Friendship changes following a friend’s school absence after serious illness or injury

Abstract

Social support is vital in helping adolescents cope following a serious illness or injury, though it is not known how their healthy peers react to potential changes in the nature of their friendships during this time. In this questionnaire-based study, emerging adults in the community indicated whether they had an experience with a friend’s serious illness during adolescence and responded to structured and open-ended questions about their experience. Participants reported diminished contact with friends following diagnosis, such as decreased frequency of visits and communication. Participants most commonly cited logistical issues, such as transportation, and their friend’s emotional and/or physical functioning as barriers to staying connected. Friends reported a mixture of positive and negative experiences associated with a friend’s illness. The communication barriers highlighted provide a potential focus for intervention. Results suggest positive communication promotion with healthy friends may be an important path to enhance social support after a serious illness diagnosis or injury.

Keywords

Friendship pediatric serious illness social support

Introduction

Between 7% and 31% of children and adolescents are living with a chronic illness (Denny et al., 2014). The definition of a chronic illness varies throughout the literature; however, the majority of studies consider a chronic illness as an illness that lasts longer than three months (van der Lee et al., 2007). For the purposes of the current study, a serious illness is considered any illness or chronic condition that requires a significant absence from school and other activities for a minimum of two weeks. Adolescents with serious illnesses are at increased risk for negative psychological effects (e.g. Patenaude and Kupst, 2005, Taylor et al., 2008), including greater depression symptomology, poorer improvement in depressive symptoms (Ferro et al., 2014), and diminished health-related quality of life (HRQoL) (e.g. Northam et al., 2010; Rueger et al., 2016). Adolescents with serious illnesses also report difficulties in multiple areas including school activities (Decker, 2007; Skucek et al., 2011; Taylor et al., 2008), extracurricular activities (Denny et al., 2014), and social relationships (Northam et al., 2010; Taylor et al., 2008). Relative to healthy peers, adolescents with serious physical and mental illnesses are less likely to graduate high school, more likely to be un- or underemployed (Davis and Vander Stoep, 1997; Maslow et al., 2011), more likely to experience sleep problems (Sivertsen et al., 2009; Valrie et al., 2013), and more likely to engage in risky behaviors (Sawyer et al., 2007).

Friendships are important to overall HRQoL in many childhood illnesses including cancer (Decker, 2007), type 1 diabetes (Helms et al., 2015; La Greca, 1992), cystic fibrosis (Christain and D’Auria, 2006), chronic kidney disease (Kiliś-Pstrusińska et al., 2013), and depression (Rueger et al., 2016). The impact of serious illnesses on social relationships during adolescence co-occurs with the increasing importance of friendships during this developmental period (Helgeson et al., 2015; La Greca et al., 2002; Waldrip et al., 2008). For typical adolescents, higher quality friendships and greater peer acceptance are associated with positive adjustment to changes that occur during this time (Waldrip et al., 2008). Same-aged friendships can lessen the impact of stressors associated with adjustment to recent diagnoses and treatment regimens (Helms et al., 2015; La Greca et al., 2002). Friendship and mentorship from other adolescents with serious illnesses can provide more nuanced emotional support and understanding (Forgeron et al., 2015; Kohut et al., 2018). Despite these benefits, friendships are consistently identified as a concern of adolescents across illnesses (McMaugh, 2011; Taylor et al., 2008).

Most work examining social support is done from the perspective of the individual or parents, or compares the functioning of healthy peers to those with serious illnesses (e.g. Maslow et al., 2011). Little information has been gathered from peers regarding their experiences with a friend’s illness (e.g. Ellerton et al., 1996). Peer perspectives have largely been assessed using sociometric measures in a school setting to examine general classroom views on the ill child (e.g. Noll et al., 1999, 2010). However, it is necessary to understand the healthy friend’s perspective on specific friendship changes that may occur. Identification of potential areas of friendship challenges and changes from this perspective can provide important information regarding maintenance of positive friendships.

