Peer Relationships and Psychosocial Difficulties in Adolescents: Evidence from a Clinical Pediatric Sample

<b>Background</b>: Adolescence is a critical developmental stage marked by vulnerability to psychological difficulties. While family relationships, peer bonds, prosocial behaviors, and health-risk factors have been linked to adolescent mental health, few studies have examined their joint effects in clinical pediatric populations. This study assessed demographic, clinical, relational, and behavioral predictors of psychological difficulties in Italian adolescents. <b>Methods</b>: A cross-sectional sample of 177 adolescents (aged 11-14 years) from a pediatric clinic completed the Strengths and Difficulties Questionnaire (SDQ). The Total Difficulties (SDQ TD) score was the main outcome. Associations were tested with ordinary least squares (OLS) and confirmed using robust MM regression. Bootstrap confidence intervals and Benjamini-Hochberg corrections were applied. Sensitivity analyses excluded the Peer Problems subscale to address part-whole overlap. <b>Results</b>: Higher friendship satisfaction was consistently associated with fewer psychological difficulties, confirming its role as a strong protective factor. Prosocial behavior and male sex were also linked to fewer difficulties in initial analyses, though these associations were less stable after correction. Sensitivity analyses further supported the protective value of friendship satisfaction, even when accounting for overlap with peer problems. Despite relatively low overall levels of psychological difficulties, nearly one-quarter of adolescents met the clinical cut-off for eating disorder risk. <b>Conclusions</b>: Friendship satisfaction was the strongest protective factor, while prosocial behavior and sex showed weaker consistency. Findings suggest that distinct aspects of peer relationships jointly shape adolescents' psychological outcomes. Interventions promoting social functioning may support mental health in clinical youth populations.