Young adolescents, depression and…the Titanic syndrome

In carrying out three fascinating studies which complete and respond to each other, Aurore Boulard has set to music, with original sounds, the factors and contexts which lead teenagers into depression. A manner of also better identifying worrying indicators and of ceasing to watch young people sink under? Doubtless the education system needs to be opened up more to the notion of wellbeing, still absent from preoccupations concerning our teenagers at school. Nonetheless certain of them are harassed or are experiencing difficult situations without being able to, as an adult can, project themselves into the future in changing their present. ‘In an institutional manner, and together with the teachers, it should be possible to think through the ways of living together at school,’ insists Aurore Boulard, who thus suggests that support groups should be set up within secondary schools on a regular basis.

Around the theme of teenager depression there are too many tunes which ring false and prevent things being heard. In her thesis, ‘From depressive mood to adolescent depression: statistics and narrativity’ (1), Aurore Boulard, Assistant at the University of Liège and a psychologist at the University Psychology and Logopedics Clinic, has taken up an orchestra conductor’s baton to better understand the form and substance of depression amongst teenagers. As a result she highlights important indicators which up until now have often been unrecognised or underestimated in young depressives. In revisiting the importance of peers, intimate friendship, exclusion, verbal violence as well as the role of parents, that of the age of puberty or what is revealed by the life stories or vocabulary used by young people, Aurore Boulard casts new light on this phenomenon. Reason, in the end, to consider it in quite another way…

It is estimated that 5 to 7% of teenagers experience a major depressive episode (MDE). Girls are twice as much affected as boys by these depressions, which in two thirds of cases are not medically treated, the psychologist reminds us. The risk? Witnessing the development of character disorders, school failures, dependencies or suicidal behaviour: in the three years following the diagnosis of MDE, 70% of young people make an attempt to commit suicide. Untreated depression can also become recurrent and chronic at adult age. It then presents itself in a more severe and incapacitating form than is the case for a later development of depression. Nevertheless depression remains little diagnosed during adolescence. And for good reason: confronted with it, people often get gets the symptoms wrong.

All wrong, or almost

‘As Professor Jean Dumas (University of Geneva, in Switzerland) says, in order to make a diagnosis amongst young people, people wrongly carry out a ‘cut and paste’ of the symptoms of depression in adults,’ says Aurore Boulard. ‘Yet for them they have neither the same expressions nor manifestations.’ Another factor is added to this label, falsified from the start: there exists a widespread idea according to which teenagers experience a crisis which pushes them to feel down in the dumps, to no longer let people know when they are going out, to no longer talk to their parents, run away, etc. It is often considered as a passing phase which will cease at the end of the crisis. ‘Of course no-one can deny that young people test their limits and those of their entourage or that they experience up and down emotions. But that should not allow us to forget that their also exists a heavier pathology which must not be confused with teen angst,’ stresses the psychologist.

‘Better considering certain indicators – a drop in school results features prominently amongst them – could precisely allow us to make a difference better. In the same way, we should be better forewarned of the fact that amongst young people the symptoms of depression vary along with age. Around the age of 12 these symptoms are principally expressed by an ensemble of somatic complaints. Around 14-15 it is irritability which dominates. Around 18 it gives way to sorrow and suicide attempts,’ she points out. Few teenagers thus clearly express a complaint which is depressive in nature. On the other hand they experience an ensemble of heterogeneous symptoms, often dependent on each other, whilst a series of risk factors end up combining and leading them into depression.

In the thesis Aurore Boulard presents and brings together three research studies. They have enabled her to better understand the complex pathology which is depression, in particular during adolescence. She began by adapting and by validating depression scale measuring tests. They have primarily allowed her to decode the subjective experience of adolescences in relation to their most intimate social sphere. She thus studied the influence of the school – an essential socialisation site – but also that of peer groups, because being accepted or rejected plays an important role in the mental health of young people. Intimate friendships were also investigated. When they are positive they have an effect on self esteem and social adaptation. When they are negative they are, particularly for girls, a source of stress, high levels of anxiety and depression. The effects of puberty and above all of perceived pubertal timing were also observed in terms of young people’s perception of being either behind or ahead in comparison with their peers.

