Perceived social support among adolescents in Residential Youth Care

Social support may be of particular importance for vulnerable adolescents' development and health and can help them to cope with stressful life events. However, knowledge of perceived social support among adolescents in Residential Youth Care (RYC) is sparse. The present study therefore aimed to investigate perceived social support among adolescents in Norwegian RYC ( N = 304, mean age 16.3 years, girls 57.2%), using a short form of the Social Support Questionnaire. The results were compared with adolescents in the general population. The findings revealed that adolescents in RYC reported a lower number of support persons compared with the general population. Both populations reported a decreasing number of support persons as they aged, except for girls in RYC. The adolescents in both populations were satisfied with the support perceived, especially those with the highest number of support persons. However, social support providers differed between the two populations; RYC adolescents reported their extended family, other sources of support, and the institutional staff more often and their parents less. The findings are important for adolescents living in RYC, as knowledge of their social support network could influence the current practices and ensure contact with important support persons, affecting their development and health.

2011). Adolescents living in RYC report high rates of psychiatric disorders (Jozefiak et al., 2016;Kepper, Van Den Eijnden, Monshouwer, & Vollebergh, 2014) and poor quality of life (Damnjanovic et al., 2012;. However, guidance, feedback, and support from significant others have been hypothesized (Sarason & Sarason, 1985) and found to buffer against serious negative life events (Bal, Crombez, Van Oost, & Debourdeaudhuij, 2003;Murberg & Bru, 2004), which adolescents in RYC have encountered, often in abundance (Berridge, Biehal, & Henry, 2012;Collin-Vézina et al., 2011). To optimize the care for and development of adolescents in RYC, it is vital to have basic information concerning the social support they experience and how it may differ from that of typically developing adolescents. As of today, such information is generally lacking. The overarching aim of the current inquiry was therefore to provide such data.
Social support has been defined as the availability of people who are supportive, caring, and loving (Sarason, Levine, Basham, & Sarason, 1983). Perceived social support reflects an individual's perception of the number of persons available to provide support, in addition to satisfaction with the support. Because diminished support is associated with low self-efficacy (Adler-Constantinescu, Beşu, & Negovan, 2013), self-esteem (Rueger, Malecki, & Demaray, 2010), and well-being (Chu, Saucier, & Hafner, 2010), as well as increased risk of mental health problems (Rueger, Chen, Jenkins, & Choe, 2014;White & Renk, 2012), the adolescents in RYC would likely benefit from perceiving social support from several sources to avoid these negative effects.
A recent trend in out-of-home placements is kinship foster care (Thørnblad, 2011), which could make social support from extended family more avilable. However, being separated from the home environment could lead to a loss of social support for adolescents in RYC.
Also, an institutional setting can make everyday leisure activities and friendships outside the institution hard to maintain .
Whether adolescents in RYC actually reports a reduced number of support persons compared with the general population or not has yet to be determined.
A Croatian study claimed that children living in children's homes had a lower number of support persons compared with the general population, but no numbers were reported, and no information was given on the instrument used to measure the social support (Franz, 2004). In other high-risk groups, an American study of adolescents in foster care found that repeated and severe disruptions in attachments through several out-of-home placements were associated with less caring relationships with adults and a decrease in the number of support persons available (Perry, 2006). Mental health might also affect number of support persons (Kawachi & Berkman, 2001), and high-risk groups, such as adult psychiatric patients, report a lower number of support persons compared with the general population (Furukawa, Harai, Hirai, Kitamura, & Takahashi, 1999).
Sex differences in perceived social support has been reported, where girls report a significantly larger number of support persons than boys. These findings were found both in a German study among adolescents in RYC (mean age 15.55, with a follow-up 2 years later; Bender & Lösel, 1997) and in research on the general population (Gecková, Van Dijk, Stewart, Groothoff, & Post, 2003;Rueger et al., 2010). Sex differences in coping strategies when faced with difficult life situations may be associated with social support. Girls have been found to be more cautious when entering new social situations after negative life events (Hampel & Petermann, 2006;Piko, 2001), whereas boys redirect their energy to more pleasant activities (Compas, Orosan, & Grant, 1993;Piko, 2001). This can affect the way the adolescents perceive social support from the institutional staff. Also, depression and anxiety, more commonly diagnosed in girls (Bronsard et al., 2011;Jozefiak et al., 2016), have been found to be associated with low perceived social support (Kawachi & Berkman, 2001;Rueger et al., 2014).
A high number of support persons does not equate to high-quality social support, as factors such as personality and needs may determine whether large numbers of support persons or only a few are adequate (Sarason et al., 1983). Of note, as adolescents in RYC often have experienced challenging home conditions, parental support might not be of the same quality as for adolescents living at home. It is therefore important to examine satisfaction with support and whether a high number of support persons equate to high level of satisfaction or not. In addition, low levels of satisfaction is associated with symptoms of both emotional and behavioural problems among both adolescents (Bender & Lösel, 1997;Garnefski & Diekstra, 1996) and patients with severe mental illness (Furukawa et al., 1999;Thomas, Muralidharan, Medoff, & Drapalski, 2016), in addition to low quality of life among psychiatric patients (Bengtsson-Tops & Hansson, 2001). At present, no information is available on RYC adolescents' satisfaction with perceived social support. Because it is probable that adolescents in RYC have a lower number of support persons compared with adolescents living at home, as well as increased challenges in daily life and social relations, it is hypothesized that their satisfaction with the perceived support will be reduced compared with the general population.
It is also useful to consider how adolescents in RYC access social support while in RYC. As noted, social support from parents and peers can be difficult to maintain, as they are often separated from their home area, and the day-to-day interactions are rather with the institutional staff. Their role in providing support and a professional form of parenting is important for the adolescents' experience of living in a caring, homelike environment (Berridge et al., 2012). A Dutch study (Harder, Knorth, & Kalverboer, 2013) found that adolescents in secure RYC tended to use the institutional staff as secure attachment figures.
One might implicate that institutional staff members, as the current care providers for these adolescents, hold an important role as support persons, given the absence of parental support.
Research on the general population has shown that both parents and peers are important support persons for adolescents (Frey & Röthlisberger, 1996). Parents provide psychological and instrumental support in daily matters and crises, with mothers more often than fathers being mentioned as support persons. In contrast, peers are a source of emotional support in day-to-day matters. Also, during adolescence, social behaviour develops towards independence from parents combined with an increasing reliance upon peers (Bokhorst, Sumter, & Westenberg, 2010;Collins & Laursen, 2004). Several studies have reported that perceived parental support declines and perceived peer support increases before the age of 16 (Bokhorst et al., 2010;Levpušček, 2006). However, little is known about RYC adolescents' perceptions of social support and whether similar age-related patterns apply to them, as in the general population.
The overall aim of this study is to gain knowledge of perceived social support among RYC adolescents, given the paucity of information currently available. The number of support persons, the satisfaction with perceived social support, and the individuals from whom the adolescents in RYC perceive social support will be examined, as well as sex differences, and whether these aspects differ from adolescents in the general population. Also, it will be examined whether a high number of support persons is necessary to perceive high satisfaction with the support. Extrapolating from related research, it is hypothesized that adolescents in RYC have a lower number of support persons than adolescents in the general population and that boys report a lower number of support persons than girls. Also, it is hypothesized that perceived social support will decrease with age. Finally, it is hypothesized that adolescents in RYC are less satisfied with the support received than adolescents in the general population.

