typical development, aged 6 to 12 years.Assessment of motor skills, severity of autistic traits, satisfaction with family quality of life (FQoL), and social support using specific questionnaires and tests.Significant differences between groups in motor skills, severity of autistic traits, satisfaction on FQoL, and social support. Social support is a positive factor that protects against reduced satisfaction on FQoL related to having a sibling with ASD.Social support is a critical aspect to consider in interventions to improve satisfaction on the FQoL of unaffected siblings of children with ASD, suggesting the need to monitor the development of these children over time.Study limited to a relatively small and specific sample, which may limit generalizability of results; need for further research to explore other potential protective factors and their long-term impact.
Van der Merwe et al., 2017 [42]To investigate how adolescents with typical development remember their past attitudes and describe their current attitudes toward siblings with ASD.Cross-sectional study with quantitative approach.30 adolescents with typical development who have siblings with ASD in South Africa.Participants completed the Lifespan Sibling Relationship Scale to assess sibling attitudes in three components: affect, behavior and cognition. Wilcoxon signed-ranks tests and ANOVAs were used to analyze significant differences between time periods and components of attitudes.Participants showed more positive attitudes toward their siblings with ASD as adolescents than when they were younger. Adolescents rated their current emotions and beliefs toward siblings with ASD as more positive than their current interaction experiences.The results suggest that sibling attitudes change over time, underscoring the importance of a lifespan approach in designing and implementing supports for siblings of children with ASD.The study is limited to a relatively small and specific sample (adolescents in South Africa), which may limit the generalizability of the results; the cross-sectional design does not allow causality to be established.
Toseeb, McChesney, and Wolke, 2018 [43]To estimate the prevalence and psychopathological correlates of sibling bullying in children with and without ASD.Prospective study based on a population-based cohort.475 children with ASD and 13,702 children without ASD, age 11 years.Analysis of data from the Millennium Cohort Study to assess the prevalence of fraternal bullying and its psychopathological correlates, including internalizing, externalizing and prosocial skills problems.Children with ASD are more likely to be bullied by siblings than children without ASD. They are also more likely to be both victims and perpetrators of sibling bullying, which is associated with lower prosocial skills and greater internalizing and externalizing problems.Interventions to improve social and emotional outcomes in children with ASD should focus on both affected and unaffected siblings to address bullying dynamics and promote prosocial skills.The study is based on self-reported data, which may introduce response bias; the cross-sectional nature of the data limits the ability to establish causality in the observed relationships.
Quatrosi et al., 2023 [44]To explore the quality of life (QoL) components of non-autistic siblings of individuals with ASD through a scoping review of the literature.Scoping review.Non-autistic siblings of individuals with ASD.Analysis of nine studies selected from peer-reviewed databases (PubMed/MEDLINE, Scopus, ERIC) evaluating the QoL of non-autistic siblings of individuals with ASD compared with siblings of non-autistic individuals and patients with other chronic diseases.The condition of having a sibling with ASD has varying effects on the QoL of non-autistic siblings, with reduced psychological well-being, less perceived social support, greater aggression and susceptibility to conflict, and higher levels of anxiety and stress.The findings suggest the need to organize and improve support services for non-autistic siblings of individuals with ASD, as their needs are often underestimated and neglected.Review limited to a small number of studies (9) and specific databases; variability in results indicates need for further research to obtain more definitive conclusions.
Brinkman, Barry, and Lindsey, 2023 [45]To explore the interrelationships between symptom severity and externalizing behavior in children with ASD, parental stress, affiliated stigma, expressed emotion (EE), and internalizing behavior of neurotypical siblings (TD).Quantitative correlational study.Families with children with ASD and neurotypical siblings.Analysis of relationships between family and behavioral variables by self-administered questionnaires on stress, affiliated stigma, EE, and sibling behavior.Significant interrelationships were found between symptom severity in children with ASD and externalizing behavior, parental stress, affiliated stigma, EE, and internalizing behavior of neurotypical siblings. Some subcomponents of affiliated stigma predicted unique variance in EE and internalizing behavior of TD siblings.The results suggest that the psychosocial functioning of neurotypical siblings is influenced by family factors such as parental stress and affiliated stigma. Interventions aimed at reducing stress and managing stigma could improve outcomes for all family members.Limitations of the study include self-reported data, limited sample diversity, and a cross-sectional design that does not allow causality to be established.
Orm et al., 2021
