Associations Between Peer Relationships and Self-Esteem After Childhood Traumatic Brain Injury: Exploring the Mediating Role of Loneliness

Abstract

Pediatric traumatic brain injury (TBI) can impact psycho-social functioning, including friendships and experiences of loneliness; however, few studies have explored associations between these factors and self-esteem. To address this gap, the objective of this study was to document inter-relationships between friendship quality, peer-related loneliness, and self-esteem 12 months post-injury. The sample in this prospective, longitudinal observational study consisted of 135 children, including 92 children with TBI (57 mild, 35 moderate-severe TBI) and 43 typically developing control (TDC) children. Children rated their friendship quality, loneliness, and self-esteem. Parents completed questionnaires measuring socioeconomic status and children's pre-injury functioning. At 12-month follow-up, ratings of friendship quality (perceived support and satisfaction with friendships), peer-related loneliness, and self-esteem were comparable between TBI and TDC participants. In mediation models, poorer quality friendships were associated with greater peer-related loneliness, and greater peer-related loneliness was related to reduced athletic and social self-esteem, at 12 months post-TBI. Loneliness with peers mediated the effects of both friendship support and friendship satisfaction on children's social self-esteem. Our preliminary findings suggest that regular monitoring of social interactions post-TBI might facilitate early identification of children who are likely to benefit from interventions targeting peer-related loneliness, which in turn may lower risk for poorer self-esteem.

Introduction

Children who sustain a traumatic brain injury (TBI) can face considerable difficulties across multiple facets as they transition back to everyday life.^1
-3 These challenges can affect how children perceive themselves (i.e., their self-esteem).⁴ There is also evidence that TBI can impact the quality of friendships, and children report increased peer-related loneliness.^5
-7

Such challenges might at least partially be explained by increased vulnerability to disruption of neural networks underpinning social competence following TBI.^8,9 Despite these preliminary reports, few studies have examined the role of friendship quality and loneliness in contributing to reductions in self-esteem. Thus, the aim of the current study was to examine inter-relationships between friendship quality, degree of peer-related loneliness, and children's self-esteem post-TBI.

Preliminary research characterizing outcomes after childhood TBI suggests that self-esteem, derived from self-perceptions of adequacy or competence,^10,11 might be susceptible to reductions post-injury. While these reductions have been previously documented for global, or a general sense of self-worth,^4,6 a more recent study found comparable ratings for global self-esteem between children with TBI and typically developing (TD) controls.¹² Evidence for self-esteem as it relates to specific domains of function is also limited and somewhat conflicting. For example, children with moderate-severe TBI rated their academic self-esteem significantly lower than healthy children.¹² In contrast, Meadows and colleagues¹³ documented comparable scores between orthopedic injury (OI) controls and children with TBI for social, athletic, and physical domains of self-esteem.

While previous literature has shown that childhood brain injury might impact both global and domain-specific self-esteem, recent evidence suggests that the quality of a child's environment may play an even greater role in recovery and rehabilitation after pediatric TBI.^14

–17 These findings are consistent with the heuristic model of social competence (HMSC) in childhood brain disorders, which provides a framework for understanding how interactions between injury, child, and environmental factors predict social and emotional outcomes, including self-perceptions/self-esteem.¹⁸ Specifically, this model proposes that factors related to brain insult, such as greater injury severity and younger age at injury, elevate risk for worse psycho-social outcomes. The model also highlights the pivotal role of non-insult related factors, specifically, environmental influences such as family functioning and socioeconomic status, which may independently or interactively moderate outcome and recovery of psycho-social skills. Despite this, only a handful of studies have examined the impact of environmental factors on children's self-esteem post-injury. Recently, Khan and colleagues¹² reported that among 84 children with mild-severe TBI, poorer family relationship quality and lower socioeconomic status contributed to worse self-esteem 12-months post-TBI, consistent with contemporary frameworks.