Research on friendship in the context of serious illness generally focuses on one disease populations (e.g. Helms et al., 2015; Noll et al., 2010). In contrast, Stein and Jessop (1982) have argued for a non-categorical approach to the psychosocial treatment of children and adolescents with chronic illnesses, arguing that children with diverse conditions have more similarities than differences. In a review of the literature, Sawyer and colleagues (2007) argue that examining chronic illnesses within a specific disease group (e.g. type 1 diabetes, cancer) limits the field’s understanding of the global impact on HRQoL. Sawyer and colleagues also argue that, across disease groups, there are similar psychosocial challenges, and maintaining a disease-specific orientation minimizes the efficiency with which professionals can identify solutions to common challenges (Sawyer et al., 2007).

With greater understanding of the general impact of serious illnesses upon HRQol (Sawyer et al., 2007; Stein and Jessop, 1982), it may be beneficial to include adolescents with serious mental health diagnoses in studies of the psychosocial impact of illnesses. For example, anorexia nervosa often requires lengthy hospitalizations and full recovery typically takes at least several months, often a year or longer (Keski-Rahkonen et al., 2007), not unlike many serious medical illnesses. Due to the similar psychosocial burden of mental health diagnoses and their chronicity, the current study included chronic mental health diagnoses in the definition of a serious illness.

The purpose of this study was to understand friendship changes associated with serious illnesses during adolescence as identified by healthy peers. To the authors’ knowledge, no work to date examines these relationships from the perspective of the friend without a serious illness. Due to the novelty of examining reactions within this population, the current study utilized a mixed-methods design to gain richer insight into the experiences and challenges faced by adolescents who are seeking to maintain a friendship with someone with a serious illness. Furthermore, the current study includes friends of adolescents with mental illnesses as well, due to the likelihood that their experiences are highly similar to friends of adolescents with physical illnesses (e.g. Sawyer et al., 2007). This study explored potential patterns in friend responses by illness category, such as physical illness, physical injury, and mental illness, in order to identify potential differences between illness/injury types. It was hypothesized that there would be similar patterns of responses across illness categories, supporting Stein and Jessop’s (1982) non-categorical approach.

Method

Participants

A community sample of emerging adults (ages 18–25) was recruited over three university semesters: Fall 2015, Spring 2016, and Fall 2016. The sample had a mean age of 21.5 years (SD = 1.79) and 57% of respondents identified as female. The majority of respondents were White (79.5%), with 4.9% identifying as African American, and 4.9% Latinx. See Table 1 for full demographic characteristics.

Table 1.

Participant demographics.

Variable	N (205)	Percentage (%)
Gender
Female	117	57.1
Male	86	42.0
Other	1	<1%
Missing	1	<1%
Student status
Full-time college student	114	55.6
Nonstudent	68	33.2
Part-time college student	15	7.3
High school student	6	3.9
Race/ethnicity
Caucasian (non-Hispanic)	162	79.0
Mixed	12	5.9
African American	10	4.9
Latinx	10	4.9
Asian	5	2.4
Native American	3	1.5

Procedure

The Institutional Review Board at a large Midwestern University in the United States approved the current method and design as part of a larger study. Students enrolled in an upper-level university course recruited adults aged 18–25 years from the community to complete an online survey via SurveyMonkey.com. Students involved in recruitment completed training in the ethical conduct of research. These students identified potential participants and provided them with written information regarding the study, including the elements of informed consent. Potential participants were then provided with a link to the survey. All participants who accessed the online survey were required to indicate that they were 18 years old or older, participated voluntarily, and understood that the student who recruited them would not be penalized should they choose not to participate. Once participants completed the survey, they were encouraged to identify other eligible participants and share the study information. Those who reported having a friend who missed at least two weeks of school in middle school or high school due to a serious illness or injury met criteria for and were included in this study. A two-week period of hospitalization and/or removal from school was used as the criteria for a serious condition to ensure a heightened level of severity while still being inclusive of a variety of different types of illnesses and injuries. The two-week requirement was also used to make it easier for participants to identify a friend who had received a chronic condition diagnosis and recall their experience.