[46]		To investigate the factor structure and convergent validity of the Negative Adjustment Scale (NAS) for measuring sibling adjustment of children with disabilities.Psychometric validation study.107 siblings of children with disabilities (M age = 11.5 years, SD = 2.1).Validation of the NAS through factor structure analysis and verification of convergent validity with a general measure of mental health. Correlations between NAS and externalizing and internalizing mental health difficulties were analyzed.A one-factor structure was confirmed for NAS. Convergent validity was demonstrated through significant correlations (r = 0.29–0.44) with externalizing and internalizing mental health difficulties in siblings.NAS shows promise as a tailored tool for assessing the adaptation of siblings of children with disabilities, useful for identifying difficulties and supporting targeted interventions.The study is based on a limited and specific sample, which may not represent all populations; further studies are needed to confirm the validity and reliability of the instrument in different contexts.
Douglas, Bagawan, and West, 2024 [47]To explore neurotypical (NT) siblings’ perceptions of their relationships with siblings with ASD and to develop a theory explaining the underlying family dynamics.Qualitative meta-synthesis.Not applicable (synthesis of existing qualitative studies).A systematic review and meta-synthesis of qualitative studies using a theory-generating approach.The findings suggest that NT siblings’ relationships with their ASD siblings are shaped by multiple factors, including the characteristics of the ASD sibling, the family context, and NT siblings’ coping strategies.The study highlights the need for targeted interventions to support NT siblings, improve relationship quality, and reduce stress associated with having a sibling with ASD.The synthesis relies on existing qualitative studies, limiting generalizability; no quantitative data are analyzed.
Watson, Hanna, and Jones, 2021 [48]To systematically review qualitative studies examining the experiences of NT siblings of children with ASD.Systematic review.15 qualitative studies met inclusion criteria.A systematic search across six databases, followed by thematic synthesis.NT siblings’ experiences are shaped by self-identity, personal development, social interactions, and coping strategies. Interactions with both ASD siblings and external individuals can be both beneficial and challenging.Emphasizes the need for interventions to support NT siblings, focusing on their coping strategies and personal development.Limited to qualitative studies; lacks a quantitative perspective on NT siblings’ well-being.
McDowell, C.; Bryant, 2024 [49]To systematically review sibling-mediated interventions (SMIs) for children with ASD.Systematic review.10 studies met inclusion criteria.Systematic literature search and synthesis of intervention characteristics, outcomes, and effectiveness.SMIs improved reciprocal play, communication, and emotional connection between NT siblings and ASD siblings. Outcomes varied due to small sample sizes and different intervention methods.Highlights the clinical potential of SMIs to enhance family relationships, but calls for standardization of intervention measures for greater replicability.Small sample sizes, lack of standardized outcome measures, and limited generalizability due to participant homogeneity.
Mokoena and Kern, 2022 [50]To explore the lived experiences of South African NT siblings of children with ASD, focusing on identity, emotional burden, and family dynamics.Qualitative study (phenomenological design).Eight university students with siblings diagnosed with ASD.Semi-structured interviews analyzed using a five-stage interpretive phenomenological analysis approach.NT siblings reported emotional burden, premature development, perceived unfair treatment, identity formation, and family dynamics. Despite these challenges, they also expressed efforts toward acceptance and appreciation of their sibling’s role in shaping their life paths.The study highlights the need for structured community-based interventions and support programs to reduce stigma and stress in NT siblings, particularly in collectivist cultures.Small sample size, limited to South African participants, which may not be generalizable to other cultural contexts.
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Cervellione, B.; Iacolino, C.; Bottari, A.; Vona, C.; Leuzzi, M.; Presti, G. Functioning of Neurotypical Siblings of Individuals with Autism Spectrum Disorder: A Systematic Review. Psychiatry Int. 2025, 6, 52. https://doi.org/10.3390/psychiatryint6020052

AMA Style

Cervellione B, Iacolino C, Bottari A, Vona C, Leuzzi M, Presti G. Functioning of Neurotypical Siblings of Individuals with Autism Spectrum Disorder: A Systematic Review. Psychiatry International. 2025; 6(2):52. https://doi.org/10.3390/psychiatryint6020052

Chicago/Turabian Style

Cervellione, Brenda, Calogero Iacolino, Alessia Bottari, Chiara Vona, Martina Leuzzi, and Giovambattista Presti. 2025. "Functioning of Neurotypical Siblings of Individuals with Autism Spectrum Disorder: A Systematic Review" Psychiatry International 6, no. 2: 52. https://doi.org/10.3390/psychiatryint6020052

APA Style

Cervellione, B., Iacolino, C., Bottari, A., Vona, C., Leuzzi, M., & Presti, G. (2025). Functioning of Neurotypical Siblings of Individuals with Autism Spectrum Disorder: A Systematic Review. Psychiatry International, 6(2), 52. https://doi.org/10.3390/psychiatryint6020052

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