It may be that broader aspects of a child's environment, such as the quality and extent of peer relations, might also confer risk for self-esteem difficulties following pediatric TBI. Consistent with this prediction, the sociometer theory¹⁹ posits that self-esteem represents a child's gauge of their own social standing, such that children are likely to rate their self-worth more highly if they have firmly established social bonds. In contrast, children who are rejected or feel isolated from social groups are likely to have low self-esteem. In keeping with this account, peer-related loneliness, conceptualized as lack of intimacy and integration with peer groups, has shown to undermine self-esteem in youth with disabilities.²⁰ This may be especially true for domains of self-esteem that rely heavily on peer-related input, such as child perceptions of social competence.^21,22 Studies characterizing peer-related loneliness in children with TBI, however, have revealed mixed findings.^6,23 As such, further research is warranted to determine whether children feel socially isolated from their friends post-TBI and the potential implications this might have for their self-esteem.

Perceptions of loneliness are heavily influenced by features that underscore a child's relationships with their peers. In particular, friendship quality, defined as the degree to which friendships meet specific provisions (e.g., security, companionships, opportunity for play and intimate disclosure), is consistently reported as a key predictor of loneliness in developmental literature.^24

–27 For instance, in a study comprising 884 mid-late adolescents (grades 9-12), self-reported friendship quality was a stronger inter-individual predictor of loneliness than social acceptance, peer victimization, and quantity of reciprocal friendships.²⁸ Findings from a recent study indicated that specific dimensions of friendship quality, namely security and companionship in friendships, made significant contributions to self-reported loneliness among primary school children.²⁹ These results are in keeping with Baumeister and colleagues' “belongingness hypothesis,” which proposes that close and meaningful social relationships represent a basic human need, the unfulfillment of which can lead to worsening mood and social isolation.³⁰

Friendship quality has also been examined in a handful of pediatric TBI studies. Bohnert and colleagues³¹ documented qualitatively poorer friendships in children with severe TBI than children with moderate and mild TBI. Conversely, Ross and colleagues²³ found that quality of friendships was comparable between children with mild-severe TBI and non-injured controls. Heverly-Fitt and colleagues⁵ extended these findings by recruiting a larger sample size and measuring friendship quality using both peer-and-self-reported questionnaires. The authors found significant differences in dimensions of friendship quality between children with TBI and children with OI, such that the TBI group reported greater friendship satisfaction and friendship support than the OI group. As with research examining peer-related loneliness in children with TBI, the limited studies exploring friendship quality have revealed inconsistent findings. In addition, despite evidence from developmental literature, even less is known about links between peer relationships and child outcomes, including experiences of loneliness and self-esteem post-TBI.

One possibility is that better friendship quality buffers against self-esteem difficulties via reduced perceptions of loneliness. This hypothesis is in keeping with the above-mentioned evidence that qualitatively poorer friendships elevate risk for experiencing loneliness in childhood and adolescence, and that loneliness is predictive of lower self-esteem. This hypothesis aligns with prior research suggesting that loneliness represents a gateway through which negative peer experiences, including poor friendship quality, elevate risk for internalizing symptoms such as depressed mood both in typically developing cohorts²⁵ and those with neurodevelopmental disorders.³² Collectively, these data lend support to the hypothesis that qualitatively poor friendships may increase the likelihood of worse child outcomes, including low self-esteem, through children experiencing feelings of loneliness. In the pediatric TBI context, it might therefore be reasonable to argue that better quality friendships might be indirectly associated with higher self-esteem by protecting against peer-related loneliness.

Taken together, conflicting findings in the existing literature underscores the need for further well-powered prospective studies to characterize the correlates of self-esteem post-injury. While extant developmental literature has reported associations between peer experiences and child outcomes, including friendship quality, peer-related loneliness, and self-esteem, the potential associations among these variables in children with TBI remains poorly understood. Therefore, the current study sought to examine the role of friendship quality and peer-related loneliness in contributing to reductions in domain-specific self-esteem (i.e., social, behavioral, athletic, and physical self-esteem) in a cohort of children with TBI and TD children. We investigated whether child perceptions of loneliness mediated the association between quality of peer relations and children's self-esteem ratings. We hypothesized that children with TBI would rate their social, behavioral, athletic, and physical self-esteem lower than TD children. Based on existing literature suggesting elevated risk of psycho-social difficulties after childhood TBI, we hypothesized that friendship quality would be poorer and peer-related loneliness would be higher among children with TBI than TD children. For the TBI group, we further predicted the following associations at 12-months post-injury: 1) poorer friendship quality would be associated with greater levels of peer-related loneliness; 2) greater peer-related loneliness would be linked to reduced social, behavioral, athletic, and physical self-esteem; and 3) peer-related loneliness would mediate the relationship between poor quality friendships and reduced self-esteem.

