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Journal of Pediatric Psychology logoLink to Journal of Pediatric Psychology
. 2025 Mar 13;50(6):479–487. doi: 10.1093/jpepsy/jsaf020

The importance of friendship: influence of peer relationships on physical and mental health in youth with spina bifida

Madeleine C Suhs 1,2, Breana L Bryant 3, Taylor L Hilderbrand 4, Grayson N Holmbeck 5,✉
PMCID: PMC12206297  PMID: 40079865

Abstract

Objective

To evaluate associations between peer relationship factors (i.e., quality and quantity) and mental and physical health outcomes in youth with spina bifida (SB).

Methods

One hundred and forty youth with SB (Mage = 11.43; 53.6% female) were recruited as part of a larger longitudinal study. Families of youth with SB were invited to ask the child’s closest friend to participate. The study included questionnaire (youth- and parent-report) and observational peer interaction data.

Results

Observational peer interaction data were associated with mental and physical health in youth with SB. The number of friends was negatively associated with withdrawn/depressed behavior. Self-reported friendship quality and peer emotional support were not associated with physical health outcomes in youth with SB. However, peer emotional support was positively associated with emotional quality of life.

Conclusions

Friendship quality, particularly observed peer interaction characteristics, was associated with better mental and physical health adjustment. The quantity of friendships was not associated with physical health outcomes but was associated with mental health outcomes. Findings have implications for clinical interventions geared toward improving social functioning in youth with SB.

Keywords: adolescents, friendships, peer relationships, adjustment, mental health, spina bifida

Adolescence is a challenging developmental period during which youth experience pubertal and cognitive changes, increased levels of autonomy, and significant changes in interpersonal relationships (Christie & Viner, 2005). Importantly, peer relationships increase in significance during adolescence and serve as a primary source of support (Sullivan, 1953). Given the importance of friendship during this time, it is not surprising that friendship quality and quantity have been found to be inversely related to loneliness and depressive symptoms (Cavell, 1990; Schwartz-Mette et al., 2020). Moreover, higher-quality friendships in adolescents are influential in overall self-esteem and well-being (Luijten et al., 2023). Friendship quality consists of the level of companionship and social support within a specific relationship and has been found to be associated longitudinally with better overall mental health adjustment and well-being (Marquis-Brideau et al., 2023; Peets & Hodges, 2018).

Peer relationships are a vital source of support for teenagers with chronic illnesses as they begin to navigate illness-specific challenges independently (Helms et al., 2015; Oris et al., 2016). Teenagers typically assume more responsibility for disease-specific tasks as they enter adolescence (Psihogios et al., 2015); this increase in autonomy is often coupled with an increased reliance on peer relationships (Oris et al., 2016). Interestingly, the presence of strong friendships has been found to be positively associated with treatment adherence, health-related quality of life (HRQOL), overall health, and disease-specific outcomes (Helgeson et al., 2023; Helms et al., 2015; Wisk & Weitzman, 2017). It may be that such social support is beneficial to individuals with chronic health conditions as they attempt to integrate their illness into a mature identity accompanied by low levels of shame and a healthy sense of self-esteem. Yet, youth with chronic conditions are also more likely to report bullying, less closeness to friends, and lower best-friend quality (Wisk & Weitzman, 2017), all of which have been found to be associated with poorer future health status in medically complex adolescents.

Spina bifida (SB) is a common congenital birth defect that significantly affects physical, psychological, neurocognitive, and social functioning (Copp et al., 2015). The severity of SB is dependent on the lesion level and the presence of neurological complications, with higher severity being associated with lower quality of life. Additionally, youth with myelomeningocele (the most severe form of SB) often have hydrocephalus for which a shunt is commonly needed to drain excess fluid from the ventricles of the brain (Copp et al., 2015). Shunt-related surgeries are often performed multiple times throughout the youth’s lifetime due to shunt failures or shunt infections. Youth with SB are also faced with complicated daily medical regimens, including catheterization and bowel maintenance programs, along with executive dysfunction and social difficulties (Lindquist et al., 2022).

Chronic pain is also a common characteristic of SB and has been associated with mental health, social, and family functioning (Bellin et al., 2013; Essner et al., 2014; Ohanian et al., 2020, 2023). For example, there appears to be a bidirectional relationship between chronic pain and family functioning in youth with SB. However, there is no research on the relationships between friendships and chronic pain in youth with SB. In the larger literature on youth with chronic health conditions, youth with chronic pain are more likely to experience loss of friendships and loneliness (Forgeron et al., 2022). It is also possible, for example, that an individual with chronic pain may be less available for social activities or, alternatively, those who are more socially engaged may be less focused on or become distracted from pain-related concerns. Such social support may also buffer individuals with SB from other medical complications as well. For example, a child with high-quality friendships and a greater number of friendships may be more likely to exhibit medical self-care activities that make complications such as urinary tract infections (UTIs) and hospitalizations less likely.

