The role of older siblings in clubfoot treatment

The role of older siblings in the treatment of clubfoot using the Ponseti method is significant at every stage of therapy and is often underestimated (or minimized), yet it has a real impact on treatment effectiveness—particularly during the bracing phase.

Being an older sibling of a child with clubfoot…

Being an older brother or sister of a child born with congenital clubfoot can be a multidimensional challenge. The balance within the family inevitably shifts toward the member who needs the most (time-intensive) care. Daily life with casts, a foot abduction brace, strict hourly wearing protocols, discipline and regular follow-up appointments—as well as exercises—changes the dynamics of families to varying degrees.

Although there are still no studies directly examining the role of older siblings in treatment compliance in clubfoot, a systematic review suggests that sibling-oriented care programs can improve the emotional and behavioral functioning of typically developing children who have a chronically ill sibling.

Qualitative research has shown that siblings of children with chronic conditions often assume caregiving and adaptive roles, which influences both their own emotional experiences and overall family relationships. Indirectly, this supports the thesis that the presence and supportive role of older siblings carries real clinical and psychosocial significance.

Emotional Role

Older siblings:

• normalize the treatment process (“it’s simply something we do every day,” “the brace is part of our routine—there’s nothing to worry about. It’s normal.”)
• reduce the sense of “being different” and help protect against exclusion
• build a sense of security for their younger sibling
• reinforce agency and consistency in both the parents and the child with the condition
• help lower parental stress, which in turn positively influences the course of treatment
• often remove negative beliefs associated with the foot abduction brace (beliefs sometimes carried by the parents), thereby reducing its emotional charge

Children respond very strongly to their siblings’ reactions. If a brother or sister treats a cast, a foot abduction brace, or an ADM orthosis as something ordinary, the child with clubfoot accepts it as the norm. On the other hand, when the older child is not jealous, does not feel excluded from the treatment process, and understands what the therapy is and how it works, they become a powerful source of support for both the treatment itself and the consistent use of the brace and exercises. That is why it is important to explain the condition in simple language, show before-and-after treatment photos, and allow the older child to ask questions.

Children who have supportive siblings are less likely to feel stigmatized and do not grow up hearing a “poor child” narrative at home. As a result, they demonstrate greater acceptance of treatment and are less likely to resist or sabotage the brace. This translates into better overall therapeutic outcomes, including a lower risk of relapse associated with poor brace compliance (consistent and rigorous use of the foot abduction brace).

Modeling Role

Older siblings can:

• show that “medical equipment isn’t scary” — by treating the brace as something ordinary, which helps remove its emotional charge
• help with putting on the orthosis
• support and reinforce the evening routine
• remind about the rules (e.g., “we don’t take it off without asking Mom”) and help make sure the shoes stay on
• praise their younger sibling for perseverance and bravery (“you’re a hero!”)

Sometimes siblings want to have “the same shoes,” and occasionally they even try to sneak them on themselves — and this can be used creatively (for example, turning it into a game about symmetry or “super-strong feet”).

In many families, it is the older child who naturally becomes the “brace guardian.”

Practical / “Technical” Support

An older child can:

• take part in the exercises as a little “coach”
• hand over the socks
• bring the foot abduction brace or ADM orthosis or AFO
• remind the family about follow-up appointments

Because this builds connection, reduces the sense of exclusion and the feeling that parental attention has shifted entirely to the child with the condition, and helps decrease jealousy.

The older child remains actively included in both family life and the therapeutic process.

Support during difficult phases

In an infant’s life, there are many challenging periods that all parents face—regardless of whether their child wears a foot abduction brace or not. Of course, the intensity varies and every child goes through these stages differently.

As parents, we often attribute temporary difficulties to the brace, believing that discontinuing it will improve the situation. And sometimes it does—but only briefly. However, such a decision can have serious consequences, as the risk of relapse increases.

In child development, we usually encounter so-called “developmental leaps” or “growth spurts,” which enable children to reach successive milestones—new skills essential for their development. The period around 2–3 years of age can be particularly challenging:

• rebellion against the foot abduction brace
• attempts to remove it (undoing the straps)
• nighttime protests and negotiations
• pain complaints or discomfort
• poor sleep and frequent awakenings
• tossing and turning in bed to “rediscover” a comfortable sleeping position, hitting the mattress, crib bars, or bed frame with the brace and shoes

During this time, an older sibling can:

• sleep in the same room and provide a sense of security
• help distract the younger child
• incorporate the foot abduction brace into play (“robot legs,” “a rocket,” “super boots”)

This transforms the orthosis from a “tool of coercion” into an element of shared imagination and connection.

“I had that too.”

If one child in the family had clubfoot and another child is later born with the same condition, the sibling’s role changes dramatically. In this situation, we are no longer speaking only about emotional support—but about a real influence on the course and success of treatment.

The older child can:

• show their straight feet—or even operated feet—either “as a warning” or, more importantly, as a way of fostering acceptance of a different appearance
• say, “I wore casts too,” “I had shoes like that as well”
• normalize the orthosis through lived experience
• motivate their younger sibling toward physical activity as a natural and lifelong part of living with (and beyond) treatment

In such families, the message becomes deeply embodied: this works, I am walking, running, living—and you will too.

For the younger child, this means reduced anxiety and less resistance toward the different stages of treatment. As a result, there is greater acceptance of both the condition and the therapy itself.