Method

Design

Children and their parents were recruited from a state-wide, tertiary pediatric hospital into a larger, single-site, longitudinal, prospective cohort study of psycho-social outcomes post-childhood TBI.³³ The current study draws on data from acute (i.e., 1-4 weeks post-injury) and 12-month time-points.

The study was approved by the Royal Children's Hospital (RCH) Human Research Ethics Committees and the State Education Department. Once parents had given verbal assent to participate, they were mailed information packs detailing the study and requesting written consent. At 12-months post-TBI, using standardized questionnaires during a face-to-face visit to the hospital or at home, children rated their peer relationships, loneliness, and self-esteem. Parents rated children's pre-injury functioning.

Participants

As part of the original study,³³ children with TBI (n = 112) were identified via review of emergency department admissions at the RCH, Melbourne, Australia, screened for eligibility, and recruited at the time of injury. Participants in the TD group (n = 43) were recruited from local Australian schools to ensure a variety of socioeconomic backgrounds and matched to the TBI group on age and sex. The present 12-month follow-up study consisted of 135 children: 92 children and adolescents with TBI (82.14% of the original sample) and 43 TD controls (100% of the original sample).

Inclusion criteria for the TBI group were: 1) age between 5 and 15 years at time of injury; 2) documented diagnosis of TBI, including a period of altered consciousness or at least two post-concussive symptoms; 3) medical records sufficient to ascertain injury severity, including lowest post-resuscitation Glasgow Coma Scale (GCS)³⁴; 4) no history of pre-injury neurological or developmental disorder; and 5) English speaking. The TD comparison group was recruited from local schools and met inclusion criteria (1), (4), and (5) above.

The TBI group consisted of children with injury severity ranging from mild-severe, classified as follows: 1) mild TBI (n = 57): GCS score of 13-15 on hospital admission and/or skull fracture not requiring surgical intervention; and 2) moderate-severe TBI (n = 35): GCS score of 3-12 on hospital admission and/or evidence of trauma-related abnormalities on computed tomography or magnetic resonance imaging, skull fracture requiring surgical intervention.

Measures

Injury characteristics

For children with TBI, standard clinical report forms were used to collect the following information: lowest GCS, duration of coma, age at injury, and injury mechanism.

Demographic factors

Participant sex, age at assessment, time since injury, pre-injury mental health, and socioeconomic status (SES) are reported. Caregivers provided retrospective ratings of their child's emotional and behavioral problems in the 6 months preceding injury using the Child Behavior Checklist.³⁵ The Total Problems scale was used in the current study, which is generated by summing the Internalizing and Externalizing Problem scales. SES was assessed at recruitment using the Australian and New Zealand Socioeconomic Classification of Occupations.³⁶ Scores range from 0-100, with higher scores reflecting higher occupational status for the primary caregiver.

Outcomes

Loneliness

The Relational Provisions Loneliness Questionnaire (RPLQ)³⁷ was used to examine child perceptions of peer-related loneliness. The summary scale utilized was Loneliness with Peers. This scale combines the following two subscales comprising seven items each: 1) Peer Group Integration (i.e., degree to which a child feels a part of or a sense of shared companionship with their peer group); and 2) Peer Personal Intimacy (i.e., degree to which a child feels they could confide in and share their thoughts and feelings with a friend). Children responded to each item on a 5-point Likert scale ranging from 1 (not at all true) to 5 (always true). All items were reverse-scored and aggregated to yield the summary scale score. Higher scores reflect a greater sense of loneliness with peers. Internal consistency for each subscale of the RPLQ has been documented to range between good and excellent.³⁷ Prior reports have also provided empirical support for the construct validity and reliability of the RPLQ.^38
-40