In addition to being associated with physical health outcomes, the quality and quantity of friendships may also be associated with mental health outcomes. As illustrated by the bio-neuropsychosocial model of psychosocial adjustment (Holmbeck & Devine, 2010), the psychosocial adjustment of individuals with SB is likely to be influenced, in part, by the interacting influences of multiple biological, neuropsychological, and social factors, highlighting the potential impact of social support and friendships on mental health outcomes and quality of life. Youth with SB tend to exhibit lower levels of companionship, closeness, and emotional support within their close friendships (Devine et al., 2012) and are more likely to exhibit higher levels of social passivity, lower levels of social acceptance, and a smaller number of friends as compared to their typically developing peers (Holmbeck et al., 2010). These social difficulties are present in preadolescents with SB (i.e., 8–9 years old) and beyond (Holmbeck et al., 2003; Stiles-Shields et al., 2021). The social struggles commonly experienced in youth with SB have been linked to lower self-esteem and higher internalizing symptoms (e.g., depression, anxiety) in typically developing adolescents (Qualter et al., 2013). In adolescents with type 1 diabetes, low self-esteem is related to worse health outcomes and self-management (Kenowitz et al., 2020). Despite the evidence that higher-quality friendships are related to better overall adjustment in youth with other conditions (Marquis-Brideau et al., 2023), no research has explored the physical health, mental health, and quality-of-life outcomes of peer relationship characteristics in preadolescents and adolescents with SB. Put another way, we now know more about the peer relationships of youth with SB, but we know far less about the mental and physical health outcomes of these social challenges. Further, studies assessing friendship in youth with chronic illness have tended not to employ observational peer interaction data, which has been shown to provide unique insights into interactions with peers that are not revealed via questionnaires (Holbein et al., 2014; Noll & Bukowski, 2012). Further research into the effects of peer relationships in preadolescents and adolescents with SB will likely have implications for evidence-based interventions designed to promote positive peer relationships.

The Current Study

Using a multi-method (observational and questionnaire) design, the purpose of the current study is to further develop an understanding of the impact of peer relationships on the physical health and mental health adjustment of preadolescents and adolescents with SB. The rationale for this study is based on evidence that higher quality of friendships is associated with better disease-specific outcomes and psychological functioning, and quality of life in youth with chronic illnesses (Helgeson et al., 2023; Helms et al., 2015; Oris et al., 2016; Wisk & Weitzman, 2017). Additionally, pain and medical complications in youth with SB are associated with psychosocial variables such as family functioning, quality of life, and family conflict (Bellin et al., 2013; Copp et al., 2015; Lindquist et al., 2022). However, there is no research evaluating how the number and quality of friendships are associated with these physical health variables and mental health adjustment in youth with SB. Moreover, to our knowledge, no research has utilized observational data to examine associations between the quality of peer relationships and important mental and physical health outcomes. In addition, the use of target youth self-report data along with observed peer interaction data allows for a comprehensive evaluation of the role of friendship quality and quantity for psychosocial adjustment. Given the centrality of peer relationships to the adolescent experience, we hypothesized that better quality and higher quantity of peer relationships would be associated with higher levels of mental and physical health (e.g., higher levels of quality of life, lower levels of externalizing/internalizing symptoms, lower levels of pain, lower presence of medical complications; Helgeson et al., 2023, Luyckx et al., 2012, Oris et al., 2016).

Methods

Participants

Participants were recruited for a larger, ongoing, longitudinal research study examining psychosocial and family functioning in youth with SB. Families were recruited from four local hospitals and a statewide SB association. Inclusion criteria at baseline (T1) for youth with SB were as follows: (1) a diagnosis of SB; (2) 8–15 years old; (3) fluent in English or Spanish; and (4) lived within 300 miles of the laboratory in Chicago (Devine et al., 2012). In total, 256 families were approached, and 163 agreed to participate in the study. Twenty-one of the families were lost to contact or later declined and two did not meet inclusion criteria, resulting in a sample size of 140 families (see Table 1). Each family was asked to invite a close friend of the child with SB to participate. Inclusion criteria at T1 for chosen peers included: (1) 6–17 years old at T1 and (2) fluent in English or Spanish. Families were encouraged to invite friends not related to the target child with SB and within 2 years of the target child’s age; however, friends who did not meet these criteria were not excluded from the larger study (Holbein et al., 2014). One hundred and twenty-one families identified a peer within the preferred age range (Devine et al., 2012; see Table 1). Fifteen of the chosen peers were related to the target child and were excluded from the current analyses due to our interest in friendships that were with individuals outside of the family context, thus resulting in 106 peers.