Measures

Participants provided basic demographic information, such as student status, ethnicity, gender, age, and education level. Participants who identified a friend with a serious illness completed a measure about their friend and his/her illness. The authors created a 14-item measure using literature outlining specific issues concerning friendships in chronically ill populations (e.g. Decker, 2007; Ellerton et al., 1996; Helgeson and Holmbeck, 2015; La Greca, 1992; Taylor et al., 2008). For full copy of the measure, refer to the Online Supplemental Figure. Participants indicated their friend’s gender, their own age when their friend was ill or injured, and the nature of the illness or injury. Participants answered four quantitative items on how often they were in contact either in person or via remote forms of communication (i.e. talking on phone, text, social media) with this friend before and after the injury on a Likert-type scale from 1 to 5 (Online Supplemental Figure). Participants also responded to 10 items about their relationship with this particular friend before and after the injury/illness. Participants responded to items asking whether they felt that their relationship with this friend changed after the illness/injury and whether they visited this friend while they were ill or recovering. Individuals who reported not visiting their friend were prompted to provide further detail in response in an open-ended question. Further, all participants answered open-ended questions regarding any challenges to maintaining the friendship, their experiencing talking to their friend about the illness/injury, and their understanding of their friend’s experience.

Data analysis

Descriptive statistics characterized the sample and frequency of responses. Qualitative items were analyzed using a Delphi method (Dalkey, 1972; Holey et al., 2007; Jones and Hunter, 1995). Members of the research team read all responses to an item and independently generated a list of possible themes. The team discussed the identified themes and came to group consensus. Team members then independently categorized all responses into the consensus themes. Items with less than majority agreement were discussed by the group until consensus was reached. Following discussion, agreement for individual themes ranged from 85% to 100%. Paired sample t-tests were used to examine the differences in time spent and frequency of contact before and after diagnoses.

Using coded qualitative data, χ² tests of independence were run to examine differences in coded response frequency between the three illness/injury categories for each coded response within each question. For example, differences across illness category were assessed among all participants who indicated that their friendship had not changed following the illness/injury. Differences among those who indicated there was a ‘negative change’ on this same question were analyzed as well. If there was found to be a significant χ² using all three illness categories, additional χ² analyses were run with just two of the three illness categories included (e.g. physical illness and physical injury), comparing each illness category to one other category individually. In order to determine a potential significant difference in response rate by illness category and gender, χ² tests of independence were used.

Results

Descriptive statistics

Two hundred and five emerging adults (18%) reported an experience with a friend diagnosed with a serious illness between the ages of 10 and 18. The average age of onset for the friend’s illness was 15.0 years (SD = 2.10). Forty-five percent reported their friend was diagnosed with a physical illness (e.g. cancer), 33% reported a mental health diagnosis (e.g. depression), and 19% reported a physical injury (e.g. concussion). Three percent reported a friend with a serious illness, but did not specify the diagnosis. See Table 2 for reported diagnoses.

Table 2.

Reported chronic illness or serious illness diagnoses.

Variable	N (205)	Percentage (%)
Physical Illness	92	44.9
Cancer	36	17.6
Infectious mononucleosis	8	3.9
Diabetes	6	2.9
Lyme disease	5	2.4
Bleeding disorder	4	2.0
Autoimmune disease	4	2.0
Arthritis	3	1.5
Chronic fatigue	3	1.5
Heart condition	3	1.5
Pneumonia	3	1.5
Seizure disorder	3	1.5
Severe infection	3	1.5
Kidney infection	3	1.5
Gastrointestinal disorder	2	1
Cystic fibrosis	1	<1
Neurological condition	1	<1
Meningitis	1	<1
Migraines	1	<1
Pancreatitis	1	<1
Ovarian cysts	1	<1
Mental health diagnosis	68	33.2
Severe depression	40	20
Eating disorder	23	11
Comorbid diagnoses	2	1.5
Anxiety	1	<1
Drug addiction	1	<1
Schizophrenia	1	<1
Physical injury	38	18.5
Traumatic brain injury	22	11
Motor vehicle accident	8	3.9
Broken neck/back	2	1.5
Multiple broken bones	2	1.5
Limb amputation	2	1.5
Hip injury	1	<1
Severe burns	1	<1
Illness/injury not specified	7	3.4

Qualitative results

Frequency of each category can be found in Online Supplemental Table 1. Original responses often contained written errors in spelling, punctuation, and syntax. Quotes have been edited for clarity. For additional representative responses, see Online Supplemental Table 2.

