The Importance of Friends

Psychiatric TimesPsychiatric Times Vol 29 No 11
Volume 29
Issue 11

It is important for clinicians to address the issue of friendships when evaluating and treating children. Parents should be apprised about the critical need for a best friend or friends for their children.

Harry Stack Sullivan1 had it right about the importance of interpersonal relationships. In 1953, he wrote about the need for a chum or a close friend for children.

A chum teaches about the reciprocity of relationships and fosters sensitivity to the needs of another person. The child learns what to do to contribute to the happiness and worthwhileness of his or her chum. Moreover, a chum provides validation of self-worth.

In my clinical practice, I often see children who have no friends. Most of these children want to have a friend, but they have been unsuccessful in forming a close friendship. They spend a lot of time at home on weekends with no interaction with age-mates. Family time can fill some of the void for these children, but it does not meet the same needs that are fulfilled by having a close friend. I can treat their depression or anxiety with medication and psychotherapy, but I cannot provide a friend for them. I find myself thinking, “Just one, if he had just one friend . . .”

With the start of a new school year, the issue of friendships becomes more acute. Many of these youths speak of their dread of going to school because they have no one to talk to and they believe that no one likes them. Lunchtime and recess can be particularly distressing because they have no one to sit with at lunch and no one to interact with during recess. One teenager spent the entire lunch period in the girls’ bathroom so that she did not have to eat by herself in the cafeteria.

Some teenagers have asked their parents that they be allowed to be homeschooled or to complete high school online because the school setting is too stressful for them. Frequently, parents accommodate this request despite my recommendation that the teenager remain in school. Isolation from peers limits a teenager’s capacity to improve the social skills needed to foster friendships. However, parents want to immediately reduce their teenager’s stress, which is understandable.

Adams and colleagues2 recently undertook an intriguing study to examine the role of a best friend in protecting against the effect of negative experiences. The study was made up of 103 public school fifth and sixth graders. Over 4 consecutive school days, students completed booklets 5 times a day. The students were instructed to write in the booklet about their experiences that had occurred 20 minutes previously. They were also to report who they were with at the time of this experience (eg, alone, with best friend, with friends, with teachers). Students were also asked to describe how they felt about the experience (eg, positive, negative). In addition, the students rated their global self-worth-“I like myself” and “I am happy with the way I am”-with responses ranging from really disagree to really agree. Saliva samples were also obtained each time the student completed a booklet, and salivary cortisol was measured.

The researchers found that a best friend buffered the effects of negative experiences. When a best friend was present, there was little change in cortisol level as the student’s experience increased in negativity. However when a best friend was absent, there was an increase in cortisol as the negativity of the experience increased. Similarly, when a best friend was present, there was no change in the student’s global self-worth in the face of very negative experiences. However, when the best friend was absent, the student’s global self-worth rating was lower in the face of very negative experiences. The researchers concluded that the presence of a best friend during negative experiences protects against decreased global self-worth and activation of the hypothalamic-pituitary-adrenocortical axis.

An important issue is whether lack of friends is a precipitant or a consequence of a psychiatric disorder such as depression. Alternatively, there may be an interaction over time between depression and lack of friends. In a recent study, Kochel and colleagues3 examined 3 models for the predictive association between depressive symptoms and poor peer relationships. The interpersonal model predicts that poor peer relationships precipitate depressive symptoms. The symptoms-driven model predicts that depressive symptoms contribute to poor peer relationships. The transactional model predicts that depressive symptoms and poor peer relationships are reciprocally associated over time.

This longitudinal study was made up of 486 youths who were in grade 4 at baseline. Follow-up assessments were conducted in grades 5 and 6. Data were obtained from study participants, their classmates, teachers, and parents. Depressive symptoms were evaluated using parent and teacher reports. Peer victimization was assessed using student, peer, and teacher reports. Low peer acceptance was assessed by peer report.

The symptoms-driven model best explained the relationship between depressive symptoms and poor peer relations. Depressive symptoms in fourth grade predicted peer victimization in fifth grade, which predicted low peer acceptance in sixth grade. These investigators concluded that depressive symptoms lead to future difficulties with peer interactions.

The finding from this study provides optimism that adequate treatment of a child’s depression will improve peer relationships. However, many children have been depressed for a significant period before treatment, which can exacerbate adverse effects on peer relations.

It is important for clinicians to address the issue of friendships when evaluating and treating children. Parents should be apprised about the critical need for a best friend or friends for their children. If a child is having difficulty in making friends in school, extracurricular activities may provide a setting for interaction with children who have similar interests. Psychotherapy can also promote skills aimed at positive peer interactions.



1. Sullivan HS. The Interpersonal Theory of Psychiatry: A Systematic Presentation of the Later Thinking of One of the Great Leaders in Modern Psychiatry. New York: WW Norton & Company Inc; 1953.

2. Adams RE, Santo JB, Bukowski WM. The presence of a best friend buffers the effects of negative experiences. Dev Psychol. 2011;47:1786-1791.

3. Kochel KP, Ladd GW, Rudolph KD. Longitudinal associations among youth depressive symptoms, peer victimization, and low peer acceptance: an interpersonal process perspective. Child Dev. 2012;83:637-650.

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