Table 1.

Demographic characteristics.

Child with SB (n = 140) Peer (n = 106)
M (SD) or n (%) M (SD) or n (%)
Age 11.43 (2.46) 10.98 (2.75)
Sex
 Male 65 (46.4%) 47 (44.3%)
 Female 75 (53.6%) 59 (55.7%)
Race
 White 74 (52.9%) 68 (64.2%)
 Black 19 (13.6%) 9 (8.5%)
 Hispanic 39 (27.9%) 19 (17.9%)
 Asian 2 (1.4%) –
 Multi-racial 6 (4.2%) –
 Other – 7 (6.6%)
 Missing – 3 (2.8%)
SB type
 Myelomeningocele 122 (87.8%) NA
 Other 17 (12.2%) NA
Lesion level
 Sacral 41 (29.3%) NA
 Lumbar 69 (49.3%) NA
 Thoracic 23 (16.4%) NA
 Unknown 7 (5.0%) NA
Shunt status
 Present 109 (78.4%) NA
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Note. NA = not applicable; SB = spina bifida.

Procedure

Study procedures were approved by university and hospital institutional review boards. At T1, data were collected by research assistants at two different in-home study visits. Prior to data collection, informed child assent and parent consent were obtained. Peer relationship data were collected by asking enrolled children with SB and their chosen peer to the second in-home study visit. Informed consent and assent were obtained from the chosen peer and their parent prior to peer interaction data collection at this second study visit. During this visit, peer and friendship-related data were collected via self-report questionnaires and videotaped structured interaction tasks. All participants received monetary compensation and small gifts for their participation at T1 ($150 for families and $50 for friends).

Measures

Demographic History, Lesion Level, and Intelligence Quotient

The child’s demographic information was collected via a parent-report questionnaire, which included age, grade, race, ethnicity, and socioeconomic status. Peer demographic information was collected via a peer self-report questionnaire and included age, ethnicity, school, and grade.

Lesion level was collected via the parent-reported Medical History Questionnaire (MHQ; Holmbeck et al., 2003). Full-scale intelligence quotient (IQ) was determined for each target youth using the Weschler-Abbreviated Scale of Intelligence (Zhu, 1999). Lesion level, IQ, and age were employed as covariates in all regression analyses.

Peer emotional support

The Emotional Support Questionnaire (ESQ), an extension of Slavin’s (1991) Perceived Emotional/Personal Support Scale (PEPSS), is a measure of emotional support, originally used with 14–19-year-olds. Although individuals rated family, non-family adults, and friends on four items, only the friend-based responses were included in the current analyses. Respondents were asked to name three friends and rate each relationship on the following four items: how much they talk about personal concerns, how close they feel to the individual, frequency of conversations, and satisfaction with the support they receive (there were no instructions to include or exclude the invited close friend when naming and rating each relationship on this questionnaire). To make the overall set of items more relevant for children who were younger than the population for which the measure was developed (Slavin, 1991), three items were developed by our research team including: how frequently they get upset at each other, how frequently they have fun, and how sure they are the relationship will last no matter what. The item assessing frequency of getting upset was reverse scored so that higher scores on total scores indicated higher emotional support/less emotional upset. The ESQ demonstrated acceptable internal consistency in the current sample (α = .87), thus supporting its use with younger children (8–15 years old, in the current study).