Friendship changes

When asked if the friendship changed after the illness/injury, the majority of participants reported no change in friendship. Approximately half of respondents answered ‘no’. Other respondents reported negative friendship changes, a stronger friendship after diagnosis or injury, provided a self-reflective statement, reported feeling unsure, or indicated the friend died post-diagnosis.

Of respondents who indicated some change, most reported a negative change. These responses primarily indicated less contact with the friend, such as, ‘They never were around anymore so it was harder to connect’, or ‘less contact’. A few participants indicated negative changes because of the friend’s change in behavior or emotions, and fewer participants indicated negative changes due to both the friend’s behavior changes and less contact. Conversely, several participants reported a stronger friendship post-diagnosis/injury. This was coded when the responses indicated a closer friendship, more time spent together, and/or a more meaningful connection with the friend. For example, ‘We became closer because I was always there for her’.

A smaller portion of participants provided a statement that indicated an evaluation of personal values. One respondent reported feeling unsure how to help the friend; they wrote, ‘It was hard to know how to be helpful/supportive’. Finally, a few participants indicated a change in relationship because the friend died shortly after diagnosis/injury.

Visiting the friend

When asked if they visited the friend in the hospital or at home, half reported not visiting. Participants reported not visiting because they were unable to, did not feel they were good enough friends, the friend did not want visitors, or the friend died. Participants who did visit the friend reported a range of positive and negative experiences.

Of those participants who did not visit their friend, most reported they were unable to visit due to logistics, or hospital staff or family limitations. The majority of these responses included a statement of inability to visit because of lack of opportunity or transportation. One participant responded, ‘No way to go see them’. Others wrote about the inability to see their friend due to restrictions, one participant wrote, ‘she wasn’t allowed to have visitors’. Finally, few participants expressed an inability to visit because of personal concerns such as risk of exposure to the illness (e.g. ‘it was contagious’) or personal emotional concerns (e.g. ‘I was scared’).

Numerous participants reported feeling that they were not close enough friends to visit. A smaller portion of participants stated that their friend didn’t want visitors. Finally, a small number of participants reported that the friend died as a result of the illness/injury.

Of the participants who reported visiting their friend, several participants provided a response indicating either a negative experience while visiting, or negative emotions associated with the visit (e.g. sad, upset, worried, or overwhelmed). Conversely, many participants provided a response indicating a positive experience associated with the visit (e.g. feeling glad to see them), feeling the visit was ‘normal’, and/or describing how they supported the friend.

Additionally, some participants gave a response indicating they either visited their friend in their home or at the hospital. The majority of these responses were included within a positive or negative experience response and explicitly stated where they visited the friend. For example, one participant wrote about where they visited the friend and the positive experience of supporting their friend: ‘Yes, her home. Her mother passed away so we often got together. I remember just being there for her, if she wanted to cry I’d let her get it out. I’d aim to make her laugh as much as I could’.

Challenges to maintaining the friendship

These responses included indications of no challenges, communication challenges, emotional challenges, and challenges associated with changes in the friend’s functioning. Several participants also described no challenges maintaining the friendship after the diagnosis. Most simply wrote, ‘none’ or ‘no challenges’, and a few gave explanations. The majority of participants (70%) who indicated that there were no challenges to the friendship also indicated that there were no changes to the friendship. Notably, several participants reported challenges to the friendship despite responding that there were no changes previously, which may indicate the challenges had no or little impact on the friendship. The most common responses indicated communication challenges. These responses included challenges with keeping in contact with the friend, not seeing the friend at school anymore, or not being able to visit the friend. For instance, ‘It was hard to keep up contact when she couldn’t respond and it made me feel like it wasn’t helping at all’.