| Setting
The Norwegian Directorate for Children, Youth and Family Affairs is responsible for all public and private RYC institutions in Norway, except in the municipality of Oslo, which administers its own RYC.
The institutions, which attempt to resemble ordinary home environments, are normally small, open units with three to five residents. A therapeutic milieu model is most often used at the institutions, and the staff members typically have limited knowledge of psychiatric diagnosis and treatment (Bufdir, 2010). The RYC is either organized with three shifts per day, or the staff members live with the adolescents for 3 to 7 days before having a longer period off. More than 90% of the adolescents report having contact with birth family or previous care givers, and almost 70% report attending school.

| RYC sample
The data were obtained from the Norwegian research project "Mental Health in Adolescents living in Residential Youth Care" . A registry of all RYC institutions in Norway (N = 98) was created on the basis of information from the Norwegian Directorate for Children, Youth and Family Affairs. All institutions were contacted by a research assistant, and the leaders were informed about the project through written and oral communications.
At this stage, 86 institutions volunteered for participation. The institutional leaders were given the responsibility for recruiting adolescents and collecting informed consent. After the institutional exclusion criteria were applied (see Figure 1), all adolescents and young adults aged 12-23 years living in RYC in Norway were invited to participate in the study, although no one over the age of 20 participated. After individual exclusions (see Figure 1), 601 eligible adolescents remained, of which 400 volunteered to participate, yielding a response rate of 67%. Because the Social Support Questionnaire (SSQ) was the last questionnaire to be completed, the attrition was high. Due to missing cases or incompletions (n = 96), the SSQ was completed by 304 participants. Analyses comparing completers with noncompleters of the SSQ did not find significant differences between the groups in terms of sex, age, or total score on the Child Behavior Checklist.