Observational Peer Interaction

Youth with SB and their friend of choice completed four videotaped interaction tasks, which were coded via the Peer Interaction Macro Scale (PIMS; Holbein et al., 2014). The tasks included: (1) ranking toys based on level of enjoyment while playing with them, (2) developing a commercial for an unfamiliar object, (3) planning an adventure, and (4) discussing a previous conflict and then brainstorming problem-solving ideas to resolve this conflict (Holbein et al., 2014). These tasks were chosen to emphasize collaborative problem-solving, opinion-based assertiveness, displays of individuality and connectedness, and social engagement (Grotevant & Cooper, 1985). The interaction tasks were coded by trained research assistants across several individual and dyadic constructs (see Holbein et al., 2014 for more information about coder training and the coding manual). A five-point Likert scale was used with descriptive anchors for all codes (e.g., 1 = “not at all” to 5 = “very often”). The scales that were included in the analyses were as follows: (1) control, or the ability to achieve submission to increase self-esteem or gain other desired resource (i.e., choosing activities to do: 2 items; scores ranged from 2 to 10), (2) prosocial skills, or the characteristics associated with peer acceptance (6 items; scores range from 6 to 30), and (3) positive affect, or the affect/emotion that results in positive and appropriate social interactions (e.g., laughing; 6 items; scores range from 6 to 30). Dyadic constructs included: (1) conflict, or interactions characterized by arguments, mistrust, or annoyance (5 items; scores range from 5 to 25) and (2) cohesion, or the degree of connection displayed (i.e., support; 5 items; scores range from 5 to 25). As was done by Holbein et al. (2014), the cohesion scale was dropped due to high correlations with other scales. For the three individual constructs and the one remaining dyadic construct, higher scores indicated higher levels on the observed individual/dyadic subscale. To assess interrater reliability, intraclass reliability correlations were computed for youth with SB and their peers for each scale at baseline and were deemed to be adequate when they were 0.60 or greater. The control, positive affect, prosocial skills, and peer conflict scales all demonstrated good to excellent interrater reliability and scale reliability (see Holbein et al., 2014, for values).

Friendship Quality

The Friendship Activity Questionnaire (FAQ), based on Bukowski’s Friendship Qualities Scale (Bukowski et al., 1994), is a 46-item scale measuring five scales of friendship qualities: companionship, conflict, help, security, and closeness (only slight modifications were made to the wording of 6 of the 46 items to make them more age appropriate, given the age range of our sample; e.g., “…play together” was changed to “…get together”). Youth with SB and the chosen peer participating in the home visit were asked to rate items on a five-point Likert scale with responses ranging from (1 = not true) to (5 = really true) in reference to the other youth participant (i.e., the child with SB answered the FAQ in regard to their chosen closest friend). However, for the purposes of this study, only data provided by the youth with SB in reference to their chosen peer (i.e., closest friend) were used to assess their perceived friendship quality. A total score was created to assess friendship quality via perceived companionship, help, security, closeness, and conflict. Higher scores indicated higher friendship quality. The FAQ demonstrated acceptable internal consistency at T1 in the current sample (α = .90).

Quantity of Friends

The Friendship Questionnaire (FRQ) is a parent-report measure developed for the larger longitudinal study assessing various characteristics of the child’s friendships. For the current study, we were interested in parent-report regarding their child’s number of actual friendships, namely, number of total friends, number of online friends, number of friends with SB, and number of friends that know the child has SB.

Physical Health Outcomes

A self-report measure of the child’s pain over the last 3 months included items that assessed the duration, location, frequency, and intensity of pain as well as emotional upset related to pain. The current study used two of these items; one assessed pain frequency and the other assessed pain intensity. These two items were combined into an overall pain score, with higher scores indicating greater pain. Pain frequency was measured using a six-point Likert scale (0 = less than once a month) to (5 = daily; Palermo et al., 2004a). The intensity of pain was assessed via ratings of pain along a 10-cm line from “no pain” to “worst pain ever” (Palermo et al., 2004b). The items included in the overall pain score demonstrated a modest level of internal consistency (α = .68) but were retained since it was close to our cut-off criterion (α = .70).

Data on medical complications were collected via the MHQ (Holmbeck et al., 2003; e.g., number and type of surgeries, UTIs, recent hospitalizations). For the current study, the total number of medical complications was included as a physical health outcome.

Mental Health Outcomes

The Child Depression Inventory (Kovacs, 1992) is a 27-item self-report measure of depressive symptoms for children with response options ranging from 0 to 2, with higher scores indicating increased severity of depressive symptoms. In the current sample, internal consistency for the total scale score proved acceptable (α = .77).

The Pediatric Quality of Life Inventory Version 4.0 Scale (PedsQL; Varni et al., 2001) is a self-report measure assessing HRQOL in youth aged 2–18 years. This 23-item measure, assessing psychological, emotional, and social health, utilizes a five-point Likert scale ranging from 0 (never a problem) to 4 (almost always a problem). The current study used the emotional, social, and school quality-of-life subscales. Items were reverse-scored; thus, higher scores indicated higher quality of life. The PedsQL emotional (α = .70), social (α = .74), and school (α = .73) subscales demonstrated acceptable internal consistency for the current sample.

The Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) is a 118-item form with multiple subscales, including problem and DSM-oriented scales. For this study, only the subscales that make up the internalizing and externalizing second-order scales were included, namely, Anxiety/Depressed, Withdrawn/Depressed, Rule-Breaking Behavior, and Aggressive Behavior. Even though the Somatic Complaints subscale is part of the internalizing symptoms cluster, it was not included, given that it would likely index, at least in part, symptoms of SB rather than internalizing-related symptoms. Parents rated their child’s behavior on a three-point Likert scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true).

