Distress Tolerance and Social Support in Adolescence: Predicting Risk for Internalizing and Externalizing Symptoms Following a Natural Disaster

  • Joseph R. Cohen
  • Carla Kmett Danielson
  • Zachary W. Adams
  • Kenneth J. Ruggiero


The purpose of the multi-measure, multi-wave, longitudinal study was to examine the interactive relation between behavioral distress tolerance (DT) and perceived social support (PSS) in 352 tornado-exposed adolescents aged 12–17 years (M = 14.44; SD = 1.74). At baseline, adolescents completed a computer-based task for DT, and self-report measures of PSS, depressed mood, posttraumatic stress disorder (PTSD), substance use, and interpersonal conflict. Symptoms also were assessed 4 and 12 months after baseline. Findings showed that lower levels of DT together with lower levels of PSS conferred risk for elevated symptoms of prospective depression (t(262) = −2.04, p = .04; reffect size = 0.13) and PTSD (t(195) = −2.08, p = .04; reffect size = 0.15) following a tornado. However, only PSS was significant in substance use t(139) = 2.20, p = .03; reffect size=0.18) and conflict (t(138) = −4.05, p < .0001; reffect size=0.33) in our sample. Implications regarding adolescent DT, the transdiagnostic nature of PSS, and the clinical applications of our findings in the aftermath of a natural disaster are discussed.


Distress tolerance Perceived social support Natural disasters Adolescence Internalizing symptoms Externalizing symptoms 



The National Institute of Mental Health supported this study and the team of collaborators: data collection occurred via grants R01MH081056 to KJR and R21MH086313 to CKD. The preparation of this manuscript was partially supported by grant R01DA031285 to CKD, grant K12-DA031794 which supports ZWA, and T32MH18869 which supported JRC.

Compliance with Ethical Standards

Conflict of Interest

Joseph R. Cohen, Carla Kmett Danielson, Zachary W. Adams and Kenneth J. Ruggiero have no conflict of interest to report.

Experiment Participants

All procedures and protocols for this study were approved by the Institutional Review Board (IRB) at the MedicalUniversity of South Carolina.