| General population Reference sample
The reference sample was drawn from the Young in Norway (YiN) study conducted in 1994, where all Norwegian junior and senior high schools (students aged 12-19 years) were included in a register from which the schools were selected. Cluster sampling was applied, and the sample was stratified according to geographical region, school size, and type (Wichstrøm, 1999). Following a first wave of data collection with 12,287 participants (Wichstrøm, 1999), the second national round used for comparison in this study had a response rate of 80% (N = 10,839; Wichstrøm, 2002), of which 8,769 completed the SSQ.
From these, 1,674 were excluded due to the age criteria or missing reports of age and sex, yielding a response of n = 7,095. For further details about the YiN project, see (Wichstrøm, 1999

| RYC sample
Four trained research assistants with comprehensive experience working with children and families and relevant bachelor or masters degrees collected data at the RYC institutions. The adolescents were approached individually and were recruited with approved procedures and informed consent. For participants younger than 16 years of age, consent was also obtained from a significant caregiver. The adolescents were asked to complete a series of questionnaires, lasting approximately 30 min. If they had trouble reading the questionnaire, it was read to them by the research assistant. All adolescents were compensated with 500 NOK for their participation, and iPhones were given to four randomly chosen adolescents. The data were collected from July 2011 until July 2014.

| General population sample
The students completed the questionnaires, which contained no personal identifiers, during two consecutive school hours. Each student placed the questionnaire in an envelope and sealed it personally. The students who were absent at the time of testing completed the questionnaire at a later time. The students under the age of 16 years provided written parental consent, whereas those 16 years or older consented themselves. The project was approved by the Norwegian Data Inspectorate.

| SSQ
A short five-item version of the SSQ (Wichstrøm & Hegna, 2003), modelled after Sarason et al.'s (1983) full version of 27 items and adapted to adolescents, was used to measure perceived social support. The SSQ examines to whom adolescents can turn in five hypothetical situations involving informational support, emotional support, and crisis intervention (see Table S1 for further information).
Eight possible support persons (mother, father, boyfriend/girlfriend, sibling(s), friend(s), relative(s), neighbour(s), and others) are listed for each situation, together with the alternative none. In the RYC sample, institutional staff was added as an alternative, giving a total of nine listed potential support persons. In the general population sample, the respondents wrote the number of friends available for support, which was recoded to match the RYC data, such that mentioning any friends FIGURE 1 Flow chart of participants from the Residential Youth Care (RYC) sample. Not able to contact = if institutional staff did not respond to repeated approaches about participation over a period of several months. There were no significant differences between participating and nonparticipating institutions with regard to geography and ownership was given the score of 1. In addition, satisfaction with the social support for each of the five hypothetical situations were measured on a Likert scale ranging from 1 to 4.

| Number of support person scores (SSQ-N and SSQ-R scores)
The SSQ-N score refers to the sum of the support persons listed over the five items (Sarason et al., 1983). Because the RYC participants had nine alternative support persons compared with eight alternatives available in the general population, the SSQ-N scores were not directly comparable between the samples. Therefore, the two SSQ-N scores were divided by the number of support persons available for each group (i.e., divided by 8 for the general population and 9 for the RYC population), giving a relative score (SSQ-R) that could be directly compared across samples. The five-item SSQ-N had an internal consistency of α = .77 when calculated across both populations.

| Satisfaction score for the perceived social support (SSQ-S score)
Satisfaction with social support was rated on a 4-point Likert scale for each of the five items, ranging from very poorly satisfied (1) to very satisfied (4), where a high value indicated higher satisfaction. A SSQ-S score (a mean score of satisfaction level across items) was obtained for both populations (Sarason et al., 1983).

| Statistical analyses
First, the SSQ-R scores were compared between the RYC population and the general population using Student's t test. Second, linear regression was used with the SSQ-R score as the dependent variable and group (the RYC population vs. the general population), age, sex, and all two-and three-way interactions as covariates. 1 The asymptotic Pearson chi-squared test was used to search for differences in the number of perceived social support persons. Finally, linear regression, with the SSQ-S score as the dependent variable and group, age, and sex as covariates, was used to analyse for differences in satisfaction between the groups. Linear regression was used to analyse the differences in SSQ-S scores according to the SSQ-R scores, with the SSQ-S score as the dependent variable and SSQ-R score, group, sex, and all two-and three-way interactions as covariates. Two-sided P values < .05 were regarded as statistically significant, and 95% confidence intervals (CIs) were reported where relevant. All the statistical analyses were conducted using SPSS 22.

| Ethics
The Norwegian Regional Committee for Medical and Health Research Ethics approved the project. Participants were recruited with approved procedures, and informed consent was always obtained, as previously described.