Data Analysis

Participants with incomplete data were excluded from analyses via listwise deletion. All analyses were conducted with SPSS Version 29. Hierarchical multiple regressions were conducted, with covariates (i.e., lesion level, IQ, age) entered first and peer variables entered in subsequent steps via stepwise regression. Analyses were run separately for each of the four peer predictor domains (peer emotional support, observational variables, friendship quality, and friendship quantity). Regressions were also run separately for each of the physical and mental health adjustment outcomes.

Results

Associations between Peer Relationship Factors and Mental Health Adjustment

Hierarchical multiple regressions were conducted to examine the quality and quantity of peer relationships in association with mental health adjustment (see Table 2) and quality of life (see Table 3). PIMS observed control during peer interactions was negatively associated with CBCL withdrawn depressive symptoms in youth with SB (b = −.265; p = .011). Furthermore, FRQ quantity of friends was negatively associated with CBCL withdrawn depressive symptoms in youth with SB (b = −.224; p = .038). PIMS prosocial behavior with peers was negatively associated with CBCL rule-breaking behavior (b = −.232; p = .046) and aggressive behavior (b = −.278; p = .017). The ESQ peer emotional support subscale was positively related to PedsQL emotional quality of life (b = .239; p = .028). PIMS conflict with peers was negatively associated with PedsQL social quality of life (b = −.211; p = .042). The number of online friends, number of friends with SB, and number of friends that know the child has SB from the FRQ were not associated with mental health adjustment variables. Contrary to our hypothesis, friendship quality, as measured by the FAQ, was not associated with mental health adjustment.

Table 2.

Associations between peer relationship factors and mental health adjustment.

Anxious/depressed behavior (PR)
 Withdrawn/depressed behavior (PR)
 Rule-breaking behavior (PR)
 Aggressive behavior (PR)
 Depression (YR)
Variable Step β △R2 Step β △R2 Step β △R2 Step β △R2 Step β △R2
Lesion level 1 −.007 .003 1 −.062 .011 1 −.068 .007 1 −.063 .011 1 −.024 .030
IQ 1 −.036 – 1 −.084 – 1 −.038 – 1 −.030 – 1 −.176 –
Age 1 .028 1 .022 1 −.049 1 −.092 1 −.011
Peer emotional support (YR) ne – – ne – – ne – – ne – – ne – –
Lesion level 1 .007 .003 1 −.036 .017 1 −.102 .014 1 −.092 .017 1 −.063 .016
IQ 1 −.039 – 1 −.127 – 1 −.035 – 1 −.043 – 1 −.121 –
Age 1 .028 1 .007 1 −.065 1 −.099 1 −.036
Obs. peer control ne – – 2 −.265 .059* ne – – ne – – ne – –
Obs. prosocial behavior ne – – ne – – 2 −.232 .037* 2 −.278 .053* ne – –
Obs. positive affect ne – – ne – – ne – – ne – – ne – –
Obs. peer conflict ne – – ne – – ne – – ne – – ne – –
Lesion level 1 .004 .006 1 −.045 .025 1 −.096 .020 1 −.084 .020 1 −.046 .026
IQ 1 −.068 – 1 −.158 – 1 −.060 – 1 −.028 – 1 −.164 –
Age .020 1 −.001 1 −.109 1 −.120 1 −.046
Friendship quality (YR) ne – – ne – – ne – – ne – – ne – –
Lesion level 1 −.031 .003 1 −.127 .023 1 −.127 .016 1 −.123 .023 1 .120 .021
IQ 1 −.050 – 1 −.100 – 1 −.025 – 1 −.077 – 1 .024 –
Age −.003 1 −.010 1 −.012 1 −.089 1 .095
Quantity of friends (PR) ne – – 2 −.224 .049* ne – – ne – – ne – –
Quantity of online friends (PR) ne – – ne – – ne – – ne – – ne – –
Quantity of friends with SB (PR) ne – – ne – – ne – – ne – – ne – –
Quantity of friends who know child has SB (PR) ne – – ne – – ne – – ne – – ne – –
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Note. The analyses were run stepwise and, therefore, some variables did not achieve statistical significance for entry into the equation.

ne = not entered; Obs. = observational; YR = youth-report; PR = parent-report.

*

p < .05.

Table 3.

Associations between peer relationship factors and quality-of-life outcomes.