Many participants described their friend’s emotional challenges as barriers, responses included indication of emotional distancing, withdrawal from peers, and/or depressive symptoms. For example, one respondent described their friend as ‘secretive and distant’. A few participants indicated both communication challenges and the friend’s emotional challenges. For example, ‘Loss of contact, enthusiasm for once loved activities, etc. really brings you as a friend down too because when you’re younger there’s only so much you can do to help’.

Finally, participants reported that their friend’s change in physical functioning and ability to engage in activities made maintaining the friendship difficult. One respondent’s especially descriptive response about his struggles with a friend after his diagnosis read:

Well. He was sluggish, less energetic. I had to often force us to get out and go do things. It was difficult to get to him to eat sometimes and there were times I couldn’t be around him. He was draining. But he is my longest best friend, and I still tried no matter what.

Discussion of the illness/injury

When asked if they discussed their friend’s illness, participants reported never discussing it, a positive experience, or a negative experience. The most common response was never discussing their friend’s illness or injury. Many participants simply responded ‘no’, and few explained their answer. Fewer participants reported having a limited discussion with the friend. These responses included indications that they rarely talked to the friend, infrequently talked about particular aspects, or only discussed the diagnosis only a few times. Most of these responses indicated infrequent discussions. For example, one participant wrote, ‘I only talked to them about it if they brought it up to me’.

More participants indicated positive feelings and/or experiences about the discussion regarding the illness than a negative experience. These responses indicated that the conversation helped them understand what their friend was going through (e.g. ‘it was helpful’, ‘comforting’), it felt good to discuss things, it was like any other conversation (e.g. ‘it was normal’), and/or they were glad to be able to discuss things. On the other hand, some participants indicated negative feelings and/or a negative experience. These responses included the participants feeling uncomfortable or awkward, sad, and/or feeling bad for their friend. One participant simply wrote, ‘sad’. Other negative responses included an indication that it was a difficult conversation. A few participants just wrote, ‘difficult’, and one wrote, ‘tough’.

Understanding the friend’s experience

When participants were asked if they understood what their friend was going through after their diagnosis, participants reported that they didn’t understand, somewhat understood, did understand, couldn’t understand, and/or expressed empathy for their friend’s experience. The most likely response was participants reporting that they did not understand, with most writing simply, ‘no’, ‘not really’, or ‘probably not’. Several respondents also expressed that they could never completely understand because they had never been in that situation before.

Many participants reported they did understand and many gave explanations as to why, most having to do with personal experiences. An exemplary response was, ‘Yes, completely. Depression can be brought on by many things. I’ve had it since 12. So I know all the ups and downs’. A smaller percentage reported they somewhat understood. Several participants specifically used the word ‘somewhat’, while others explained using the phrase, ‘yes and no’.

A few participants provided an empathetic response, often in addition to reporting their level of understanding. These responses indicated sympathy for the friend. For example, one respondent wrote, ‘No, but I was empathetic’. Finally, few participants reported that they tried to understand without indicating whether they did actually understand.

Quantitative results

A paired sample t-test demonstrated a significant difference between participants’ reported time spent with the friend before (n = 203; M = 2.76, SD = 1.33) and after diagnosis (n = 203; M = 2.36, SD = 1.27; t(201) = 5.75, p < .01), with participants reporting less time spent with their friend after diagnosis or injury. Additionally, participants reported significantly less contact with their friend after (n = 202; M = 2.69, SD = 1.45) than before the diagnosis (n = 202; M = 3.06, SD = 1.39; t(200) = 4.73, p < .01).

χ² tests identified no significant difference in time spent with friends before or after diagnosis by illness category or gender. Regarding changes to friendship after the illness/injury, there was a significant difference between illness categories when participants reported a stronger friendship post-diagnosis (n = 201; χ² = 8.37, p < .05; η =.16). Participants with a friend diagnosed with a mental illness were significantly more likely to report a stronger friendship compared to participants with a friend with a physical injury (n = 102; χ² = 5.32, p < .05) and a physical illness (n = 161; χ² = 5.32, p < .05). There was no significant difference between participants with a friend with a physical illness and those with a friend with physical injury (n = 137; χ² = 0.62, p = .43).