| Number of support persons (SSQ-R)
The  As seen in Figure 2 (and Table S2 Several sensitivity analyses were completed. Because relatively few respondents in the two samples were below 14 or above 18 years of age, as seen in Table 1, a secondary linear regression analysis was carried out including only adolescents from 14 to 18 years of age. The same patterns as for the whole sample were found. The data were also analysed using nonlinear regression (LOESS regression curves), which showed similar patterns as the linear regression (data not shown).
For completeness, a three-way interaction was also examined.
The three-way interaction was not statistically significant (p = .064), but all the variables were part of at least one two-way interaction that was statistically significant (see Table S2).

| Satisfaction with social support
Linear regression analyses showed that the SSQ-S score for adolescents in RYC (Mean (SD)) was 16.07 (4.123), compared with 16.22 (3.404) for adolescents in the general population. The maximum SSQ-S score was 20.00. Although adolescents in RYC reported a slightly lower SSQ-S compared with the general population, this was not significant (p = .27) when adjusted for sex and age.
The result of a linear regression analysis with SSQ-S score as dependent variable and SSQ-N score, group, and sex and all twoand three-way interactions as covariates is shown in Figure 3. The findings revealed that satisfaction with perceived social support was positively associated with the number of support persons for both populations. The association was slightly less for boys in RYC An additional linear regression analysis was carried out to investigate possible age effects, but age did not act as a confounder explaining the effects found in satisfaction with support and number of support persons in either of the two populations (data not shown).

| Providers of social support
Examining the identified providers of social support for adolescents in the two samples, a Pearson chi-squared test revealed that adolescents from the general population reported support from their mother, father, sibling(s), and neighbour(s) significantly more often compared with adolescents in RYC (see Table 2). Relative(s) was the only source of support mentioned significantly more often in the RYC sample. For the RYC adolescents, institutional staff was the third most reported source of social support, after friend(s) and mother.

| DISCUSSION
In this national study, the adolescents in RYC perceived support from a lower number of support persons than adolescents in the general population. For both the RYC boys and girls, perceived social support developed differently across age than for general population adolescents. Although the adolescents in RYC at the age of 14 perceived support from a lower number of support persons than the general population, especially for girls, no difference in the number of support

| Number of support persons
The findings that adolescents in RYC have a lower number of support persons available compared with adolescents from the general population was as expected, as the same pattern has been found among children's home residents in Croatia (Franz, 2004) and in other high-risk groups (Furukawa et al., 1999 forming new relationships with adolescents outside the institutional setting and that they prefer unorganized over organized leisure activities . These are factors that can influence perceived social support. Finally, the ability to perceive and accept social support might be affected by psychiatric disorders (Kawachi & Berkman, 2001) and lead to a reduced number of support persons (Furukawa et al., 1999). Jozefiak et al. (2016) found a prevalence of 76% of psychiatric disorders among RYC adolescents, which might partially explain their lower number of support persons compared with the general population.
A surprising finding was that the girls in RYC reported the lowest number of support persons available at the age of 14, which is inconsistent with previous research, where girls have reported a higher number of support persons than boys (Bender & Lösel, 1997;Gecková et al., 2003;Rueger et al., 2010). Differences in coping styles among boys and girls might explain these findings. Girls have a tendency to use passive ways of coping with difficult or challenging situations (Hampel & Petermann, 2006;Piko, 2001), making them cautious when entering new social contexts after experiencing several prior disrupted attachments. Girls might therefore seek new relationships for social support less often than boys. Boys tend to cope with difficult situations by emotion distracting through turning attention to more pleasant activities rather than to the acute situation (Compas et al., 1993;Piko, 2001). Seeking social contact instead of focusing on their feelings might positively affect boys' relations to the institutional staff and other residents. In addition, the observed differences between girls and boys in RYC might be explained by the fact that girls have been found to have a significantly higher prevalence of anxiety and depression (Jozefiak et al., 2016), which has been reported to be associated with low levels of support (Furukawa et al., 1999;Rueger et al., 2014).
According to age, the adolescents in RYC reported a lower number of support persons at the age of 14 compared with adolescents in the general population, whereas no difference was observed between the two groups at the age of 18. This interaction was caused by fewer support persons across age in the general population, whereas it remained relatively stable for the RYC adolescents. The findings might be explained by an increase in autonomy (Piko, 2001) and reduced reliance on adults, which is a natural part of the developmental process during adolescence. For some adolescents in RYC, their life situations might have expedited autonomy development at an earlier age, caused by family problems and out-of-home placements, reducing the likelihood of perceiving family members as supportive. At age 18, the reliance on and need for social support from adults is less pronounced.

