Understanding best friendships and psychosocial health in pediatric brain tumor survivors

In the landscape of life, best friends stand out as trusted confidants with whom we share interests, experiences and support. Having and maintaining these types of meaningful friendships is an enriching part of life that has positive impacts on our health and well-being. But for those facing unique life circumstances, such as those who have survived childhood cancer, the importance — and difficulty — of having a best friend takes on increased significance.

For pediatric brain tumor survivors (PBTS), the necessity and challenge of sustaining meaningful friendships is more pronounced due to differences in social, emotional and neurocognitive abilities, areas collectively called psychosocial functioning. The nature of a pediatric brain tumor — type, location, size and aggressiveness — combined with the effects of treatment on the developing brain, can lead to impairments in psychosocial functioning that may show up as challenges when conversing, comprehending social situations and developing social relationships.

To further examine the impact of various factors on social functioning, investigators at St. Jude conducted a study called SOCFUN: Social Functioning in Survivors of Pediatric Brain Tumors. While many studies have assessed survivors’ social outcomes, few have focused on the role of friendships.

A novel approach to examining friendships in pediatric brain tumor survivors

Investigators used data from the SOCFUN study to analyze the characteristics of friendships in survivors of pediatric brain tumors aged 8 to 12 years. While the analysis compared psychosocial functioning of PBTS with and without self-identified best friends, it also sought to understand the reciprocal nature of these friendships and the caregiver’s role in the success of these friendships: two previously understudied areas. The results were published in the Journal of Pediatric Psychology.

“We’ve understood for a while that there are social difficulties among some of our survivors, particularly with social isolation, social reciprocity and not perceiving friendships the same way the other person does,” said corresponding author Heather Conklin, PhD, Division of Neuropsychology chief and Department of Psychology & Biobehavioral Sciences member. “Over time, it emerged that these pediatric brain tumor survivors have fewer friendships, which could impact their psychosocial health and quality of life. We wanted to focus on friendships as an area of study so we can better identify those at risk and develop methods to support them.”

McCall Schruff, MA, first author and clinical psychology doctoral student at the University of Mississippi, recalls examining the literature on the psychosocial functioning of PBTS with her mentor, the late Victoria (Tori) Willard, PhD, Department of Psychology & Biobehavioral Sciences, and noticing a gap.

“Many survivors of childhood cancer could not identify as having a best friend. So, we homed in on that friendship piece and began asking questions about what the functional aspects are that contribute to a survivor’s friendships, especially for brain tumor survivors,” said Schruff. “We wanted to examine the differences between survivors who had best friends and those who did not to understand the psychosocial functioning of these two groups.”

A caregiver’s role in sustaining friendships

Schruff emphasizes the importance of gathering a variety of perspectives in the survivor’s social world. “We wanted to see what the friendship looks like from the other person’s point of view, especially in relation to the caregivers’ impact on their child’s social outcomes,” she said.

Most caregivers want their children to experience social success. But for this young population, caregivers’ contributions play a larger role. A caregiver’s investment in arranging playdates, organizing carpools or signing up for activities are all actions that contribute to their child’s social outcomes.

To assess the caregiver’s impact, caregivers were asked to complete a 58-question survey that asked questions about their parenting style, called the Facilitative Parenting Scale. Of all the parenting practices assessed, parental warmth, or the enjoyment a caregiver experienced through spending time with their child and supporting their social wellbeing, was identified as an influential parenting practice correlated with a child’s social success.

The team found that the survivors who identified as having a best friend had a significantly higher parental warmth rating as reported by their caregivers, which corresponded with increased caregiver engagement in their child’s social life.

Examining the quality of friendship through reciprocity

To further assess the survivor’s social world, the team chose to gather perspectives other than those self-reported by survivors of pediatric brain tumors. To gauge the quality of friendships, investigators asked the best friend who was identified by the survivor to complete a questionnaire. The questions sought to assess the quality of the friendship and whether feelings and perspectives about the friendship were reciprocated.

For Schruff, it was surprising that, “The self-identified best friends reported higher quality friendships than the survivors did.”

Investigators also examined where and when these friendships were being forged: aspects never before studied. Again, Schruff was surprised to see that many of these friendships were developing at school, or even among family members, after diagnosis of a pediatric brain tumor. Understanding the social context in which these friendships develop can help investigators as they work to develop interventions to better support families and guide future studies.

Strengthening skillsets and friendships through social support development

While the purpose of the study was not to identify causative factors that impact friendships, it does identify correlative patterns that can guide investigators in developing interventions and education that provide psychosocial support for patients and caregivers as they navigate school-age social spheres.

Conklin stressed that these findings can inform the development of supportive systems that bolster pediatric brain tumor survivors and their caregivers. “I’m always looking for modifiable factors, which are things we can change and support. A cancer diagnosis is not something we can change, but in this case, we can work with caregivers to address parenting styles or their approach to their child’s friendships,” said Conklin. “This is an area where we could potentially influence the outcome.”

For Schruff, “supporting or modifying some of the parenting behaviors, along with explaining the importance of friendship for their children, is something we can bring to our clinical work with patients and their caregivers.”

Thanks for being a friend

While the results of the study were published by a team led by first author Schruff and corresponding author Conklin, the study began with Willard’s work. Willard dedicated her career to better understanding psychosocial health throughout childhood and early adulthood. Her research at St. Jude led to advancements in care that prioritized psychosocial outcomes and supported peer relationships and social and family functioning for this population of childhood cancer survivors.

After Willard’s passing, Conklin and Schruff dedicated themselves to seeing her work to completion. For Conklin, who mentored Willard when Willard first arrived at St. Jude as a postdoctoral research associate, stepping up to serve as the corresponding author on this publication ensured Willard’s contributions to science, along with the efforts of the study participants, were not lost.

“This is really Tori’s line of work that we’re carrying out for her. Her interests were unique because her work bridged neuropsychology and pediatric psychology in a way the field is still exploring. This work is really her brainchild and her passion, so it’s important we continue to ensure that people acknowledge her contributions to science,” said Conklin.

Schruff, one of Willard’s mentees and doctoral students, recalls an appreciation for Willard’s “perspective of looking at social functioning in relationships and understanding the social world of individuals. For cancer patients who may experience isolation, we must continue Tori’s work to better understand how they can navigate the social world before, during and after treatment.”

By ensuring Willard’s work continues to contribute to advancements in psychosocial research and clinical care, the team shows a continual dedication to science and to the ongoing effort to provide survivors of pediatric brain tumors with the psychosocial supports and skills they need to improve their quality of life, beyond a cure.