Introduction

Disasters, terrorism, and other mass trauma events cause disruption to and devastation for many individuals and families worldwide [1]. Children and adolescents have the highest risk of becoming maladjusted, because they are further disadvantaged in the help seeking process by their own developmental status, as well as their lack of experience and knowledge about how to seek help [2]. Furthermore, their providers of support, who are also affected by these stressors, might be less available to them, both emotionally and physically. Because adolescents are perceived as more capable than children to deal with stress, the former are at an even higher risk than the latter in the context of these stressors, as their distress might not be noted or attended to. Added to this consideration is the fact that adolescence is a life period characterized by marked biological, psychological, and social changes, which in and of themselves increase the risk of psychopathology and risky behavior.

Nevertheless, many adolescents survive, and even thrive, in the face of these two devastating stressors, i.e., disasters and political violence [3], suggesting the presence of resilience. Therefore, it is crucial that this concept be better understood [4]. The purpose of the present article is to review recent research on one of the building blocks of such resilience, namely, social support. We begin by briefly reviewing extant—and quite voluminous—theory and research on social support, with a focus on adolescence. Next, we turn to the role of social support in the reactions of adolescents exposed to (a) political violence and (b) mass disasters. Lastly, we point out overarching themes, gaps in the literature, and future research directions.

Social Support Theory and Research: the Basics

According to Sheldon Cohen, “social support refers to a social network’s provision of psychological and material resources intended to benefit an individual’s ability to cope with stress” (p. 676) [5]. Social support theory and research can be analyzed based on the following dimensions: the reality of the support (actually received vs. perceived), the protective effect exerted by the support (a main effect vs. stress-buffering), and the source that provides the support (friends vs. family).

Perceived vs. Received Social Support

Perceived social support refers to the belief that support will be offered when help is needed. Received social support, on the other hand, is defined as support that is actually provided, and it is regarded as less beneficial than perceived social support [6, 7]. Additionally, the influence of received support might be mediated by perceived support, such that the actual received support strengthens one’s perception that future support is available, in turn increasing perceived support [7]. This could be attributed to the fact that recipients of actual support are usually more in need. In addition, high received social support might be related to decreased self-esteem, which is a known risk factor [8].

However, perceived social support is not always beneficial and, under certain conditions, it might even increase stress. One possible explanation for this is that supportive relationships might inherently increase sense of responsibility toward the providers of the support, which in turn may increase one’s stress level and ultimately result in increased symptomology [9].

Main vs. Buffering Effects

Cohen and Wills [10] distinguished between two modalities in which social support might be beneficial: the main effect and the stress-buffering modalities. According to the main effect model, social support is beneficial, regardless of stress. Whereas, as per the stress-buffering effect model, under high perceived social support, stress affects distress less than that under low perceived social support. Support for the latter is lent from researchers’ findings that at low levels of social support, greater exposure to rocket attacks was associated with increased depression, whereas at high levels of social support, greater exposure to rocket attacks was associated with decreased levels of depression [11].

Acute vs. Chronic Stress

An additional important domain of social support is the difference between situations in which the stress is either chronic or acute. The chronicity of a stressor can influence the stress-buffering potential of social support, because the role of social support tends to shift over time, emphasizing the importance of longitudinal studies. In addition, many chronic stressors are resistant to change and thus may require more palliative or emotional types of support. If the given support is from another type (e.g., instrumental support), then support recipients’ perceived support may increase distress. Therefore, the stress-buffering effect of social support might be found if individuals experience primarily acute stressors, rather than if they experience primarily chronic stressors [12].

Source of Social Support

Relations between disasters, terrorism, or other forms of political violence and child development do not occur in a vacuum. The impact can be understood as related to changes in the communities, families, and other social contexts in which children live and in the psychological processes engaged by these social ecologies [13]. It is important to consider the multilayered nature of social ecology to the understanding of adolescents’ perceived social support. The social–ecological theory, as put forth by Bronfenbrenner [14], posits that children, adolescents, and adults develop in the context of multiple, nested social systems: the microsystem (interpersonal relations experienced by the developing person in a given direct setting), mesosystem (links between various microsystems, e.g., the relations between home and school), exosystem (social structures and events impacting the microsystem and mesosystem, e.g., for a child, the relation between the home and the parents’ workplace), macrosystem (norms, expectations, and attitudes of culture /society, e.g., attitudes of influential political or religious leaders), and chronosystem (changes and transformations experienced by individuals over their lifespan, e.g., historical events).