| Satisfaction with support
The RYC adolescents appeared generally satisfied with the support they perceived and did not differ from the general population in this regard. This was an unexpected finding. Earlier research has found associations between low levels of satisfaction with social support and mental health problems among adolescents and adults (Garnefski & Diekstra, 1996;Thomas et al., 2016) and low quality of life for adult psychiatric patients (Bengtsson-Tops & Hansson, 2001). As the RYC adolescents also reported a high prevalence of mental health problems (Jozefiak et al., 2016) and a low quality of life (Damnjanovic et al., 2012;, they were expected to report low satisfaction with support. It may be that when RYC adolescents report being satisfied with social support despite their negative life experiences Note. Each support person is only counted once, regardless of being mentioned as a support person in more than one item. Bold indicates significant differences between groups. The category "institutional staff" is only available for the adolescents in RYC.  -Hansen et al., 2011;Jozefiak et al., 2016;Kepper et al., 2014). It will therefore be important for the institutional staff to monitor how social relationships develop and affect the adolescents' daily functioning while in RYC.

| Providers of social support
The RYC adolescents reported support from their immediate family members and neighbours significantly less often compared with adolescents in the general population. These results were not unexpected because adolescents in RYC are separated from their family and home environment, often caused by difficult home conditions. At the same time, perceived social support from other relatives was more common among the RYC adolescents, indicating that these adolescents may favour using their extended family network for social support even though relationships with their immediate family members are disrupted. This tendency might be a consequence of the policy in CWS in recent years, where kinship foster care and placements in the children's wider social network are preferred (Thørnblad, 2011).
In addition, friend support was by far the most often mentioned source of support among the adolescents in RYC, followed by their mothers, who were second. RYC staff should facilitate the maintenance of the relations between adolescents and their friends and family. Also, institutional staff was the third most reported source of social support for adolescents in RYC, being mentioned almost as often as their mothers. Close to two-thirds of the RYC adolescents reported that staff members were supportive. Staff members were found to be important attachment figures that provided a caring environment (Berridge et al., 2012;Harder et al., 2013). The need for adolescents in RYC to find alternative sources of support in the absence of family support suggests that the members of the institutional staff are important support persons for these adolescents.

| Limitations
A limitation in the current study is the Social Support Questionnaire, measuring the number of support persons available and overall satisfaction on each item. In this form, satisfaction with the support from different support persons could not be determined. Also, the cat-

| Implications for practice
The current study underscores the important role that institutional staff play in providing social support for adolescents in RYC when living away from their family and friends. The support they provide should be of high quality, which might require training in relational competence for those working in RYC. Also, the adolescents' primary contacts have important roles as mentors for the adolescents and should have an extended role in providing social support for these vulnerable adolescents, as they often have the closest relationships with the adolescents.
In addition to strengthening the competence of the staff in relational processes, upholding contact between adolescents in RYC and their existing social support providers, as well as establishing new connections, should be prioritized when possible. As previous research has demonstrated, social support influences adolescents' mental health, perceptions of stress, and well-being. The quantity and quality of available social support should be a focus in interventions for these vulnerable youths.
As institutional staff members are important providers of social support for adolescents in RYC, they risk losing an important source of social support when moving out of institutional care at the age of 18. Placement in RYC, especially if some distance away from their home environment, may have disrupted their peer and family social support network. Receiving aftercare from the CWS could be of great importance for these adolescents and should last until the age of 23. This would give these adolescents time to settle into young adulthood.

| CONCLUSIONS
The current study is the first to broadly investigate perceived social support among adolescents in RYC, addressing both the number of support persons available, satisfaction with support, and the specific support providers for adolescents in RYC. Including adolescents from the general population for comparison provides an important context for the illuminating findings for adolescents in RYC.
In this study, adolescents in RYC perceive social support from a lower number of support persons compared with adolescents in the general population. Even though they have a lower number of support persons available, they are satisfied with the support. In addition, having a larger number of support persons is associated with higher satisfaction with the perceived support. As adolescents in RYC are in need of social support from an extended network, measures to increase social support in RYC are needed. As adolescents in RYC at a young age and especially girls perceive less social support than the general population, new measures should be implemented among the youngest adolescents. When adolescents live in RYC, measures should be taken to increase the availability of social support from family members and friends. Because institutional staff members are found to be important support persons for these adolescents, relational skills and competence among staff should be strengthened. In addition, initiatives such as aftercare following aging out of CWS should be ensured to avoid another disrupted attachment for these already highly challenged adolescents as they enter adulthood.