  1. Abela, J. R. Z., & Hankin, B. L. (2008). Cognitive vulnerability to depression in children and adolescents. In J. R. Z. Abela & B. L. Hankin (Eds.), Handbook of depression in children and adolescents (pp. 35–78). New York: Guilford.Google Scholar
  2. Adams, R. E., & Boscarino, J. A. (2006). Predictors of PTSD and delayed PTSD after disaster: the impact of exposure and psychosocial resources. The Journal of Nervous and Mental Disease, 194, 485–504.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Adams, Z. W., Sumner, J. A., Danielson, C. K., McCauley, J. L., Resnick, H. S., Grös, K., et al. (2014). Prevalence and predictors of PTSD and depression among adolescent victims of the spring 2011 tornado outbreak. Journal of Child Psychology and Psychiatry. doi: 10.1111/jcpp.12220.PubMedPubMedCentralGoogle Scholar
  4. Amstadter, A. B., Daughters, S. B., MacPherson, L., Reynolds, E. K., Danielson, C. K., Wang, F., et al. (2012). Genetic associations with performance on a behavioral measure of distress intolerance. Journal of Psychiatric Research, 46, 87–94. doi: 10.1016/j.jpsychires.2011.09.017.CrossRefPubMedGoogle Scholar
  5. Auerbach, R. P., Bigda-Peyton, J. S., Eberhart, N. K., Webb, C. A., & Ho, M. H. R. (2011). Conceptualizing the prospective relationship between social support, stress, and depressive symptoms among adolescents. Journal of Abnormal Child Psychology, 39, 475–487. doi: 10.1007/s10802-010-9479-x.CrossRefPubMedGoogle Scholar
  6. Bauer, D. J., Preacher, K. J., & Gil, K. M. (2006). Conceptualizing and testing random indirect effects and moderated mediation in multilevel models: new procedures and recommendations. Psychological Methods, 11, 142–163. doi: 10.1037/1082-989X.11.2.142.CrossRefPubMedGoogle Scholar
  7. Beauchaine, T. P., & Gatzke-Kopp, L. M. (2012). Instantiating the multiple levels of analysis perspective in a program of study on externalizing behavior. Development and Psychopathology, 24, 1003–1018. doi: 10.1017/S0954579412000508.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Birman, D., Trickett, E. J., & Vinokurov, A. (2002). Acculturation and adaptation of soviet Jewish refugee adolescents: predictors of adjustment across life domains. American Journal of Community Psychology, 30, 585–607. doi: 10.1023/A:1016323213871.CrossRefPubMedGoogle Scholar
  9. Bonanno, G. A., Brewin, C. R., Kaniasty, K., & La Greca, A. M. (2010). Weighing the costs of disaster consequences, risks, and resilience in individuals, families, and communities. Psychological Science in the Public Interest, 11, 1–49. doi: 10.1177/1529100610387086.CrossRefPubMedGoogle Scholar
  10. Boscarino, J. A., Galea, S., Ahern, J., Resnick, H. S., & Vlahov, D. (2002). Utilization of mental health services following the September 11th terrorist attacks in Manhattan, New York City. International Journal of Emergency Mental Health, 4, 143–155. doi: 10.1176/ Scholar
  11. Brown, B. B., & Bakken, J. P. (2011). Parenting and peer relationships: reinvigorating research on family–peer linkages in adolescence. Journal of Research on Adolescence, 21, 153–165. doi: 10.1111/j.1532-7795.2010.00720.x.CrossRefGoogle Scholar
  12. CDC. Centers for Disease Control and Prevention. (2011). Youth Risk Behavior Survey (YRBS). U.S. Department of Health and Human Services.Google Scholar
  13. Cicchetti, D., & Rogosch, F. A. (1996). Equifinality and multifinality in developmental psychopathology. Development and Psychopathology, 8, 597–600. doi: 10.1017/S0954579400007318.CrossRefGoogle Scholar
  14. Colarossi, L. G. (2001). Adolescent gender differences in social support: structure, function, and provider type. Social Work Research, 25, 233–241. doi: 10.1093/swr/25.4.233.CrossRefGoogle Scholar