In psychological terms, this is classic social modeling—often more powerful than parental instruction alone.

For parents whose second child is born with clubfoot, the situation is often easier emotionally. They are less frightened, they know how to approach treatment and how to prepare for it, and they understand that the therapy works (or, in cases of primary surgical treatment or significant modifications of the Ponseti method, that certain approaches may not have worked as expected).

They have a “living proof” of effectiveness. The older child becomes tangible evidence—of outcomes, of possibilities, of what the future may look like. However, in cases where the older child was treated improperly or experienced complications, certain risks may arise.

Potential Risks

An older child may:

• feel jealous of the attention given to the younger sibling
• feel less important within the family
• begin to provoke or even sabotage treatment (e.g., by removing the brace)
• experience anxiety (“Will I have to wear those shoes again too?”)
• show developmental regression
• take on too much responsibility

That is why balance is essential. It is crucial to find one-on-one time for the older child, to acknowledge and appreciate their role, and to name their emotions (“I know this might be hard for you”).

At the same time, it is equally important not to turn the older sibling into a caregiver for the child with clubfoot. Their role is to offer support and companionship—not to carry responsibility for the treatment.

Several studies have shown that siblings of children with chronic conditions:

• have a higher risk of emotional difficulties (e.g., anxiety, sadness) compared to siblings without such experiences
• may experience rebellion, fears, and an increased sense of responsibility
• but also tend to develop strong caregiving and adaptive skills

It is also important to consider situations in which the older child had clubfoot as well (GENETICS), but their treatment followed a different pathway than that of the younger sibling. This often happens when there is a significant age gap between the children and treatment standards have changed over time.

In some families, this creates a positive reference point—when the older child had effective treatment and good outcomes. In others, however, it may generate comparison, confusion, or even tension, especially if the older child’s treatment was more invasive or less successful.

In such situations, the older sibling may experience:

• a sense of failure
• constant comparison with their younger sibling
• lowered self-esteem due to physical differences or functional limitations
• withdrawal and feelings of stigmatization
• resentment (“I was treated incorrectly, and now he/she gets a better chance”)
• frustration

These emotions can be complex and deeply layered—especially when advances in treatment mean that the younger child’s therapeutic pathway looks different, less invasive, or more effective than what the older sibling experienced.

“User Manual” for the older sibling

An older sibling is not an “add-on” to treatment. They are part of the therapeutic system. Including them in the process is essential. Invite them to appointments, to casting visits, show them the foot abduction brace or ADM orthosis, let them put similar “equipment” on a stuffed toy. But above all—name things clearly and honestly. This reduces fear.

It is important to devote time to the older child and gradually introduce them to their brother’s or sister’s treatment—explaining the condition and its stages at a level they are able to understand. Simple messages are powerful:

• “It doesn’t hurt him/her.”
• “Your little brother has special shoes so his foot can grow straight and strong—so you can run and play together later!”
• “You can help, but Mom and Dad are the ones who decide.”

At the same time, the older sibling needs permission not to be constantly involved. A little distance or apparent indifference may simply be their way of coping with a new family dynamic.

They need space for their emotions and worries—and time when parental attention is focused solely on them.

Long-Term Impact

Although there are currently no direct studies in the literature specifically examining siblings in the treatment of clubfoot, indirect evidence suggests that:

• siblings influence the psychosocial functioning of a child with a medical condition
• sibling support positively affects adaptation and overall family quality of life
• sibling-inclusive interventions show beneficial emotional and behavioral outcomes

This opens space for a clinical hypothesis: that active involvement of older siblings may positively influence both acceptance and maintenance of treatment (e.g., brace wear) through:

• better emotional adaptation
• reinforcement of routines and treatment compliance
• strengthening overall family support

When thoughtfully included in the therapeutic process, siblings often develop deeper empathy toward “difference” and become more aware of people with disabilities in society. They learn responsibility, sensitivity, and relational maturity—competencies that extend far beyond the treatment period itself.

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Researches:

1. Baner photo: Image by shurkin_son on Freepik
2. Hartling L, Milne A, Tjosvold L, Wrightson D, Gallivan J, Newton AS. A systematic review of interventions to support siblings of children with chronic illness or disability. J Paediatr Child Health. 2014 Oct;50(10):E26-38. doi: 10.1111/j.1440-1754.2010.01771.x. Epub 2010 Jun 27. PMID: 20598075
3. Subasinghe K, Petsky H, Mitchell AE, Plummer K. Experiences of siblings of children with chronic health conditions: A qualitative study in the Australian context. J Pediatr Nurs. 2025 Nov-Dec;85:378-387. doi: 10.1016/j.pedn.2025.08.019. Epub 2025 Sep 8. PMID: 40925105
4. Kirchhofer SM, Orm S, Briggs NE, Fredriksen T, Zahl E, Prentice CM, Botta M, Kelada L, Sansom-Daly UM, Vatne TM, Fjermestad KW. Siblings in families of children with chronic disorders: a model of risk and protective factors. J Pediatr Psychol. 2025 Jun 1;50(6):488-499. doi: 10.1093/jpepsy/jsaf017. PMID: 40327755; PMCID: PMC12206301
5. Boruszak J., Gryglicka H.: “Sytuacja zdrowego rodzeństwa w rodzinie z dzieckiem przewlekle chorym“, Borgis – Nowa Pediatria 3/2014, s. 103-110