Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 10, e69, p. 1-16, 2020
DOI: 10.5902/2179769239810
ISSN 2179-7692
Submission: 09/01/2019 Acceptance: 04/15/2020 Publication: 10/08/2020
Original Article
Experiences of adolescents with depressive symptoms in school context
Vivências de adolescentes com sintomas depressivos em contexto escolar
Vivencias de los adolescentes con síntomas depresivos en el contexto escolar
Fernando Fraga HerzogI
Aline Cammarano RibeiroII
Lisiane dos Santos WelterIII
Graciela Dutra SenhemIV
Lidiana Batista Teixeira Dutra SilveiraV
Fernanda Franceschi de FreitasVI
I Nursing student from the Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil. E-mail: fernando-fraga@hotmail.com ORCID: https://orcid.org/0000-0002-6968-9104
II Nurse. PhD in Nursing. Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil. E-mail: alinecammarano@gmail.com. ORCID: https://orcid.org/0000-0003-3575-2555
III Psychologist. MSc student from the Postgraduate Program in Psychology of the Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil. E-mail: lisianewelter27@gmail.com ORCID: https://orcid.org/0000-0002-6781-0847
IV Nurse. PhD in Nursing. Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil. E-mail: graci_dutra@yahoo.com.br ORCID: https://orcid.org/0000-0003-4536-824X
V Nurse. PhD student in Nursing from the Postgraduate Program of the Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil. E-mail: lidianadutrasilveira@gmail.com ORCID: https://orcid.org/0000-0001-6373-9353
VI Nurse. MSc in Nursing. University Hospital of Santa Maria (HUSM), Santa Maria, RS, Brazil. E-mail: fe_franceschi@yahoo.com.br ORCID: https://orcid.org/0000-0002-9618-4400
Abstract: Objective: to know the experiences of adolescents with depressive symptoms in school context. Method: qualitative study carried out in a public school in the countryside of the state of Rio Grande do Sul. The interviewees were 05 adolescents with depressive symptoms or diagnosis of depression, according to a checklist. The interviews occurred from April to May 2019 and the data were treated by Content Analysis of Minayo. Results: two categories emerged from the adolescents’ speeches: the adolescence and the intensification of the depressive symptoms and sources of support and the prospects for the future. Final Thoughts: the adolescents present common experiences for age, such as the interaction with the family, school and peers, as well as behaviors of indecision and doubt. Due to the process of adaptation to changes of adolescence, many times, they have not developed the ability to deal with certain situations yet.
Descriptors: Adolescent; Depression; Mental health; Nursing
Resumo: Objetivo: conhecer as vivências dos adolescentes com sintomas depressivos em contexto escolar. Método: estudo qualitativo realizado em uma Escola Pública do interior do Estado do Rio Grande do Sul. Foram entrevistados 05 adolescentes que apresentassem sintomas depressivos ou diagnóstico de depressão, conforme checklist. As entrevistas ocorreram de abril a maio de 2019 e os dados foram tratados pela Análise de Conteúdo de Minayo. Resultados: emergiram das falas dos adolescentes duas categorias: O adolescer e a intensificação dos sintomas depressivos e Fontes de apoio e as perspectivas para o futuro. Considerações finais: os adolescentes apresentam vivências comuns para a idade, como o convívio com a família, escola e pares, além de comportamentos de indecisão e dúvida. Devido estar adaptando-se ao processo de mudanças da fase adolescência, muitas vezes, ainda não desenvolveu habilidade para lidar com determinadas situações.
Descritores: Adolescente; Depressão; Saúde mental; Enfermagem
Resumen: Objetivo: conocer las vivencias de los adolescentes con síntomas depresivos en el contexto escolar. Método: estudio cualitativo realizado en una escuela pública del interior del estado de Rio Grande do Sul. Fueron entrevistados 05 adolescentes con síntomas depresivos o diagnóstico de depresión, de acuerdo con una checklist. Las entrevistas se produjeron de abril a mayo de 2019 y los datos fueron tratados mediante el Análisis del Contenido de Minayo. Resultados: emergieron de los discursos de los adolescentes dos categorías: la adolescencia y la intensificación de los síntomas depresivos y fuentes de apoyo y las perspectivas para el futuro. Consideraciones finales: los adolescentes presentan vivencias comunes para su edad, como la interacción con la familia, la escuela y sus compañeros, así como los comportamientos de la indecisión y la duda. Debido al proceso de adaptación a los cambios de la adolescencia, muchas veces, aún no desarrollaron la capacidad para afrontar determinadas situaciones.