  15. Cummings, J. R., Bornovalova, M. A., Ojanen, T., Hunt, E., MacPherson, L., & Lejuez, C. (2013). Time doesn’t change everything: the longitudinal course of distress tolerance and its relationship with externalizing and internalizing symptoms during early adolescence. Journal of Abnormal Child Psychology, 41, 735–748. doi: 10.1007/s10802-012-9704-x.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Danielson, C. K., Ruggiero, K. J., Daughters, S. B., & Lejuez, C. W. (2010). Distress tolerance, risk-taking propensity, and PTSD symptoms in trauma-exposed youth: pilot study. The Behavior Therapist, 33, 28–34.Google Scholar
  17. Danielson, C.K., Sumner, J., Adams, Z., McCauley, J., Carpenter, M., Amstadter, A.B., & Ruggiero, K. (2014). Substance use patterns and problems among disaster-exposed adolescents: Findings from the Alabama/Missouri Tornados of Spring of 2011. Manuscript submitted for publication.Google Scholar
  18. Daughters, S. B., Reynolds, E. K., MacPherson, L., Kahler, C. W., Danielson, C. K., Zvolensky, M., & Lejuez, C. W. (2009). Distress tolerance and early adolescent externalizing and internalizing symptoms: the moderating role of gender and ethnicity. Behaviour Research and Therapy, 47, 198–205. doi: 10.1016/j.brat.2008.12.001.CrossRefPubMedGoogle Scholar
  19. Daughters, S. B., Gorka, S. M., Magidson, J. F., MacPherson, L., & Seitz-Brown, C. J. (2013). The role of gender and race in the relation between adolescent distress tolerance and externalizing and internalizing psychopathology. Journal of Adolescence, 36, 1053–1065. doi: 10.1016/j.adolescence.2013.08.008.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Dhalla, S., Zumbo, B. D., & Poole, G. (2011). A review of the psychometric properties of the CRAFFT instrument: 1999-2010. Current Drug Abuse Reviews, 4, 57–64.CrossRefPubMedGoogle Scholar
  21. Ehrlich, K. B., Cassidy, J., Gorka, S. M., Lejuez, C. W., & Daughters, S. B. (2013). Adolescent friendships in the context of dual risk: the roles of low adolescent distress tolerance and harsh parental response to adolescent distress. Emotion, 13, 843–851. doi: 10.1037/a0032587.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Feder, A., Ahmad, S., Lee, E. J., Morgan, J. E., Singh, R., Smith, B. W., et al. (2013). Coping and PTSD symptoms in Pakistani earthquake survivors: purpose in life, religious coping and social support. Journal of Affective Disorders, 147(1), 156–163.CrossRefPubMedGoogle Scholar
  23. Fink, E. L. (2009). The FAQs on data transformation. Communication Monographs, 76, 379–397. doi: 10.1080/03637750903310352.CrossRefGoogle Scholar
  24. Flynn, M., Kecmanovic, J., & Alloy, L. B. (2010). An examination of integrated cognitive-interpersonal vulnerability to depression: the role of rumination, perceived social support, and interpersonal stress generation. Cognitive Therapy and Research, 34, 456–466. doi: 10.1007/s10608-010-9300-8.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Furr, J. M., Comer, J. S., Edmunds, J. M., & Kendall, P. C. (2010). Disasters and youth: a meta-analytic examination of posttraumatic stress. Journal of Consulting and Clinical Psychology, 78, 765–780. doi: 10.1037/a0021482.CrossRefPubMedGoogle Scholar
  26. Hedeker, D., & Gibbons, R. D. (1997). Longitudinal data analysis. Hoboken: Wiley.Google Scholar
  27. Hofer, C., Eisenberg, N., Spinrad, T. L., Morris, A. S., Gershoff, E., Valiente, C., et al. (2013). Mother–adolescent conflict: stability, change, and relations with externalizing and internalizing behavior problems. Social Development, 22, 259–279. doi: 10.1111/sode.12012.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A. K., Gegenheimer, K., et al. (2010). Children's mental health care following hurricane Katrina: a field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23, 223–231. doi: 10.1002/jts.20518.PubMedPubMedCentralGoogle Scholar
  29. Kane, P., & Garber, J. (2009). Parental depression and child externalizing and internalizing symptoms: unique effects of fathers’ symptoms and perceived conflict as a mediator. Journal of Child and Family Studies, 18(4), 465–472. doi: 10.1007/s10826-008-9250-x.CrossRefGoogle Scholar