Emotional QoL (YR)
 Social QoL (YR)
 School QoL (YR)
Variable Step β △R2 Step β △R2 Step β △R2
Lesion level 1 −.014 .035 1 −.080 .027 1 .141 .100
IQ 1 −.055 – 1 −.157 – 1 −.280 –
Age 1 −.196 1 −.060 1 −.050
Peer emotional support (YR) 2 .239 .054* ne – – ne – –
Lesion level 1 .037 .033 1 −.070 .012 1 .163 .110
IQ 1 −.035 – 1 −.095 – 1 −.274 –
Age 1 −.180 1 −.024 1 −.034
Obs. peer control ne – – ne – – ne – –
Obs. prosocial behavior ne – – ne – – ne – –
Obs. positive affect ne – – ne – – ne – –
Obs. peer conflict ne – – 2 −.211 .037* ne – –
Lesion level 1 .018 .036 1 −.077 .018 1 .167 .109
IQ 1 −.071 – 1 −.120 – 1 −.277 –
Age 1 −.193 1 −.032 1 −.042
Friendship quality (YR) ne – – ne – – ne – –
Lesion level 1 .100 .026 1 .002 .014 1 .146 .130
IQ 1 −.052 – 1 −.122 – 1 −.326 –
Age 1 −.122 1 −.010 1 −.106
Quantity of friends (PR) ne – – ne – – ne – –
Quantity of online friends (PR) ne – – ne – – ne – –
Quantity of friends with SB (PR) ne – – ne – – ne – –
Quantity of friends who know child has SB (PR) ne – – ne – – ne – –
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Note. The analyses were run stepwise and, therefore, some variables did not achieve statistical significance for entry into the equation.

QoL = quality of Life; ne = not entered; Obs. = observational; YR = youth-report; PR = parent-report.

*

p < .05.

Associations between Peer Relationship Factors and Physical Health Outcomes

Additional hierarchical multiple regressions were conducted to examine the quality and quantity of peer relationships in association with physical health outcomes (see Table 4). PIMS positive affect was significantly and negatively associated with the presence of medical complications (b = −.246; p = .011) and PIMS prosocial behavior with peers was significantly and negatively associated with SBPQ pain score (b = −.223; p = .042). Emotional support and the quantity and quality of peer relationships variables were not associated with pain or the presence of medical complications.

Table 4.

Associations between peer relationship factors and physical health outcomes.

Medical complications
 Pain
Variable Step β △R2 Step β △R2
Lesion level 1 −.051 .039 1 .092 .034
IQ 1 −.204 – 1 −.139 –
Age 1 −.049 1 −.104
Peer emotional support (YR) ne – – ne – –
Lesion level 1 −.004 .058 1 .033 .067
IQ 1 −.245 – 1 −.203 –
Age 1 −.016 1 −.208
Obs. peer control ne – – ne – –
Obs. prosocial behavior ne – – 2 −.223 .035*
Obs. positive affect 2 −.246 .052* ne – –
Obs. peer conflict ne – – ne – –
Lesion level 1 −.007 .038 1 .059 .057
IQ 1 −.201 – 1 −.190 –
Age 1 −.030 1 −.181
Friendship quality (YR) ne – – ne – –
Lesion level 1 −.066 .060 1 .052 .102
IQ 1 −.248 – 1 −.240 –
Age 1 −.068 1 −.270
Quantity of friends (PR) ne – – ne – –
Quantity of online friends (PR) ne – – ne – –
Quantity of friends with SB (PR) ne – – ne – –
Quantity of friends who know child has SB(PR) ne – – ne – –
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Note. The analyses were run stepwise and, therefore, some variables did not achieve statistical significance for entry into the equation.

ne = not entered; Obs. = observational; YR = youth-report; PR = parent-report.

*

p < .05,

**

p < .01.

Discussion

Adolescence is a complex and potentially challenging developmental period during which youth experience increased autonomy as well as changes in social relationships (Christie & Viner, 2005; Sullivan, 1953). Although youth with SB also often assume increased responsibility for disease management during this developmental period (Psihogios et al., 2015), they also tend to exhibit lower levels of friendship quality (e.g., companionship, emotional support; Devine et al., 2012) and quantity of friends than their typically developing peers (Holmbeck et al., 2010). The present study aimed to examine the observed and perceived quality and quantity of peer relationships in association with mental health adjustment and physical health outcomes. In past work, friendship characteristics have been significantly associated with treatment adherence, overall health, and disease-specific outcomes (Helgeson et al., 2023; Helms et al., 2015; Wisk & Weitzman, 2017), yet this is the first study to examine associations between relationship factors and psychosocial adjustment in youth with SB. Importantly, our overall hypothesis that the quality and quantity of peer relationships would be associated with higher levels of mental and physical health was partially supported across several areas.