In responses to the questions regarding visitation, there was a significant difference by illness category for those friends who did not visit (n = 201; χ² = 7.74, p < .05; η = .14). Participants with a friend diagnosed with a mental illness were significantly less likely to visit their friend compared to participants with a friend with a physical injury (n = 103; χ² = 6.64, p < .05) and physical illness (n = 161; χ² = 4.75, p < .05). There was no significant difference between the physical injury and the physical illness categories (n = 138; χ² = 0.82, p = .37).

Additionally, participants with a friend with a mental health diagnosis most often answered that their friend did not want visitors, resulting in a significant difference between the illness categories (n = 97; χ² = 10.0, p < .01; η = .27). Participants with a friend diagnosed with mental health illness were significantly more likely to report that their friend did not want visitors compared to friends with a physical injury (n = 52; χ² = 5.02, p < .05) and physical illness (n = 82; χ² = 6.31, p < .05). There was no significant difference between the physical illness and physical injury categories (n = 60; χ² = 1.05, p = .31).

Regarding challenges after diagnosis/injury, there was a significant difference between illness categories when participants reported that their friend’s emotional challenges created difficulty within the friendship (n = 150; χ² = 29.54, p < .01; η = .16). Participants with a friend with mental health diagnoses were significantly more likely to report challenges due to a friend’s emotional challenges compared to friends with a physical injury (n = 75; χ² = 7.74, p < .01) and physical illness (n = 120; χ² = 4.49, p < .05). There was no significant difference between the physical illness and physical injury categories (n = 105; χ² = 2.29, p = .13). There were no other significant differences between illness categories in response rate to free-response questions. Notably, there were no meaningful significant gender differences of participant qualitative responses including no significant gender differences within each illness category.

Discussion

Within the current sample, emerging adults tended to report diminished contact following the friend’s serious illness during adolescence. Participants identified several barriers to maintaining contact, including lack of communication and their friend’s emotional and/or physical functioning. Lack of communication most often involved loss of contact with the friend post-diagnosis/injury and/or difficulty maintaining contact via phone (i.e. friend responded to text messages less often). Commonly, when participants reported communication challenges they cited difficulty maintaining contact due to the friend not being present for school and other social activities. These data reinforce the concerns adolescents with serious illnesses have expressed in previous studies regarding feelings of isolation and lack of communication with peers (Taylor et al., 2008). Participants also reported little communication regarding the illness and reported a mixture of positive and negative experiences associated with visiting their friend. Overall, friends reported the most difficulty maintaining communication with the friend including less contact in person and via phone and negative experiences discussing the illness. Specifically, participants most often reported minimal discussion about their friend’s experience and when there was discussion some participants reported emotional difficulty with the discussion.

Some participants reported a closer friendship post-diagnosis or injury, with many of these participants describing a more meaningful relationship, particularly those with a friend diagnosed with a mental illness. These same participants were also more likely to report the friend’s emotional distancing behavior and/or the friend’s other emotional challenges (e.g. secretive, depressive symptoms). Potentially, mental health diagnoses may be especially polarizing, creating emotional-laden scenarios and an atmosphere of potential friendship growth. Positive friendship changes may reflect a type of post-traumatic growth, often seen in adolescents after trauma exposure (Waters et al., 2013). In contrast to these reports of deeper relationships, friends of those with a mental health diagnosis were less likely to visit, which may reflect typical family-only restrictions observed in mental health residential programs (Robst et al., 2012) and/or the stigma that continues to surround mental health diagnoses (Jorm et al., 2005). It is possible that those friends with a mental health diagnosis are better able to engage in physical activities post-intensive treatment (i.e. residential or intensive outpatient treatment), while friends with physical illness diagnoses/injuries may have lasting physical restrictions. This continuation of ‘normal’ activities for those with mental health diagnosis may lessen the impact of reduced contact during residential or intensive outpatient treatments.