  30. Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156, 607–614. doi: 10.1001/archpedi.156.6.607.CrossRefGoogle Scholar
  31. La Greca, A. M., Silverman, W. K., Vernberg, E. M., & Prinstein, M. J. (1996). Symptoms of posttraumatic stress in children after Hurricane Andrew: a prospective study. Journal of Consulting and Clinical Psychology, 64(4), 712.CrossRefPubMedGoogle Scholar
  32. La Greca, A. M., Silverman, W. K., & Wasserstein, S. B. (1998). Children’s predisaster functioning as a predictor of posttraumatic stress following Hurricane Andrew. Journal of Consulting and Clinical Psychology, 66, 883–892.CrossRefPubMedGoogle Scholar
  33. La Greca, A. M., Silverman, W. K., Lai, B., & Jaccard, J. (2010). Hurricane-related exposure experiences and stressors, other life events, and social support: concurrent and prospective impact on children's persistent posttraumatic stress symptoms. Journal of Consulting and Clinical Psychology, 78, 794–805. doi: 10.1037/a0020775.CrossRefPubMedGoogle Scholar
  34. La Greca, A.M., Taylor, C.J., & Herge, W.M. (2012). Traumatic stress disorders in children and adolescents. The Oxford handbook of traumatic stress disorders, 98–118.Google Scholar
  35. Lai, B. S., La Greca, A. M., Auslander, B. A., & Short, M. B. (2013). Children's symptoms of posttraumatic stress and depression after a natural disaster: comorbidity and risk factors. Journal of Affective Disorders, 146, 71–78. doi: 10.1016/j.jad.2012.08.041.CrossRefPubMedGoogle Scholar
  36. Lejuez, C.W., Daughters, S.B., Danielson, C.W., & Ruggiero, K. (2006). The behavioral indicator of resiliency to distress (BIRD). Unpublished manual.Google Scholar
  37. Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychological Bulletin, 136, 576–600. doi: 10.1037/a0019712.CrossRefPubMedPubMedCentralGoogle Scholar
  38. MacPherson, L., Reynolds, E. K., Daughters, S. B., Wang, F., Cassidy, J., Mayes, L. C., & Lejuez, C. W. (2010). Positive and negative reinforcement underlying risk behavior in early adolescents. Prevention Science, 11, 331–342. doi: 10.1007/s11121-010-0172-7.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Marroquín, B. (2011). Interpersonal emotion regulation as a mechanism of social support in depression. Clinical Psychology Review, 31, 1276–1290. doi: 10.1016/j.cpr.2011.09.005.CrossRefPubMedGoogle Scholar
  40. Marshall-Berenz, E. C., Vujanovic, A. A., Bonn-Miller, M. O., Bernstein, A., & Zvolensky, M. J. (2010). Multimethod study of distress tolerance and PTSD symptom severity in a trauma-exposed community sample. Journal of Traumatic Stress, 23, 623–630.CrossRefPubMedPubMedCentralGoogle Scholar
  41. McClelland, G. H., & Judd, C. M. (1993). Statistical difficulties of detecting interactions and moderator effects. Psychological Bulletin, 114, 376–390.CrossRefPubMedGoogle Scholar
  42. McHugh, R. K., Daughters, S. B., Lejuez, C. W., Murray, H. W., Hearon, B. A., Gorka, S. M., & Otto, M. W. (2011). Shared variance among self-report and behavioral measures of distress intolerance. Cognitive Therapy and Research, 35, 266–275. doi: 10.1007/s10608-010-9295-1.CrossRefPubMedPubMedCentralGoogle Scholar
  43. Missouri Department of Public Safety and Statistical Analysis. (2012). Nature and extent of the illicit drug problem in Missouri Report. Google Scholar
  44. National Oceanic and Atmospheric Association. (2012). Tornadoes–annual 2011. Retrieved from
  45. Neumayer, E., & Barthel, F. (2011). Normalizing economic loss from natural disasters: a global analysis. Global Environmental Change, 21, 13–24. doi: 10.1016/j.gloenvcha.2010.10.004.CrossRefGoogle Scholar
  46. Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology, 76, 28. doi: 10.1037/0022-006X.76.1.28.CrossRefPubMedGoogle Scholar
  47. Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best, C. L. (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984–991. doi: 10.1037/0022-006X.61.6.984.CrossRefPubMedGoogle Scholar