Adolescent Social Support in the Context of Political Violence

Political violence pertains to conflicts which are raging in many regions around the world, often erupting into extreme acts of violence. These conflicts often result in people becoming refugees or immigrants, most of whom are victimized by ethnic–political violence [15]. Adolescents exposed to political violence are at risk of developing a host of physical and psychiatric symptoms, including depression, anxiety, post-traumatic distress, conduct problems, violence at school, and drug use [3, 16,17,18•]. Moreover, these effects appear to be long-lasting [19, 20]. According to a United Nations Children’s Fund [21] report, over one billion children under the age of 18 are growing up in armed conflict and politically violent environments [22]. Frequent exposure to racial discrimination leads to the release of stress hormones which decrease smooth muscle tone in the gastrointestinal tract and increase coagulation. Although these processes may have a beneficial effect in the short term, they can cause hypertension, lead to heart disease, and weaken the body’s immune system, when they are overproduced [23], a process called “allostatic load.” In yet another study, it was found that, when parental warmth is low, the relationship between childhood abuse and allostatic load is stronger [24]. Similar results were produced in another study, where it was shown that the lower the family support, the relationship between discrimination and cellular aging through a methylation mechanism was stronger. This effect was consistent with the stress-buffering model of social support: when family support was high, no association between discrimination and epigenetic aging was detected [25].

Some important gender differences in adolescents’ responses to political violence have been revealed. Among Israeli adolescents exposed to a suicide bombing, relational exposure (or knowing others directly affected by a suicide bombing) predicted an increase in depressive symptoms in girls, but not in boys [26]. Also, among Palestinian children in three cohorts (ages 8, 11, and 14), whereas exposure to political violence was related to post-traumatic stress (PTS) symptoms almost equally for both boys and girls and for all of the age groups examined in that study, exposure to political violence seemed to have almost no relation to aggression in girls or in 8-year-olds [27].

In Table 1, we present a list of studies examining the role of social support in the link between adolescents’ exposure to political violence and psychopathological outcomes. In the studies that examined the role of social support as a resilience factor, only perceived support was examined. Furthermore, in most of the studies presented in the table, evidence was found for the stress-buffering effect [11, 28,29,30,31,32].

Table 1 Adolescent social support in the context of political violence
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While most of the studies employ longitudinal designs [3, 11, 19, 29,30,31,32,33,34,35,36], there are some cross-sectional studies [28, 37]. Although the stress-buffering effect was found in one cross-sectional study [28], it is more commonly found in longitudinal studies [11, 29,30,31,32, 35]. This might be explained by the fact that longitudinal studies enable researchers to detect the relations between children and their social environment over time and to rule out the possibility that the association between symptoms and support rests on the effect of the former on the latter.

In most of these studies, support from parents or family was shown to have the most protective effect [29–30••]. The effect of support from peers, however, differed between the studies [28, 31, 32]. For example, in a study among Israeli early adolescents who have witnessed community and terror violence, it was found that support from parents operated as a protective factor, whereas support from friends acted as a risk factor by increasing the likelihood of violent behavior. Moreover, the results of this study found that support from the adolescent’s school can act as either a protective or risk factor, depending on the type of violence on adolescent witnesses [28]. In another study, perceived family social support buffered against the effect of exposure on depression and severe violence, indicating that this support is beneficial when exposure to rocket attacks is high [30••]. Social support from friends has also been found to buffer against the effects of stress: adolescents reporting high bombing-related perceived stress evinced an increase in depression, if they reported low levels of friends’ support, but not in high levels of friends’ support. However, when bombing-related perceived stress was low, social support from friends predicted an increase in depression over time [31].