Friendship quality

The Network of Relationships Inventory⁴¹ was used to examine child perceptions of friendship quality. The present study employed the Social Support scale which measures seven characteristics of friendship, namely reliable alliance, enhancement of worth, instrumental help, companionship, affection, and intimacy. The Satisfaction with Relationship scale was also used to assess the characteristic of enjoyment a child experiences in their friendship. On both scales, each item is rated on a 5-point Likert scale ranging from 1 (little or none) to 5 (the most). Higher scores are indicative of greater perceived friendship support and friendship satisfaction, respectively. Cronbach's alpha scores indicated that internal consistency for all scales was satisfactory.⁴¹

Self-esteem

The Harter Self Perception Profile for Children (HSPPC)⁴² is a self-report measure used to examine children's self-esteem across specific life domains. Of particular interest in the present study were subscales that tap into domains that tend to rely heavily on, or can be strongly influenced by, input from peers: social competence, behavioral conduct, athletic competence, and physical appearance. Each subscale comprises six items and each item has two opposite descriptions. Children are required to select the statement that best describes them, and whether the statement is “sort of true” or “really true” for them. Scores for each item range from 1-4, with higher scores reflecting better self-esteem for each subscale. Cronbach's alpha coefficients were found to be in the acceptable–excellent range for all subscales.⁴³ Construct validity has been evidenced by empirical support.⁴⁴ Convergent validity was additionally demonstrated by medium strength correlations with related measures of both global self-worth and domain-specific self-esteem.⁴⁴ The HSPPC has been used in children with chronic illnesses, including TBI.^13,44

Statistical analysis

Independent sample t-tests were conducted to compare groups (i.e., TBI vs. TD) on:

friendship quality;

peer-related loneliness; and

self-esteem domains at 12-months post-injury.

The effect of group membership (i.e., mild TBI vs. moderate-severe TBI vs. TD controls) on friendship quality (perceived support and satisfaction), peer-related loneliness, and self-esteem domains (social competence, behavioral conduct, athletic competence, and physical appearance) was examined using one-way analyses of variance and Tukey post hoc tests. An alpha level of p < 0.05 was used to indicate significance.

Mediation analyses were conducted for all TBI participants using PROCESS macro V3.4 for SPSS. Mediation in statistical literature is demonstrated by the indirect effect [i.e., the effect of the independent variable (X) on the dependent variable (Y) through the mediating variable (M)]. Conversely, direct effect is quantified as the effect of X on Y that is not mediated by M. The following effects were examined:

direct effects of friendship quality on peer-related loneliness, friendship quality on self-esteem domains, and peer-related loneliness on self-esteem domains; and

indirect effects of friendship quality on self-esteem domains as mediated by peer-related loneliness.

For each model predicting self-esteem outcomes, friendship quality was entered as an independent variable (friendship support, friendship satisfaction), and peer-related loneliness was entered simultaneously as a mediator of effects of friendship quality on self-esteem domains. PROCESS was conducted using model 4 and 5000 bootstrap resamples were used for estimation.⁴⁵ If the 95% confidence interval for indirect effects excluded 0, the effect was considered statistically significant.

Results

Sample attrition

The participating group at the 12-month time-point (n = 135) was compared with the non-participating group (n = 20) on several injury and socio-demographic variables: injury age, lowest GCS, duration of coma, sex, age at testing, family SES, and child intelligence quotient (IQ). No significant between group differences were found on these characteristics.

Sample characteristics

Demographic characteristics for all participants are displayed in Table 1. At the 12-month time-point, children with mild-severe TBI and TD children did not differ in terms of sex, age at study participation, time since injury, and pre-injury mental health. Significant between-group differences were found for family socio-economic status (SES) and child IQ; in comparison to the TD group, SES was lower for the moderate-severe TBI group. Child IQ was poorer for children with mild TBI and moderate-severe TBI, relative to TD controls. Since risk of sustaining a TBI is greater for children with lower IQ and SES backgrounds and controlling for elements intrinsic to a condition can result in misleading findings, we did not treat SES and child IQ as covariates in data analyses.⁴⁶

Table 1.