The weight of attacks

The school forms a whole within which the influence of peers, adults and the establishment model (it could be elitist for example) interact and affect the wellbeing of the teenager. The ensemble of the factors involved – including harassment – has been analysed by Aurore Boulard within a complete model used for her first investigation on ‘The social context and its links with depressive humour’. These results arose from a wider research study on school victimisation carried out in 2003, working together with the Catholic University of Louvain, in 38 school institutions representing the three levels of education, taking in 2,896 pupils aged 12 to 18. They each responded to a fifty minute questionnaire.

The psychologist was thus able to confirm that the depression scores were twice as high for girls aged 15 in comparison with boys. She also brought to light variables and depression predictors: the gender of the teenager, their age and also the presence of verbal attacks, a feeling of exclusion, as well as school results and, which could appear surprising – including to the researchers themselves initially – prosocial behaviour.

‘Teenagers at the greatest risk of depression tend to seek out contact with others,’ explains the psychologist. ‘They are always ready to help others and are attentive that everyone is well integrated. Several hypotheses can help to explain this attitude. One might at first think that a young person who is himself experiencing exclusion, or who feels poorly integrated, is doubtless more attentive or more sensitive to the moods of others. He might also try not to reproduce behaviour which hurts him. Moreover when a teenager feels that he is dropping out of the group he tries to stay within it at all cost. A kind of survival behaviour thus pushes him to be ‘nice’ in order to keep a social link which is important, if not vital, at this age.’

Nonetheless this prosocial behaviour is far from settling everything, on the contrary. ‘These attempts can be frowned upon and lead to exclusion being favoured,’ warns Aurore Boulard. Another factor deserves to be placed side by side with this point: that of the weight of intimate friendships (investigated in the second research study). No matter at what age, the fact of not having a best friend of the same sex is highly correlated with feelings of depression (and that is so even if one has one or two close friends from the opposite gender). In this context it is also important to understand the attitude of teenagers – and above all female teenagers – who have a great close friend. ‘Girls, in particular, are likely to want a strong and exclusive relationship. In fact they cling onto this friend, which stops them ‘letting go.’ If this relationship cracks, or it doesn’t meet their demands, which are often high, the risks grow of falling into a depression likely to lead to hospitalisation,’ points out the psychologist.

Another little known element is highlighted in this first research study by Aurore Boulard, that of the effects of verbal attacks on depressive moods, and their impact on the factors which can lead to serious depression. ‘Young people do not relate injurious statements they have been subject to, any more than they express themselves, generally speaking, when they feel excluded from the group. Very often verbal attacks are not picked up by teachers or school staff, if only because it is difficult to be aware of them when one only spends a few hours, spread out over a week, with the young people. In practice this phenomenon is thus minimised by teenagers and teachers,’ she observes.

Nevertheless, words can hurt. A young person who is verbally attacked regularly also risks becoming the black sheep, the one who is excluded. ‘One of the tasks of adolescence consists of learning to live in a group: if a young person likes school, it is for the friends she or he makes there. It is vital for them to belong to a group. When they are excluded from it, they are also deprived of the skills to be acquired through this group and the questions, the self questioning and the feelings of doubt the others are confronted with,’ explains the psychologist.

She also notes that, besides the victims of harassment, the ‘persecutors’ can also be going through a bad time. Thus certain of them have themselves been harassed (or have experienced aggressiveness within the family), which has led them to develop behaviour based on aggressive functioning. ‘Without a doubt neither the parents nor the teachers would associate aggressiveness with depression, particularly as far as girls are concerned,’ points out the clinician, here signalling one of the signs about which it would be possible to be more vigilant.

Irritability, a red light

In 2011-2012 the psychologist’s second research study was devoted to ‘Links between depressive moods and close relationships with parents and friends.’ The study involved 1,496 teenagers, brought together according to their age (12, 14 and 16), from eleven teaching institutions. The study allowed her to, amongst other things, confirm that teenagers express their depressive feelings through somatic aspects (such as headaches or stomach pains). Irritability also occupies a striking place on the ‘hit-parade’ of indicative signs. ‘Whilst in the mind of the general public this sign is rarely connoted with depression it is one of the most striking precursor criteria or symptoms to be found amongst girls,’ observes Aurore Boulard.