The results suggest some differences between illness categories, specifically participants with friends diagnosed with a mental illness were more likely to report stronger friendships and to identify their friend’s emotional challenges, less likely to visit friends, and that their friends were less likely to want visitors during treatment. Despite finding some differences between categories, there were several similarities as well. Participants across categories cited concerns regarding loss of contact, challenges with communication about the illness/injury, and difficulty understanding their friend’s experience. With more similarities than differences, this study provides partial support for the non-categorical approach to treatment of adolescents with various illness (Sawyer et al., 2007; Stein and Jessop, 1982), specifically related to common difficulties with peer contact and communication. However, the conclusions from this study are limited to the range of illnesses within each category. Future research should examine friendship changes between illnesses within each category.

Future research should examine friendship changes as a function of the healthy friend’s personality type and age of onset of a friend’s diagnosis. There may be particular individuals more likely to provide meaningful social support. For example, more empathetic children may be more likely to provide support, and this may result in a closer, more meaningful friendship. Further, positive friendship changes may be more likely when a diagnosis or injury occurs at a particular age.

Although the importance of social support after a chronic illness diagnosis is well known (e.g. Rueger et al., 2016; Taylor et al., 2008), the friends’ reports of difficulties maintaining friendships is concerning. The communication barriers highlighted in these results provide an important area of further investigation and intervention. Promotion of communication with healthy friends after diagnosis could help with enhancing social support. This could mitigate some of the impact of a diagnosis during adolescence. A simple intervention, such as a standardized message to a friend following a serious diagnosis/injury, could facilitate continued communication and address concerns regarding lack of understanding about the illness. Such a message could be tailored to the specific individual and their illness/injury experience with the help of professionals such as social workers, child life specialists, and/or psychologists. Additionally, a standardized message could be used to communicate via social media with one or multiple friends in order to share their experience and reach out to friends when there is loss of contact and communication during treatment and/or recovery. Furthermore, this simple message could work as a catalyst to positive discussions surrounding the illness. Other psychosocial interventions involving adolescents with chronic illnesses that target socialization have demonstrated decreased peer problems and increased social acceptance (for full review, see Forgeron et al., 2017).

Limitations

Although this study is one of the first to characterize friendship changes associated with a serious illness in older childhood and adolescence, it is not without limitations. The current sample is largely Caucasian, limiting the potential for generalization to the more ethnically and socioeconomically diverse serious illness population. The participants retrospectively reported changes that occurred several years earlier, which may create a recall bias in responses. The survey did not ask participants for their perceived level of friendship. Specifically, different types of friendships (i.e. best friends, romantic partners) may foster different challenges and changes post-diagnosis. The two-week criteria allowed the researchers to capture a wide array of illnesses, but may have limited diagnosis specificity. Challenges could look different for friends out of school for a few weeks versus several months. Additionally, the operational definition for serious illness used in the current study included both acute and chronic illnesses which may have impacted response patterns. Future research should prospectively gather information from both a recently diagnosed adolescent and an identified friend, follow the progression of this friendship throughout a portion of treatment to capture a more complete picture of the experience, and assess perceived level of friendship.

Conclusion

A significant portion of children and adolescents with a serious illness experience negative effects on HRQoL (e.g. Rueger et al., 2016; Taylor et al., 2008); however, social support can mitigate some of these effects (e.g. McMaugh, 2011), and promote positive health behaviors (La Greca et al., 2002). The current study is the only study to investigate friendships and related challenges during late childhood and adolescence after a serious illness diagnosis or injury from a friend’s perspective. This investigation suggests that promoting communication to enhance social support is a potential area of intervention. Additionally, it may be important to provide friends with adequate information about the illness/injury, how to communicate with their friend about their illness/injury experience, and how to approach communication either in person, via phone or social media.

Supplemental Material

Supplemental_Table._Measure - Friendship changes following a friend’s school absence after serious illness or injury

Supplemental_Table._Measure for Friendship changes following a friend’s school absence after serious illness or injury by Eva C Igler, Ellen KD Sejkora, Jillian E Austin and W Hobart Davies in Journal of Child Health Care

Footnotes

Authors’ Note

Jillian E Austin is now affiliated to Nemour’s Children’s Specialty Care. Ellen KD Sejkora is now affiliated to Nationwide Children’s Hospital.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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