Specifically, analyses revealed a positive association between peer emotional support and emotional quality of life. This finding aligns both with our hypothesis and extant literature in typically developing populations that demonstrate a positive longitudinal relationship between social support and well-being (Marquis-Brideau et al., 2023; Peets & Hodges, 2018). However, contrary to our hypothesis, peer emotional support was not significantly associated with other measures of mental health adjustment or the physical health outcomes. It is possible that this lone finding for emotional support emerged because of overlaps or item similarity across self-reports of similar constructs (i.e., emotional support and emotional quality of life).

Previous research illustrates a positive relationship between PIMS control (i.e., the ability to achieve submission or gain desired resources in a social context), activities with friends, and higher assertion in social relationships (Holbein et al., 2014). In the present study, PIMS control was negatively associated with withdrawn/depressed symptoms. Moreover, PIMS prosocial behavior (i.e., characteristics associated with peer acceptance) was negatively associated with rule-breaking and aggressive behavior. Regarding physical health outcomes, PIMS positive affect (i.e., affect resulting in positive social interactions) was negatively associated with medical complications, and PIMS prosocial behavior was negatively associated with pain. Such findings support prior work detailing a relationship between friendship quality and condition-specific outcomes (Helgeson et al., 2023; Helms et al., 2015; Oris et al., 2016; Wisk & Weitzman, 2017); in the current instance, psychosocial benefits were accrued in youth who demonstrated higher levels of control, positive affect, and prosocial behavior during interactions with peers. It is possible that there are bidirectional relationships between these peer relationship factors and the physical and mental health outcomes examined in the current study. Future research should further evaluate this possibility, especially given that a bidirectional relationship has been found between chronic pain and family functioning in youth with SB in previous work (Ohanian et al., 2023). It is also of interest that this first attempt to examine observational peer interaction data to evaluate the relationship between friendship characteristics and condition-specific outcomes yielded more findings than emerged in our analyses involving self-reported peer data. Such differences in findings across methods support the use of observational peer data in future work.

Conflict is known to negatively impact the quality of friendships in youth with chronic illness (Helgeson et al., 2023). This study found that observed conflict with peers was negatively associated with social quality of life. It is important to note that this finding may have emerged due to construct similarity (i.e., both assessing social factors). Given associations between conflict and medical outcomes in prior research (Helgeson et al., 2023; Ohanian et al., 2023), it is surprising that more of these types of findings did not emerge in the present research. This relative lack of findings for conflict may have occurred because the PIMS conflict scale is dyadic; thus, in this case, the examination of conflict-management skills for the target youth may have been confounded with the simultaneous inclusion of conflict skills for the peers in the total conflict score (Holbein et al., 2014).

Surprisingly, despite previous research indicating that friendship quality is positively associated with mental health adjustment and well-being (Marquis-Brideau et al., 2023; Peets & Hodges, 2018), no significant associations emerged with friendship quality as measured by the FAQ. Additionally, the FAQ friendship quality score was not associated with pain or medical complications in youth with SB. However, the observational peer interaction data assessing similar thematic constructs as the FAQ (e.g., connectedness) revealed several significant relationships with mental and physical health outcomes, as described above. Thus, in addition to the explanations provided above, these differences in findings between observational data and self-reports also may have emerged due to biases present in self-report data (e.g., social desirability biases; Althubaiti, 2016) that are probably less likely to emerge with investigator-coded observational data.

Furthermore, although it is known that youth with SB have a smaller number of friends compared to their typically developing peers (Holmbeck et al., 2010), this study did not find that quantity of friends was associated with pain or medical complications. This finding may have emerged because the number of friends was assessed with parent-report, rather than with self-report (Kapetanovic & Boson, 2022). That is, the multiple contexts outside of the home in which friendships can exist may not be accurately captured via parent-report of the youth’s quantity of friends. However, the present study did find that the quantity of friends was negatively associated with withdrawn/depressed symptoms. This aligns with prior work documenting a negative relationship between friendship quantity and depressive symptoms in typically developing adolescent populations (Cavell, 1990; Schwartz-Mette et al., 2020).

Limitations, Directions for Future Research, and Clinical Implications

This study had several limitations. First, this study used a cross-sectional design to evaluate the relationship between peer relationship characteristics and mental and physical health outcomes. Given that peer relationships increase in significance during adolescence, a longitudinal perspective is needed in future research. Second, the use of parent-report for two of the measures assessing friendship quantity and mental health (i.e., FRQ and CBCL, respectively) may provide less accurate data than relying on youth-report data, particularly for the older youth in our sample. Third, although it is a strength of this study that we collected observational peer interaction data, we also allowed families to choose a peer to participate in the study, which may have introduced a selection bias. Thus, it may not be possible to generalize our findings to other friendships present in the lives of our participants. Finally, although the number of significant findings relative to the number of analyses run was modest, all significant effects were in the predicted direction.