Girls nevertheless are sadder, more depressed (above all for the eldest amongst them) and more subject to crying fits than boys. Amongst them depressive problems often go hand in hand with eating disorders, around the age of fifteen in particular.

‘In the final analysis four items are more marked amongst girls than amongst boys: a feeling of having no energy, being irritable, doubting your worth and feeling bad about themselves. For girls we could add the fact of crying easily, and having concentration problems for boys,’ notes the psychologist.

This second study also stresses that parental attachment certainly has an influence on depressive moods, but does not intervene first and foremost. ‘In fact this influence is manifested jointly with life events, which occupy just as important a place,’ points out the psychologist. ‘This insight concerning parental attachment could enable certain parents who feel guilty to be reassured.’

Parents in effect often feel they are more to blame for what they see as an educational ‘failure’ which has led their child into depression. The subjective scale the teenagers were presented with showed that those with high depression scores felt that they had received few marks of care, affection, listening and empathy from their parents, whom they moreover judged ‘controlling’ because they imposed very strict rules, prevented them from going out, read their mail, etc. Nonetheless it would be a mistake to imagine that all the difficulties arise due to family attachment, even if it figures amongst the risk factors. Finally, an important observation rounds off this assessment of the link between depression and the family situation: this link is strongest not when the teenager lives with just one of his or her parents but when he or she lives with a person other than his or her father or mother.

Neither too early nor too late

This second study has also brought to light the importance of perceived pubertal timing, a phenomenon which remains little studied by psychologists. ‘We sensed that the problem was likely to be situated around the difficulty of people accepting their differences in comparison with others,’ explains the psychologist. The question asked of young people thus concerned their feelings and the way they situated themselves in comparison with others in terms of puberty.

Two categories of young people obtained high depression scores: those who feel very far in advance and those who feel very far behind. ‘Whatever the case a deviation in comparison with the group one belongs to is very stressful,’ observes Aurore Boulard in her thesis. Thus late puberty brings about exclusion from the peer group of the same sex. It isolates whilst leaving the young person insecure about his or her physique. It also gives the young people involved the feeling of being judged, a determining point in the face of depression. The girls who declared that they were behind were also those with the highest depression scores. As for early puberty, it can prove just as unsettling for them.

Once again the first two research studies have completed each other: they have shown that for severe depression, verbal attacks, perceived pubertal timing and the judgement of others which arises from it, bring about the same reasons, for both boys and girls, to feel bad about themselves.

The words of sorrows

In choosing to look into life narratives the third study presented in this thesis has really gone off the beaten path. It was carried out on the basis of the accounts of 60 young people, distributed into statistically representative groups of 20, each containing 13 girls and 7 boys. They were met face to face with for 50 minutes. Next to the group with those who have a low score on depression scales another was composed of depressive teenagers who remain in school, whilst the last one was made up of depressive teenagers hospitalised in child psychiatry units for a major depressive episode.

The psychologist’s objective was to study and compare, depending on the groups, the content and form of these different stories, and to see if they differed according to the depression score. In order to do so in the most scientific possible, a software application allowed the syntax as well as the use and repetition of words to be classified. ‘Beyond any currents in philosophy and any interpretation which could be linked to words, the software thus provided raw and refined material which objectified the statements made by the teenagers,’ notes Aurore Boulard.

Narration allows a meaning to be given to the experience of identity development, one of the most important psychosocial tasks of adolescence. It goes beyond simply reporting events, because it also carries emotions with it and it contributes to providing meaning, for others and the self. Through their life narratives teenagers begin to reconstruct their past, their present such as they perceive it and (normally) they anticipate their future. They thus deliver a history which has meaning for them or for the people they are addressed to. In providing these life stories teenagers are also saying: ‘this is the way I want you to understand me today.’

The only question asked of all the young people was: ‘What has made you become who you are today?’ When this question did not seem clear enough to the teenager it was completed in this form: ‘Are there positive or negative events which have made you become who you are today?’

The analysis of the stories shows that young depressives use fewer words than the others. Between depressive teenagers in school and those who had been hospitalised there was also a large difference between the words used and the redundancies within the stories (more frequent in the case of hospitalisation). The hospitalised people took longer to start their stories, had longer pauses, spoke in a lower and less strong voice, and displayed more emotions.