Descriptores: Adolescente; Depresión; Salud mental; Enfermería
Introduction
Adolescence is a stage of the vital cycle characterized by many changes and peculiarities, continuous and intense, which affect the lives of individuals, in the physical, emotional and social aspects. At this stage, there is a profound transformation between the child and the young adult.1
The adolescent, due to his/her period of development, can become a vulnerable individual, and is subject to developing psychopathologies, which, until the middle of the 1960’s, were considered adults’ exclusive pathologies, such as depression.2 For the World Health Organization (WHO), depression is a common mental disorder, and is characterized by symptoms such as anhedonia, low self-esteem, guilt, sadness, worthlessness, changes in sleep and appetite for at least two weeks.3
Data from the WHO show that, between the years 2005 and 2015, there was a significant increase in the number of cases of depression, 18%. Moreover, according to estimates from 2017, 300 million people live with depression. Brazil is the country of Latin America with the highest prevalence of this psychopathology, affecting 5.8% of the population, i.e., 11.5 million people suffer from this mental disorder. This change may occur at any stage of the vital cycle.3
In adolescents, the symptoms may present differently from adulthood. Some behaviors common to the age group, such as irritability, mood changes, aggressiveness and sleep disorders are observed in cases of depression, which are frequent characteristics of the adolescence period and hinder the proper diagnosis.4
The depression in adolescence is complex and constitutes a problem that demand challenges for public health and requires an attentive look, because if not cared for and treated, it can cause serious damage to the development, mental health and quality of life of adolescents. In a study related to depression in adolescents, with high-school students from four European countries (Austria, Germany, Slovenia and Spain), the results indicated a combination of individual factors, which include self-esteem, self-acceptance, optimism, and the protective factors, such as family support and stability and a participatory school, which considered the need for a multifactor approach associated with mental health assessment in the context of prevention and intervention.5
The adolescent’s context presents factors that are related to the onset of symptoms of depression, such as social vulnerability, low income, separation from parents, violence suffered by the adolescent caused by the mother, use of psychoactive substances and the dissatisfaction with the self-image.6
Aiming to decrease these vulnerabilities, one possibility is the School Health Program (PSE), created in 2007, which aims to integrate health promotion actions, performed by primary care teams, in the school context.7 In this way, the Health at School space is appropriate for creating and strengthening the bonds between the nursing and adolescents, with the possibility of carrying out actions of promotion, prevention and intervention, thus minimizing potential harms to their health.
Knowing the importance of nursing and the care in this context, the research question of the study is: what are the experiences of adolescents with depressive symptoms in the school context? In order to enable nursing professionals and school the approximation of subjective aspects shown by adolescents, to conduct health education based on actions of health promotion and prevention of depression.
The research on this theme is justified, as it is emerging in adolescent health and a public health problem; moreover, it is in line with the goals of sustainable development of the United Nations,8 described in goal 3: Ensure healthy lives and promote well-being for all at all ages, and establishes the following goal: by 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. Thus, this study aimed to understand the experiences of adolescents with depressive symptoms in school context.
Method
This is a descriptive and exploratory study with a qualitative approach. The scenario was a State Public School, located in a city in the countryside of Rio Grande do Sul. This school offers the following steps of education: elementary education, secondary education and Education for Young People and Adults. The participants were adolescent students from elementary or secondary education of the selected school.
The selection criterion was adolescents aged between 12 and 18 years, as defined by the Byelaw of Children and Adolescents (ECA), who presented depressive symptoms or diagnosis of depression, according to the perception of the teaching staff of the school and as checklist delivered to teachers. For this selection, the teachers were trained from a qualification for the recognition of depressive symptoms, based on the Diagnostic and Statistical Handbook of Mental Disorders.9
Data collection occurred through a semi-structured interview, consisting of sociodemographic questions regarding sex, age and family composition, and questions related to the objective of this research. The interview was conducted according to the adolescents’ demand to talk, giving them an environment of listening and confidentiality. The productions were analyzed according to the thematic content analysis technique, which consists of unveiling the meaning cores, whose presence or frequency is expressive for the analytic objective pursued, covering the phases: pre-analysis, material exploration; treatment of the results obtained and interpretation.10
The participants were eight adolescents with depressive symptoms and diagnosis of depression based on the checklist used by the teachers. From this, they were contacted, and two of them were interested in participating, but the parents refused the participation and one refused to participate in the research. Therefore, five interviews were performed, in a room available in the school itself. The collection was carried out during April and May 2019.
The research was approved on March 20, 2019, by the Human Research Ethics Committee (REC) of the proponent institution, in accordance with the terms of resolution 466/12 of the National Health Council, with opinion n. 3.210.655 and CAAE n. 08034219.6.0000.5346. The research was conducted according to the ethical standards required.