Demographic Characteristics of the Sample

	TDC	Mild TBI	Moderate-severe TBI	F/χ2(df)	p
Demographics
Sex (male), n (%)	24 (55.8)	41 (71.9)	21 (60.0)	3.03 (2)	0.219
Age at 12-month assessment (years)	10.79 (3.02)	11.39 (2.32)	11.40 (2.61)	0.78 (2,132)	0.461
Time post-TBI at 12-month assessment (months)	12.65 (1.04)	12.61 (1.01)	12.57 (1.59)	0.04 (2,132)	0.964
Pre-TBI child mental health (CBCL)	45.61 (7.23)	47.14 (10.93)	50.31 (8.94)	2.50 (2,132)	0.086
Socioeconomic status	76.75 (14.19)	68.35 (21.62)	62.10 (25.33)	4.97 (2,132)	0.008
Child IQ at 6-month testing (WASI)	106.35 (13.39)	99.90 (12.93)	94.63 (13.86)	7.60 (2,132)	< 0.001

Bold denotes statistical significance.

TDC: typically developing controls; TBI: traumatic brain injury; CBCL: Child Behavior Checklist; IQ, intelligence quotient; WASI: Wechsler

Abbreviated Intelligence Scale.

As expected, comparisons between mild and moderate-severe TBI groups revealed differences in lowest post-resuscitation GCS score and loss of consciousness (Table 2). In terms of mechanism of injury, falls/blows were most common among children with mild TBI, whereas motor vehicle accidents and falls/blows were equally common among children with moderate-severe TBI.

Table 2.

Injury Characteristics of the TBI Sample

	Mild TBI	Moderate-severe TBI	t/χ2(df)	p
Age at injury (years)	10.35 (2.33)	10.35 (2.60)	-0.00 (90)	0.999
Lowest GCS	14.47 (1.09)	9.74 (3.07)	8.78 (39)	< 0.001
Duration of coma, n (%)			10.70 (4)	0.016
None	27 (47.4)	7 (20.0)
< 5 min	21 (36.8)	22 (62.9)
> 5 min, <24 h	3 (5.3)	1 (2.9)
> 24 h	0 (0.0)	2 (5.7)
Unknown	6 (10.5)	3 (8.6)
Cause of injury, n (%)			21.65 (1)	< 0.001
MVA (passenger, cyclist, pedestrian)	3 (5.3)	16 (45.7)
Fall/blow	54 (94.7)	19 (54.3)

Bold denotes statistical significance.

TBI, traumatic brain injury; GCS, Glasgow Coma Scale; MVA: motor vehicle accident.

Group differences in self-esteem, friendship quality, and peer-related loneliness

At 12-months post-injury, the TBI group and TD controls did not differ significantly across subscales of domain-specific self-esteem (Supplementary Table S1). There was also no significant effect of group membership on these subscales nor on social variables, such that children with mild TBI, moderate-severe TBI, and TD controls had comparable ratings of: 1) self-esteem across social, behavioral, athletic, and physical domains; 2) friendship satisfaction and friendship support; and 3) peer-related loneliness (Table 3).

Table 3.

TBI Severity Effects on Child Ratings of Domain-Specific Self-Esteem, Friendship Quality, and Loneliness

	TDC	Mild TBI	Moderate-severe TBI	F(df)	p	η²
Self-esteem
HSPPC: Athletic Self-Esteem	3.21 (0.69)	3.34 (0.70)	3.36 (0.55)	0.64 (2,132)	0.527	0.010
HSPPC: Behavioral Self-Esteem	3.20 (0.63)	3.07 (0.63)	3.03 (0.80)	0.72 (2,132)	0.488	0.011
HSPPC: Social Self-Esteem	3.41 (0.48)	3.26 (0.58)	3.27 (0.57)	1.11 (2,132)	0.333	0.017
HSPPC: Physical Self-Esteem	3.28 (0.65)	3.25 (0.61)	3.15 (0.61)	0.46 (2,132)	0.634	0.007
Friendship quality
12-month NRI: Friendship Support	78.44 (13.86)	79.40 (14.91)	78.43 (15.84)	0.07 (2,132)	0.932	0.001
12-month NRI: Satisfaction with Friendship	13.23 (1.82)	13.16 (1.97)	12.91 (2.29)	0.26 (2,132)	0.772	0.004
Loneliness
12-month RPLQ: Loneliness with Peers	1.69 (0.55)	1.64 (0.51)	1.63 (0.48)	0.17 (2,132)	0.842	0.003

TDC, typically developing controls; TBI, traumatic brain injury; HSPPC, Harter's Self Perception Profile for Children; NRI, Network of Relationships Inventory; RPLQ, Relational Provisions Loneliness Questionnaire.