Beyond these limitations, we believe that this study is valuable in informing future research, given the lack of past research that has examined associations between peer relationship factors and mental health and physical health outcomes. The physical health outcomes examined included pain and number of medical complications, as these issues are known to impact youth with SB (Copp et al., 2015; Ohanian et al., 2023). However, future studies assessing the impact of friendship should consider examining other measures of physical health, such as sleep and exercise, as these constructs are positively associated with the functioning of adolescents with chronic conditions (Badawy et al., 2019; West et al., 2019).

More research is needed to further understand the significance of control and conflict in peer relationships in youth with chronic illness. Due to the dyadic nature of the PIMS conflict scale, we were not able to examine the associations with person-specific conflict management skills. Thus, it may be useful for future research to assess observed conflict behaviors in a non-dyadic way to further evaluate the influence of conflict on mental health adjustment and physical health outcomes. More generally, in the present study, the inclusion of observational data highlighted specific significant statistical associations that were not found when only using self-report data. Additionally, it is important to note that self-report measures were not related to physical health outcomes, again supporting the use of an observational data collection strategy.

These results also offer important clinical implications regarding the development of psychosocial interventions for youth with SB. Given the findings of this study, it may be important for clinical interventions to assist in fostering prosocial behaviors and behaviors that represent healthy levels of assertiveness (i.e., control). In fact, it appears that helping youth to practice supportive social skills within preexisting social networks has been effective within the SB population (Betz et al., 2015). The promotion of positive peer relationships in youth with SB via clinical interventions should focus on education about and modeling of prosocial behaviors (e.g., empathy, self-control, emotional expression, eye contact; Holbein et al., 2014) and positive affect. It may also be important to teach youth ways of bolstering healthy levels of control in peer interactions, such as initiating activities and social interactions. It is also important to note that there may be a bidirectional relationship between peer relationship factors and mental and physical health outcomes. Thus, evidence-based interventions for depression and anxiety may also have downstream positive impacts on the quality of friendships and social interactions. More research is needed to further define these relationships. Increasing opportunities for practice and education for behaviors that can lead to positive social outcomes within and outside the home may also be beneficial for youth with SB. Yet, youth with more severe cognitive profiles may benefit from more basic and specific social skills training (Stiles-Shields et al., 2021).

Conclusion

Peer relationships are integral to adolescent development, particularly for youth with complex medical conditions such as SB. However, past research had not examined associations between peer relationship factors and physical and mental health outcomes in preadolescents and adolescents with SB. In the current study, friendship quality, particularly observed control, prosocial behavior, and positive affect were related to better mental and physical health adjustment. Thus, studies of youth with chronic illness would benefit from examining the quality and quantity of friendships with a multi-method approach. Furthermore, interventions tailored toward improving social functioning in youth with SB should focus on promoting positive affect, prosocial behaviors, and healthy levels of control behaviors in peer interactions in an attempt to improve mental and physical health outcomes.

Acknowledgments

This study is part of an ongoing, longitudinal study. Portions of these findings were presented as a poster at the 2024 Society of Pediatric Psychology Annual Conference in New Orleans, LA, United States.

Contributor Information

Madeleine C Suhs, Department of Psychology, Loyola University Chicago, Chicago, IL, United States; Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States.

Breana L Bryant, Department of Psychology, Loyola University Chicago, Chicago, IL, United States.

Taylor L Hilderbrand, Department of Psychology, Loyola University Chicago, Chicago, IL, United States.

Grayson N Holmbeck, Department of Psychology, Loyola University Chicago, Chicago, IL, United States.

Data availability

Data are available on request.

Author contributions

Madeleine Claire Suhs (Conceptualization [lead], Formal analysis [equal], Investigation [equal], Methodology [equal]), Breana Bryant (Conceptualization [equal], Formal analysis [equal], Methodology [equal], Supervision [equal]), and Grayson N Holmbeck (Conceptualization [equal], Formal analysis [equal], Supervision [lead])

Funding

Data collection and preliminary analyses were funded by the March of Dimes Birth Defects Foundation (12-FY13-271), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; R01-HD048629), and National Institute of Nursing Research (NINR; R01-NR016235).

Conflicts of interest: We have no conflict of interest to disclose.

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Data Availability Statement

Data are available on request.

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