Adolescents who participated in the study signed an assent form and their guardians signed the informed consent form, both in two copies, leaving a copy with the researcher and the other with the participant and the guardian. Thea participants’ anonymity was maintained and the same were identified by the letter “A”, of “adolescent”, followed by the numbers from 1 to 5 (A1, A2, A3; successively).
Results and discussion
The adolescents were aged between 14 and 18 years, four were female and one, male. None reported having any religion or spirituality. Three adolescents lived with the mother, one with the grandparents and one with the parents. The income of four participants was greater than one minimum wage. Four teenagers attended psychological follow-up and two were in use of psychiatric medications. In this direction, two categories emerged: The adolescence and the intensification of the depressive symptoms and Sources of support and the prospects for the future.
The adolescence and the intensification of the depressive symptoms
The adolescents, when asked about their feelings on a day-to-day basis, were confused to speak, had difficult to explain, oscillation of feelings, and, in some moments, were sad and/or agitated. One teenager reported that her mother thought that this oscillation of feelings was strange and compared herself to her friends who also had negative thoughts.
[...] it is pretty confusing to be honest, I cannot explain. Sometimes, I stay quiet in my bedroom, I cannot name my feelings, I just want to stay quiet. (A1)
[...] some days I am very agitated, some days, I feel blue, more quiet, and my mother finds it strange [...] some friends of mine are like me, feel blue, have the same thoughts I do. (A2)
[...] I feel so sad, anxious, worried, with some moments of joy, so, I feel many things. (A3)
[...] I do not know, I am bipolar, it depends. It is all together. (A5)
Adolescence is a critical step in the process of evolution of the subject, with peculiarities inherent to this phase.11 The statements revealed specificities related to adolescent behavior. In the pursuit of its emancipation, adolescence can be a conflicting and uncertain phase. These physical and psychosocial modifications may generate their own identity and should be lived naturally.12
According to the Pan-American Health Organization (PAHO),13 this prototype, idealized to adulthood, can become vulnerable, according to the situations experienced by adolescents, such as exposure to violence, family vulnerabilities, financial difficulties and history of abuse. This period and the way it is experienced are considered a mental health determinant in adolescents.
Some feelings that permeate the daily life of these adolescents are negative, which sometimes go beyond their understanding of what is natural and negatively affect their day-to-day, in social, school and family spaces. The adolescent perceives his/her negative thoughts, reports their sudden emergence and cannot establish a connection to a reason, leaving them distressed. During the interviews, all participants were restless and frequently shook their hands when talking about their feelings, which shows anxiety.
[...] depending on the day [I feel] so sad [...] sometimes I look at the mirror and ask myself, why am I like this? It is awful, it is sudden. (A1)
[...] somehow I feel sad, bad, blue, I just do not know why, but I feel so. (A2)
[...] I feel so sad, anxious, worried. Most of the time I feel sad or lonely. (A3)
[...] suddenly I feel sad, I feel like crying. (A4)
[...] I have a diagnosis of depression, a bit of anxiety. So, sometimes I have attacks too [...] I have panic attacks, I cannot explain [...] I get so desperate, my heart beats faster, I feel like crying, I start to tremble a lot, I cannot remember, because it is momentary and then I cannot remember much. (A5)
The expression of emotions is a skill developed from experiences, being this experience responsible for enabling the subject to certain attitude. In this sense, the statements show the difficulties to recognize expressions, emotions and thoughts, a process that is in a phase of improvement in adolescents’ lives.
Only at the final stage of adolescence, the individual begins to shape the emotional maturity and, during this process, the adolescent may be already susceptible to the vulnerability.14 According to information published by the PAHO,13 the adolescent with emotional instability must be approached very early, with the development of actions for health promotion and protection, because there may be consequences regarding altered mental wellbeing in adulthood.
Social isolation is seen as a way of dealing with the thoughts that cause this affliction in the daily life of adolescents, as well as the desire to disappear, a way reported by the adolescent to mitigate that anguish and suffering. The subsequent statements demonstrate this concern.
[...] I stay in my room, I do not like going out much [...] [I think about] disappearing. I think about being somewhere else, away from everyone, until it is over. (A1)
[...] when I am bad, I wish I was not there. (A2)
[...] I kind of created a fantasy world in my head where I spend most of my time, I spend more time in my fantasy world than in the real world. (A3)
[...] I think about disappearing, leaving that place. It seems that when I disappear, so does the sadness. (A4)
[...] at night, when I go to my bedroom, it seems I am more alone, I am not with people, it seems I do not have to pretend I am better for the others [...] then my real me appears, it is worse. So, everything that was locked inside of me the whole day comes back at night when I am all alone. (A5)
The social distancing is considered the isolationist behavior of the individual in relation to his/her peers, continuously, and affects the adolescent, requiring attention from his/her guardians and teachers.15 The lack of social interaction is worrying in the healthy development of children and adolescents, and indicates an increased probability of social and behavioral problems, and in interpersonal relationships in the future.16
Below, there are some testimonials that demonstrate behaviors of self-injury without suicidal intent, ideations and aggressiveness.
