Friendships are developmentally important and personally beneficial relationships for all children and youth. Despite emphasis from families and educators of students with severe disabilities on the importance of promoting and supporting friendships with their typically developing (TD) peers in inclusive settings, such relationships remain infrequent. We conducted an integrative thematic literature review of research that directly examined the nature of friendship between students with and without severe disabilities to better understand how researchers define friendship, identify participants, and confirm participants' friendships. Implications for future research are discussed. We also sought to identify themes in extant research to guide future intervention. The thematic findings point to the importance of adults providing direct support while fading their proximity to students, and of TD peers negotiating the ongoing tension between the roles of helper and friend.