Boxer and colleagues [36] conducted a longitudinal study from three age cohorts (ages 8, 11, and 14), representing three populations in the Middle East: Palestinians, Israeli Jews, and Israeli Arabs. They found that events in higher-order social ecosystems influence human development through their impact on events in lower-order social ecosystems, lending support to Bronfenbrenner’s [14] social–ecological model, in which ethnopolitical violence increases community, family, and school violence and children’s aggression. Specifically, they found that political violence affects microsystem violence, but that microsystem violence does not affect political violence, and that aggression does not affect exposure to political or microsystem violence. For all age cohorts, exposure to political violence at time 2 was strongly related to exposure at time 1 and had a significant direct effect on aggressive behavior at time 3. In addition, exposure to political violence at time 1 significantly predicted changes in microsystem violence from time 1 to time 2. Microsystem violence at time 2, in turn, significantly predicted aggressive behavior at time 3 for 8-year-olds, with the effects decreasing as the age of the youth increased. This means that violence in the exosystem would impact child development through its role in increasing violence in microsystems.

Adolescent Social Support in the Context of Mass Disasters

Natural disasters may result in adolescents’ impaired functioning, including behavior problems, substance use, and psychopathology such as post-traumatic stress disorder (PTSD), anxiety, and depression [38]. The PTS symptoms resulting from natural disasters tend to be persistent over time, with 35% of children reporting moderate to very severe levels of PTS symptoms 9 months post-disaster and only declining to 29% a year later [39].

In Table 2, we present studies focusing on the role of social support in the link between adolescents’ exposure to natural disasters and psychopathological outcomes. In these studies, which examined the role of social support as a resilience factor among adolescents, only perceived support was examined. In a study among Chinese adults who were exposed to a natural disaster, it was found that disaster exposure and received family support were significantly and positively related to depressive symptoms. In contrast, perceived family support moderated the relationship between disaster exposure and depressive symptoms. Yet, no association was found between support from friends and severity of depressive symptoms [6].

Table 2 Adolescent social support in the context of mass trauma
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Although most of these studies are longitudinal [39,40,41,42,43], there are some cross-sectional studies (e.g., [44]). Unlike the longitudinal studies, which investigated social support in the context of the stress-buffering hypothesis, the cross-sectional studies examined the effects of social support, albeit not via the stress-buffering hypothesis. In addition, the longitudinal studies investigated the effects of social support as a protective factor using prospective designs, whereas the cross-sectional studies employed retrospective designs. These types of studies also differed in their findings of the benefits of social support: while the longitudinal studies found significant effects of social support, the cross-sectional studies (e.g., [44]) found that social support was unrelated to either parent or youth report of their post-traumatic growth (PTG) following the disaster. The authors defended the latter finding by citing that less than half of the studies investigating the effects of social support on PTG in youth found a significant relation [45].

When comparing across different providers of support, most of the studies found that support from parents and peers has the most protective effect. Although some of the studies examined the stress-buffering effect, it was not always supported [40], as can be seen, for example, in a study which examined the impact of daily stressors on Sri Lankan adolescents and the 2004 Indian Ocean tsunami that affected various areas of Sri Lanka. Researchers found that social support buffered the effects of trauma and daily stressors on daily impairment, but not on PTS symptoms or emotional and behavioral problems [42]. This finding could possibly be explained by the deterioration deterrence model.

According to this model [46, 47], mass trauma has the potential to disturb victims’ ongoing perceptions of support. Because mass trauma affects the entire environment, the need for support may simply exceed the amount of support available, causing expectations to be violated. Thus, exposure is associated with deterioration of perceived support. However, when support is actually provided, perceived support has a promotive role with respect to psychological distress. Hence, it is critical to strengthen the providers of the support, so that they can have the capacity to be supportive [18•, 47], and to also distinguish between episodic and chronic stresses, the latter being likely to erode social support.

This model may explain why children are more prone to suffer from this type of erosion as a function of age: the more an individual is dependent on his/her environment, the more she/he will suffer from deterioration of perceived social support. For instance, Banks and Weems [48] found that among youth whose neighborhoods were almost flooded following Hurricane Katrina, older children reported fewer symptoms of distress than did younger children. In addition, according to social learning theory [49], new patterns of behavior, such as violence, can be acquired through direct experience or by observing others’ behavior. This can explain why children are at higher risk than adolescents and adults for developing aggressive behavior after observing violence in their environment.

Additionally, the deterioration deterrence model emphasizes that post-disaster social support is more important than pre-disaster social support. In a study that examined the relation of pre-disaster child characteristics, pre-disaster environmental characteristics, and level of disaster exposure to youths’ PTS symptoms in the wake of the 2010 Nashville, Tennessee flood, it was found that the effects of youths’ experience of the flood on post-flood trauma symptoms were not moderated by any of the pre-existing child characteristics or pre-disaster environmental variables in this study, including pre-disaster social support from peers [40]. Social support from other providers, however, was not examined in this study.