Relations among friendship quality and peer-related loneliness in children with TBI

In each model, the variable representing degree of social support from peers was significant, indicating that greater friendship support was associated with lower peer-related loneliness. Similarly, the variable representing degree of satisfaction with peer relations was significant for all models, indicating that higher levels of friendship satisfaction was associated with children feeling less alone in their peer group. The results from the mediation models are presented in Figure 1.

FIG. 1.

Direct effect pathways of friendship and mediator variables. (A) Direct effect of friendship variable on proposed mediator; (B) direct effect of mediator variable on self-esteem outcome; (C) direct effect of friendship variable on self-esteem outcome; *p < 0.05; **p < 0.01; ***p < 0.001.

Relations among peer-related loneliness and self-esteem domains in children with TBI

For both social and athletic self-esteem, the variable measuring peer-related loneliness was a significant predictor, suggesting that lower perceived loneliness was associated with more favorable perceptions of social and athletic competence in children with TBI. Effects of peer-related loneliness were not significant for behavioral nor physical self-esteem domains (Fig. 1).

Mediation analyses

In all models, a weak but significant indirect effect was found for friendship quality on social self-esteem (i.e., perceived social competence) via peer-related loneliness. Specifically, the effects of both perceived friendship support and perceived friendship satisfaction on child ratings of social competence were mediated by perceptions of loneliness (effect = 0.008, 95% confidence interval [CI] = 0.004, 0.012; effect = 0.047, 95% CI = 0.017, 0.079, respectively), such that greater friendship support and satisfaction predicted lower peer-related loneliness, which in turn predicted higher social self-esteem in children with TBI. Mediation effects were not significant for behavioral, athletic, and physical self-esteem domains (Table 4).

Table 4.

Indirect Effects of Friendship Quality on Domain-Specific Self-Esteem

		Indirect effects
	Effect	Lower CI	Upper CI
HSPPC Athletic Self-Esteem
Friendship Support	0.005	-0.001	0.010
Friendship Satisfaction	0.034	-0.003	0.075
HSPPC Behavioral Self-Esteem
Friendship Support	0.004	-0.000	0.001
Friendship Satisfaction	0.025	-0.004	0.064
HSPPC Social Self-Esteem
Friendship Support	0.008	0.004	0.012
Friendship Satisfaction	0.047	0.017	0.079
HSPPC Physical Self-Esteem
Friendship Support	0.000	-0.003	0.009
Friendship Satisfaction	-0.007	-0.034	0.022

Bold denotes significant indirect effects.

CI, confidence interval 95%; HSPPC, Harter Self-Perception Profile for Children.

Discussion

Despite growing literature documenting associations between pediatric TBI and reduced self-esteem, current evidence is weakened by methodological limitations, including over-reliance on measures which focus exclusively on global self-esteem. Research examining whether post-injury changes in self-esteem may be linked to friendship quality and peer-related loneliness and whether loneliness underlies the association between friendship quality and self-esteem is also lacking. To address significant gaps in existing literature, our study aimed to quantify the impact of TBI on friendship quality, loneliness, and various domains of self-esteem. Further, we sought to explore possible relationships between friendship quality and self-esteem domains, with the hypothesis that greater peer-related loneliness would mediate the effects of friendship quality on social, behavioral, athletic, and physical aspects of self-esteem in children with TBI.

Group comparisons of friendship quality, loneliness, and self-esteem

Although theoretical models used to predict childhood TBI outcomes suggest that self-esteem may be detrimentally impacted post-injury, we found no significant differences in self-esteem for social, athletic, behavioral, and physical domains among children with TBI and their TD counterparts. Lack of evidence for an association between childhood TBI and diminished self-esteem broadly converges with previous research where children with TBI and OI comparably rated their athletic ability, physical appearance, and social competence.¹³ Quality of limited existing literature, however, is weakened by recruitment of heterogenous injury and comparison groups. As such, results from our longitudinal research specifically comprising children with TBI extend previous findings and suggest that self-esteem domains strongly influenced by peer-related input remain intact one-year post-TBI. Replication is warranted by future studies, however, before any firm conclusions can be drawn.