  48. Rice, M. E., & Harris, G. T. (2005). Comparing effect sizes in follow-up studies: ROC area, Cohen’s d, and r. Law and Human Behavior, 29, 615–620. doi: 10.1007/s10979-005-6832-7.CrossRefPubMedGoogle Scholar
  49. Rigby, K. (2000). Effects of peer victimization in schools and perceived social support on adolescent well-being. Journal of Adolescence, 23, 57–68. doi: 10.1006/jado.1999.0289.CrossRefPubMedGoogle Scholar
  50. Robin, A. L., & Foster, S. L. (1989). Negotiating parent-adolescent conflict: A behavioral-family systems approach. New York: Guilford Press.Google Scholar
  51. Rodman, S. A., Daughters, S. B., & Lejuez, C. W. (2009). Distress tolerance and rational-emotive behavior therapy: a new role for behavioral analogue tasks. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 27, 97–120. doi: 10.1007/s10942-009-0090-4.CrossRefGoogle Scholar
  52. Rudolph, K. D., Flynn, M., & Abaied, J. L. (2008). A developmental perspective on interpersonal theories of youth depression. 79–102. In J. R. Z. Abela & B. L. Hankin (Eds.), Handbook of depression in children and adolescents (pp. 79–102). New York: Guilford.Google Scholar
  53. Ruggiero, K. J., Resnick, H. S., Paul, L. A., Gros, K., McCauley, J. L., et al. (2012). Randomized controlled trial of an internet-based intervention using random-digit-dial recruitment: the Disaster Recovery Web project. Contemporary Clinical Trials, 33, 237–246. doi: 10.1016/j.cct.2011.10.001.CrossRefPubMedGoogle Scholar
  54. Seidman, E., Allen, L., Aber, J. L., Mitchell, C., Feinman, J., Yoshikawa, H., et al. (1995). Development and validation of adolescent-perceived microsystem scales: social support, daily hassles, and involvement. American Journal of Community Psychology, 23, 355–388.CrossRefPubMedGoogle Scholar
  55. Silvers, J. A., McRae, K., Gabrieli, J. D., Gross, J. J., Remy, K. A., & Ochsner, K. N. (2012). Age-related differences in emotional reactivity, regulation, and rejection sensitivity in adolescence. Emotion, 12, 1235–1247. doi: 10.1037/a0028297.CrossRefPubMedPubMedCentralGoogle Scholar
  56. Tabachnick, B. G., & Didell, L. S. (2007). Using multivariate statistics (5th ed.). Boston: Allyn and Bacon.Google Scholar
  57. Tandon, S. D., Dariotis, J. K., Tucker, M. G., & Sonenstein, F. L. (2013). Coping, stress, and social support associations with internalizing and externalizing behavior among urban adolescents and young adults: revelations from a cluster analysis. Journal of Adolescent Health, 52, 627–633.CrossRefPubMedGoogle Scholar
  58. Tang, B., Liu, X., Liu, Y., Xue, C., & Zhang, L. (2014). A meta-analysis of risk factors for depression in adults and children after natural disasters. BMC Public Health, 14, 623–635.CrossRefPubMedPubMedCentralGoogle Scholar
  59. Trickett, E. J., & Birman, D. (2005). Acculturation, school context, and school outcomes: adaptation of refugee adolescents from the former Soviet Union. Psychology in the Schools, 42(1), 27–38.CrossRefGoogle Scholar
  60. Zvolensky, M. J., Leyro, T. M., Bernstein, A., & Vujanovic, A. A. (2011). Historical perspectives, theory, and measurement of distress tolerance. In M. J. Zvolensky, A. Bernstein, & A. A. Vujanovic (Eds.), Distress tolerance: Theory, research, and clinical applications (pp. 3–27). New York: Guilford.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Joseph R. Cohen
    • 1
  • Carla Kmett Danielson
    • 2
  • Zachary W. Adams
    • 2
  • Kenneth J. Ruggiero
    • 3
    • 4
  1. 1.Department of PsychologyUniversity of IllinoisChampaignUSA
  2. 2.National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral SciencesMedical University of South CarolinaCharlestonUSA
  3. 3.Technology Applications Center for Healthful Lifestyles, College of NursingMedical University of South CarolinaCharlestonUSA
  4. 4.Health Equity and Rural Outreach Innovation CenterRalph H. Johnson VAMCCharlestonUSA

Personalised recommendations