[...] some time ago, I used to cut myself. I felt sad, so I cut myself. (A2)
[...] I think I am worthless, so I will end up alone. I fear something worse may happen, like killing myself, or something like that. (A3)
[...] my aunt killed herself, I keep wondering if I will do the same thing. I am afraid to be alone. (A4)
[...] I get so angry, I do not know, sometimes I feel like killing someone, feel like breaking everything, then I start to calm down and get sad [...] when I was worse, I thought about suicide. (A5)
The unsociability and lack of hope may be related to suicide attempts, being the third leading cause of death among adolescents from 15 to 19 years and, according to estimates, 62 thousand teenagers died worldwide from harms committed against themselves.13 In 2017, in Brazil, there were 1,047 deaths from voluntary self-inflicted injuries in children and adolescents aged between 10 and 19 years, and in the state of Rio Grande do Sul, there were 80 cases in this age range.17
A literature review that analyzed 33 studies in several countries related to the prevalence and factors associated with suicidal behavior in adolescence considers this behavior as multifactorial and may be influenced by personal and behavioral characteristics of adolescents, friends and family circle. The idea of death can occur, eventually, when considering the process of becoming older and development of methods to deal with problematic situations experienced in everyday life, however, it is worrying and alarming when they occur intensely and constantly.12
The main factor of vulnerability to suicide is the existence of a mental disorder (predominantly mood disorders), associated with other triggering factors.18 Some susceptibilities to suicide are: adolescents with a history of sexual abuse, questions regarding sexuality, history of adoption, abuse of drugs and pathological use of the internet.19
Support in the relationships, the bonds of trust and support are elements that enable a healthier growth.20 In emerging adulthood, the young person has self-esteem and self-efficacy as protection, and social relationships experienced in groups of friendship, study or work can be potential support networks.21 Nevertheless, a study about suicidal ideation interviewed 257 people in the city of Fortaleza, aged between 18 and 56 years, and related as protective factors for suicide the religious commitment and satisfaction with life and health. People engaged with religiosity have less chances of presenting suicidal ideation.18
The embracement of family, teachers and friends, the follow-up of a nursing and interdisciplinary team together with the adolescent are important at this stage, because he/she shows some signs of suicidal ideation, which are added to situations susceptible to such behavior. The psychiatric and psychological assistance and the use of antidepressants and anxiolytics may be necessary to treat the symptoms.
Sources of support and the prospects for the future
The adolescents’ statements reveal the importance of support in moments of stress and confusion. The school shows its important role in their experience. The teacher is seen as a source of support for some, and this professional senses when the student is not well and tries to assist them in resolving their conflicts.
In the family, one adolescent cites the mother as support. Although there occur family disagreements, which are common at this stage, he seeks his independence and triggers, in this way, conflicts as a way to differentiate himself and tries to drift apart, at the same time he still has some dependency.
[...] a teacher, she knows all about me, when I am not fine, she just stares at me and knows it. If I am on a good day, she says: “something happened”, she barely sees me and says: you are not ok [...] this teacher, I count on her for everything, I trust her 100%. (A1)
[...] there is this teacher in the school, I trust her a lot, when I was bad, she knew it. (A2)
[...] although not always she understands me, I go after my mother. (A3)
[...] [I feel supported] by the teacher, friends, by those people. (A4)
The experiences of adolescents with their parents and teachers are decisive for the development of their identity. Effective and appropriate communication with these young people helps them in in their safety and well-being. The satisfaction with life is often linked with the good relationship established with parents, and minimum family conflicts may act as a protective factor for depression.22
In the school context, the work of nursing together with the PSE has an important role in health promotion and prevention of its injuries. Health actions should be structured between the Primary Care team and the school, observing the need and the trends with the increased number of cases of depression and suicide in adolescents.