Inter-relationships among friendship quality, loneliness, and self-esteem

In keeping with some,²³ but not all⁶ previous reports, there was no evidence for TBI-specific effects on measures of friendship quality, such that children with TBI rated their degree of support and satisfaction with friendships comparable to TD controls. Children with TBI also scored their peer-related loneliness similar to TD counterparts. These results might suggest that the nature and quality of peer relationships are not adversely impacted after pediatric TBI; however, given the current study reports on findings 12 months post-TBI, it is possible that children with TBI have yet to fully integrate back to school and may be appraising peer relations based on their pre-injury self, potentially contributing to over-estimations. Such inaccurate appraisals may be exacerbated by poorer insight/awareness post-injury.⁴⁷ Relatedly, perhaps group differences in friendship quality and perceived loneliness might become apparent in the longer term as children with TBI “grow into” cognitive deficits over time. The full impact of these cognitive difficulties on psycho-social function might not be evident at the 12-month time-point.

Consistent with expectations and the “belongingness hypothesis,” ³⁰ both greater friendship support and friendship satisfaction were associated with lower peer-related loneliness. While previous developmental research ^28,29 has shown that friendship quality contributes to children's experiences of social isolation, to our knowledge, these associations have rarely been examined in child TBI samples. In addressing this gap, results of the current study provide preliminary evidence to suggest that efforts to improve friendship quality might represent a promising target for mitigating risk of peer-related loneliness.

Partially consistent with our hypotheses, greater peer-related loneliness was associated with reduced self-esteem for athletic and social domains, but not physical and behavioral domains. These findings are broadly consistent with previous studies where children with disabilities were more susceptible to low self-esteem if they felt isolated from their peers.²⁰ Our current results, specific to the childhood TBI context, extend these findings and lend support to theoretical propositions¹⁹ that self-esteem may diminish if children feel disconnected from social groups. These results further suggest that children with TBI who experience social isolation may be particularly susceptible to reductions in self-esteem for specific domains.

As predicted, mediator models revealed significant indirect effects of friendship quality on children's self-esteem as measured using the HSPPC. Specifically, peer-related loneliness mediated the effect of both friendship support and friendship satisfaction on child-rated social self-esteem. There was, however, no significant indirect effect of friendship quality variables on broader domains of children's self-esteem. Taken together, these findings suggest that for children who sustain a TBI, having poorer quality friendships may elevate risk for poorer self-esteem as it relates to perceived social competence, particularly if they experience social isolation. In other words, peer-related loneliness is one possible factor that links poorer friendship quality to reduced social self-esteem. Additional research is needed to identify other factors that might contribute to self-esteem problems in children with TBI, especially in the context of physical, athletic, and behavioral self-esteem.

Implications

Our findings align with the HMSC framework, which posits that children's self-esteem may be impacted by a variety of environmental factors, including the nature of their social interactions with peers. Broadly consistent with the assumptions of this model, results from the current study provide support for the effects of social relational variables on children's self-esteem after TBI. Present findings also converge with the sociometer theory which emphasizes the influential role of perceived social acceptance and relational value for children's self-worth. From a clinical perspective, our findings highlight the importance of regular monitoring to optimize recovery and outcomes after pediatric TBI. As such, evidence for associations between poorer friendship quality and increased loneliness, as well as greater isolation and reduced self-esteem, suggest that routine screening of social dysfunction and peer relations might be useful for identifying children who could benefit from the provision of targeted interventions to mitigate risk for such difficulties. Preliminary studies have reported on the effectiveness of social interventions for improving social participation ⁴⁸ and relational skills ⁴⁹ for adolescents with acquired brain injuries; however, less is known about the utility of such interventions for children with TBI specifically.