When it comes to physical health, a more positive T1 parent–child relationship quality (PCRQ) has been shown to be associated with perceptions of their child having better health at both 18 and 30 months after the hurricane. For the global rating of child health, greater exposure and higher PCRQ were jointly associated with perceptions of poorer health, yet this effect was most pronounced for boys whose families were both more affected by the hurricane and enjoyed better relations between parents and children. For the number of medical problems in the past year, for girls, highly exposed families whose parents were closer to their daughters reported more medical problems. For boys, the interaction between exposure and PCRQ resembled the “old reliable” features of social support as a buffer against stressors. While PCRQ did not matter for medical problems when the exposure to the hurricane was low, at higher levels of exposure, boys from families with lower PCRQ presented more medical problems than boys whose parents had high PCRQ. Thus, high PCRQ protected boys from the deleterious influence of natural disasters on a number of medical problems in the following year [43].

Comparing Social Support across the Two Stressors

In both longitudinal and cross-sectional studies, support is predominantly provided by family and peers. The difference between the stressors is found on the dimension of the protective effect exerted by the support. While there is evidence for the stress-buffering model of social support in studies of adolescents exposed to political violence or adults exposed to natural disasters [6, 50], support for this model is less common among adolescents exposed to natural disasters. Considering the different natures of these stressors and in light of the deterioration deterrence and the social–ecological models, one can argue that natural disasters tend to have broader effects and, therefore, erode more of the adolescent’s providers of support by eroding social systems from higher orders. Thus, they are less capable to provide social support and mediate the destructive effects of the disaster. Yearwood and colleagues [32] found that peer support significantly moderated the effect of stress on internalizing and externalizing symptoms, only in complex trauma, meaning that the aspects of violence in children can be encountered in their caregiving environment, and not in environmental adversity, which referred to violence in three areas of life: the community, school, and media.

Gaps in the Literature

While most of the studies examined support from different providers of support, there is a considerable amount of studies that either did not differentiate between the different providers [35, 42] or focused only on a single source of support [40]. Differentiating between the different sources of support will enable the protective effects of social support to be revealed.

Although there is a significant amount of both longitudinal and cross-sectional studies, additional longitudinal studies are needed. The importance of longitudinal studies is that they enable researchers to see if there is a possibility that the association between symptoms and support rests on the effect of the former on the latter. One such longitudinal study found that initial hurricane-related stressors (actual life threat, initial loss/disruption) were related to children’s PTS symptoms at time 1 through their presumed impact on life events at time 1. This impact on life events at time 1, in turn, directly affected children’s PTS at time 1 and adversely impacted social support from peers at time 1, thereby weakening the social support buffer available to children. In addition, major life events appeared to adversely impact children’s levels of social support from peers. However, children’s perceived social support did not buffer the effects of major life events on children’s PTS symptoms at time 1 [39].

Most importantly, although some qualitative studies have been conducted [51], there is still a lack of qualitative- or mixed-method studies. Using qualitative methods provides a better understanding of complex phenomena such as social support (e.g., what facet of social support is supportive and under which conditions), and this understanding would help to build intervention programs, which in turn may prevent or decrease the development of maladjustment symptoms. In addition, according to the stress-buffering model, under certain conditions (e.g., when there is no stress), social support is less beneficial and might even increase distress. Considering the deterioration deterrence model, when facing an adverse stressor, there is a need to use social support effectively, so the expectations for perceived support will not be violated. Understanding the specific conditions and mechanisms under which support is beneficial will allow this violation to be avoided.

Additionally, while there are some studies being conducted in an attempt to uncover the mechanism behind the protective effects of social support, there are a considerable number of studies that do not refer to any particular mechanism. However, it is possible that different personality attributes and/or different concepts of the self may serve as mechanisms. In a study by Pagorek-Eshel and Finklestein [52••] who aimed to predict variables of family resilience, differences between adolescents’ and their parents’ resilience were identified. Specifically, high levels of individual resilience and self-differentiation predicted parents’ family resilience, whereas gender and individual resilience were found to predict adolescents’ family resilience. In addition, the researchers found that only when parents’ level of self-differentiation was high did adolescents’ self-differentiation predict family resilience. Perhaps, parents with higher levels of self-differentiation were better able to understand the need of their adolescents to develop autonomy, even if emotionally it would have been difficult for them as parents to do so in circumstances of ongoing rocket fire [52••]. This better understanding on their part would in turn increase adolescents’ beliefs about their own ability to deal with those circumstances, as well as decrease their guilt toward their parents. In other words, adolescents’ self-efficacy will increase and their self-criticism will decrease.