The PSE, in addition to consolidating promotion and prevention, has significant allocation of fighting the vulnerabilities presented by those subjects. The cooperation between the health team, school and family is essential to the satisfactory functioning of the program.7
In addition to the school and the family as a source of support, the adolescent perceives the music as an aid, as reported below:
[...] at the university, there is this garden, I stay there quiet, put my earphones [listen to the music] and wait [...] at home, I listen to a sad song. I try to calm down. (A1)
[...] I try to stay quiet in my bedroom, listening to music, to relax a little. (A2)
[...] [to calm down] I listen to music, watch a video on youtube, a movie, a tv series. (A5)
The music is defined as the practice of health promotion in adolescence. Study about the perception of adolescents in relation to music as an instrument to promote health had as results the physical, emotional and social benefits, highlighting the nursing as intensifier to explore it for promoting the health of adolescents.23
Concerning the prospects for the future, most respondents showed interest in continuing their studies and going to university. These young people express confident thoughts, and, through their effort, they will achieve their goals. They feel optimistic, even with the difficulties they are facing in relation to the negative feelings in the day-to-day.
[...] I think about going to college. (A1)
[...] I want to graduate at many things, If I work hard, my future will be great. (A2)
[...] I see myself as a successful radiologist, without negative thoughts, happy. (A4)
[...] I am going to college to graduate. (A5)
Having a plan for the future is a way of better visualization of the direction to follow. These plans may suffer from the influence of interpersonal relationships and the context of the adolescent and involves some dimensions, such as: professional, affective and citizenship. Defined prospects and good family relationships help decrease the stress load in adolescents.24 The adolescent’s context has fundamental importance in his/her expectations and plans.
Nonetheless, one teenager, when asked about the future, stated differently in relation to the other adolescents:
[...] I do not see any future at all, do not even imagine, and I do not know how the future is going to be [...] I have no hope at all. (A3)
From the analysis of the cognitive triad, alteration in which the subject has changed visions of oneself, the world and the future, in the form of recurring negative thoughts, configuring as automatic, one can have a dimension of the individual’s mental condition, directly related to depression. The presence of stress higher in female adolescents, and, among the stressor causes, there is the misadjusted family context, affecting the lack of prospects for the future.24
In the negative perception, the influence of one’s current mood state undermines the understanding, with a predominance of defeatist feelings, as seen in several excerpts during the interview. In this case, there were low self-esteem, deep sadness, social isolation, difficulty in relationships with peers and teachers, feelings of worthlessness, suicidal ideation, which affect their prospects for the future.
Final thoughts
This study allowed understanding the experience of adolescents with symptoms of depression. They present with behaviors common to age, such as indecision, doubt, conviviality and bond with the family, school and their peers. The adolescents are concerned when taken by feelings they do not consider as normal, such as the sadness, which is the most common in the experiences of any human being. Due to the process of adaptation to changes of adolescence, many times, the adolescent has not developed the ability to deal with certain situations yet. In this context, some statements contained more worrying situations, such as the self-inflicted injury without suicidal intent and suicidal ideation, which, when observed by the family, school or friends, must be referred to the health service for specialized care and follow-up.
In relation to the development of researches, there is need for further investigations that relate the adolescent, mental health and nursing. This issue is still incipient in the discussions and investigations, but is emerging and a public health problem. As a limitation in this study, there is the implementation of more participants, because it depended on external factors, such as the consent of parents, who sometimes did not want their children to expose situations that occurred in the family circles.
As implication for nursing practice, nurses need to perceive themselves as a qualified professional to listen to this adolescent, and develop actions of health promotion, prevention and intervention, from the PSE and Primary Care Teams.
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Corresponding author
Aline Cammarano Ribeiro
E-mail: alinecammarano@gmail.com
Address: Av. Roraima nº 1000. Cidade Universitária. Prédio 26. Centro de Ciência da Saúde. Bairro Camobi. Santa Maria, RS, Brazil.
CEP: 97105-900
Contribuições de Autoria
1 – Fernando Fraga Herzog
Conception and planning of the research project, acquisition, analysis and interpretation of data, writing and critical review.
2 –Aline Cammarano Ribeiro
Conception and planning of the research project, analysis and interpretation of data, writing and critical review.
3 – Lisiane dos Santos Welter
Conception and planning of the research project, analysis and interpretation of data, writing and critical review.
4 – Graciela Dutra Senhem
Analysis and interpretation of data, writing and critical review.
5 – Lidiana Batista Teixeira Dutra Silveira
Analysis and interpretation of data, writing and critical review.
6 – Fernanda Franceschi de Freitas
Analysis and interpretation of data, writing and critical review.
How to cite this article
Herzog FF, Ribeiro AC, Welter LS, Senhem GD, Silveira LBTD, Freitas FF. Experiences of adolescents with depressive symptoms in school context. Rev. Enferm. UFSM. 2020 [Cited: Year Month Day]; vol.10 e69: 1-16. DOI: https://doi.org/10.5902/2179769239810