Limitations and future directions

Despite being one of the first longitudinal prospective studies to examine inter-relationships between peer-related variables and children's self-esteem across a variety of life domains, there are several notable limitations. Given we only examined cross-sectional associations from a single time-point, we cannot infer causal relations between variables of interest. Secondly, despite the relatively large sample size, we cannot rule out the possibility that our analyses were slightly underpowered to detect significant group differences. We also exclusively employed child-rated measures to examine peer relations and self-esteem outcomes. While this methodology allows for consideration of children's own perspectives of their functioning, it is possible this approach introduces bias, particularly since children might have reduced insight into their difficulties post-TBI. Future studies might benefit by incorporating assessment measures which tap into perspectives of multiple informants, including parents, friends, and teachers. Including direct assessment techniques, such as home and classroom observations,^15,50 might also prove useful for comprehensively examining children's social interactions and self-esteem.

Another caveat relates to the age group of our participants, comprising primarily of children and younger adolescents. Given self-esteem continues to develop into early adulthood, and late adolescence in particular represents a period of increased peer-related influence on self-representations,^51,52 it could be worthwhile to recruit older participants in further replication studies. We further acknowledge that participants with mild and moderate TBI represented that majority of our TBI group. Future research should consider recruiting a larger sample of children who sustained more severe injuries to improve generalizability of findings.

Conclusion

This longitudinal, prospective study is one of few to examine inter-relationships between friendship quality, peer-related loneliness, and children's self-esteem outcomes 12 months post-TBI. Preliminary results from our TBI sample show that poorer friendship quality is linked to greater peer-related loneliness, which in turn contributes to reduced self-esteem in both the social and athletic domains. Importantly, child ratings of peer-related loneliness mediated the effects of both friendship satisfaction and friendship support on children's social self-esteem, suggesting that experiencing social isolation might represent one possible factor that helps explain the relationship between poorer friendship quality and lower perceived social competence. Routine monitoring and evaluation of children's social interactions, including nature and extent of integration with peer groups, may help identify children who are likely to benefit from rehabilitation programs specifically targeting social isolation post-TBI. This may in turn mitigate risk of reduced self-esteem for athletic and social domains.

Footnotes

Transparency,Rigor,and Reproducibility Summary

A total sample size of 144 participants was planned based on a medium Cohen's f effect size for the primary outcome measures, calculated to yield 90% power to detect significant differences using analyses of variance with a p value <0.05. A total of 139 children and families participated in the 12-month follow-up, and primary measurements were completed by and analyzed for 135: 92 children and adolescents with traumatic brain injury (82.14% of the original sample) and 43 typically developing controls (100% of the original sample). Participants were provided with a summary of their results after the assessments were complete. Data collection was performed by investigators blinded to participant characteristics such as pre-defined group membership (e.g., TBI vs. control, injury severity category). Data analyses were conducted by team members who were aware of relevant injury and demographic characteristics of the sample, but not personally identifiable information. All participants were recruited between 2007 and 2010. Data collection occurred over multiple longitudinal time-points (acute, 6-, 12-, and 24-months post-injury) and ceased in 2013. Surveys and software used to acquire and analyze data are widely available online and can also be made available upon request from the authors. The key inclusion criteria for TBI participants and primary outcome measures employed are in keeping with established standards. Assumptions of parametric analyses were assessed, and statistical review was performed by study statistician, Stephen Hearps. Replication by the study group is undergoing planning. Consistent with institutional ethics requirements, the study data are stored on the institute's research repository and access is available with consultation from the senior author, Vicki Anderson. There is no analytic code associated with this study. The authors agree to provide the full content of this manuscript on request by contacting the corresponding author, Noor Khan.

Ethical Standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Acknowledgments

The authors wish to acknowledge all children and families who participated in the study.

Authors' Contributions

All authors have participated in the concept and design; analysis and interpretation of data; and drafting of the manuscript.

Funding Information

This work was supported by a grant from the Victoria Neurotrauma Initiative (CO6E1), Australia, a NHMRC Practitioner Fellowship (to V.A.), and the Victorian Operational Infrastructure Scheme. The funding bodies did not play a role in the design of the study, analysis, interpretation of the data, or writing of the manuscript.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Table S1

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