Self-esteem is another type of self-concept that may have either protective or harmful effects, depending on whether it is high or low. Research has shown that the relation of exposure to ethnic–political conflict leading to higher subsequent PTS symptoms is moderated by youth having high self-esteem and by them receiving a high level of positive parenting [29]. Also, poor academic performance, along with witnessing the traumatic event, being a female, and being an older adolescent were significant predictors of PTS symptoms [53]. Thus, perhaps as poor academic performance gives rise to decreased self-esteem, this in turn may lead to adolescents’ maladjustment.

Additionally, Liu and Xia [54•] found that T1 interpersonal flexibility—defined as the tendency to deal with interpersonal events contingently and flexibly—predicted T2 perceived social support (i.e., 6 months later). People with high interpersonal flexibility tend to selectively attend to the positive interpersonal information, and they consequently experience their environment as more supportive. Therefore, experiencing the environment as benevolent may increase self-esteem, allowing individuals to benefit more from this protective factor.

Interestingly, another study found that social support buffered resource loss. Namely, the results indicated that (a) resource loss only affected less supported survivors and (b) more family support was associated with lower severity of PTS symptoms, albeit only in those survivors who had medium or lower self-efficacy beliefs. This suggests that low levels of self-efficacy can be compensated by higher levels of family support, as receiving family support at T1 enabled survivors to feel more self-efficacious [41].

Conclusion

Acquiring a better understanding of the mechanism(s) behind social support holds great importance, from a therapeutic point of view. This is reflected in the effects of the Youth Leadership Program, a program that was established as a school community–university partnership after Hurricane Katrina and whose aim was to foster resilience by increasing post-disaster self-efficacy. Self-efficacy scores of students who participated in the YLP were significantly higher compared with the self-efficacy scores of students who did not participate. This intervention revealed a significant self-efficacy by trauma symptoms within-subject effect, such that decreases in trauma symptoms were contingent on gains in self-efficacy. Moreover, this interaction effect was exhibited for both groups of students [55•].

Taking both the deterioration deterrence model and the social–ecological model into consideration, there is a need for intervention programs that are aimed at assisting the individuals from various aspects of life who provide children and adolescents with support. Garfin and colleagues [56] conducted a study on 2nd-grade students from nine different schools, all of which provide government-run mental health intervention programs. They found that, approximately 9 months following the 2010 Chilean earthquake, children’s self-reports of characteristics of their home environment (e.g., conflict with their caregiver, availability or not on the part of the caregiver to discuss the earthquake) were positively associated with PTS symptoms. In addition, higher ongoing earthquake-related worry was shown to be associated with children’s perceptions of their caregiver’s unavailability to discuss the earthquake. However, participation in their school’s government-run mental health intervention was associated with children having significantly lower earthquake-related worry. Moreover, participation seemed to protect at-risk youth from elevated PTS symptomatology [56]. In another study, it was found that, among 11- to 14-year-old Palestinian students, students who were randomly assigned (by class) to the intervention condition, rather than to the wait-list control condition, reported significant decreases in PTSD, grief, and depression. The control students, on the other hand, reported only small mean reductions for traumatic grief and mental health difficulties, reductions of 0.18 and 0.24, respectively [57]. The benefits of participating in an intervention program were also shown in a study in which Syrian refugee students living in Istanbul attended a group cognitive behavioral therapy (CBT) program delivered by trained teachers. After participating in the CBT program, not only did these students have lower mean anxiety scores than the baseline, but also their post-intervention PTSD total score revealed a significant improvement and a similar improvement was also observed in their intrusiveness and arousal symptoms [58].

Thus, given the positive impact that these types of intervention programs are shown to have, it is essential that the protective factors and mechanisms behind social support be further studied, so that researchers and practitioners may develop and implement appropriate interventions to help those who are most vulnerable: children and adolescents.