When the ‘I’ is depressed

Young non-depressed people use the ‘I’ followed by a subjunctive: ‘I say, I think, I find, I like,’ but also the ‘you’ or ‘we’ in which they include other people. They can project themselves into a future conditional (‘I would like’). They insist on the factors which have contributed to the construction of their identity, they evoke groups of people such as parents, family and friends. They broach themes concerning their leisure activities or their membership groups.

It is quite another story for depressives! Their ‘I’ is completed by the imperfect form of ‘be’ and ‘have’. They speak of single people (the father, the mother, the friend). But once again large differences between the hospitalised people and the others are discovered. Even if they speak of the external world (going out, the city, people), the statements made by depressive teenagers in school turn widely around the school. And when they think about their future it is in terms of their professional life.

The young people in hospital for their part contextualise their response in terms of their depressive illness, around which they define themselves. Their discourse is characterised by the significant presence of the expression: ‘I have the impression,’ often followed by a feeling of rejection, abandonment or inferiority. These young people, who recount the most negative life events, are also those who ‘have the most difficulties in decentring themselves from a negative event, to stand back, and to see the positive things in their life. They display difficulties in bringing together their life events into a coherent whole,’ notes Aurore Boulard.

‘Several points surprised us,’ continues the psychologist. ‘Thus when an teenager is doing fine, he or she says that their hobbies, in other words the things he or she has chosen to do over and beyond parental choices, have enabled him or to become who they are. Young people thus define themselves above all in terms of their own choices.’ This parameter is completely absent from depressed teenagers.

The hospitalised young people, in an environment of isolated people which they bring up their accounts of negative events, often connected to the family sphere, also describe themselves as very alone. As for those who remain in school, they polarise their discourse around the cognitive aspect tied to the school and their difficult life events. In fact, to the extent that they don’t control their family life (divorce, illness, etc.) they bank everything on the school, as would an adult who concentrates on their work if their private life is on the skids. Tomorrow, for them, comes down to their professional future. ‘As a young girl said: ‘I’ve chosen hairdressing so that I can be independent in three years’,’ recounts Aurore Boulard.

But when one is experiencing significant personal and family difficulties it is not enough to focus on the school to solve the problems, quite the contrary. In effect it is not necessarily a lifeline. ‘The life stories confirm that school is stressful,’ stresses the psychologist. ‘School and orientation difficulties can crop up, as can the ability to do higher education studies. School results are moreover correlated negatively with a depressive mood: a fall in concentration capabilities, sleeping problems, loss of interest and few personal initiatives due to depression do not favour good results.’

Wellbeing, at school, as well

This thesis opens out onto a great number of reflections or even action plans. That is the case, for example, for the consequences one could draw from the results and the analysis of the life narratives of depressed teenagers who remain in school. ‘School anxiety is clearly present amongst them,’ insists the psychologist-clinician. ‘The teaching system could be attentive in spotting it and raising questions. Does a young person who wants to be the best do so because he or she is going through a bad time? Are they focused solely on their studies? Or do they continue to have friends and get on well with them?’

More generally, pleads the psychologist, the school system should doubtless open up more to the notion of well-being, used in the world of work but still absent from preoccupations concerning our teenagers at school. Nonetheless certain of them are harassed or are experiencing difficult situations without being able to, as an adult can, project themselves into the future in changing their present. ‘In an institutional manner, and together with the teachers, it should be possible to think through the ways of living together at school,’ insists Aurore Boulard, who thus suggests that support groups should be set up within secondary schools on a regular basis.

The psychologist also highlights the value of raising awareness concerning heightened vigilance as to a change which leads the teenager to become irritable, talk back, fight or panic in disproportionate ways at exam time. ‘It would be worth thinking about this change in behaviour and to try to see whether or not a malaise is taking root in the young person, with the risk of major depression,’ she says.

She would also like to examine other pathways born from the thinking through process of her thesis: ‘It is currently estimated that half or two thirds of the young people who go through a bout of severe depression come through it. For the others from 2 to 3% find themselves in hospital. Why are only certain young people hospitalised? To explain this situation, a hypothesis related to social ties deserves to be verified: every hospitalised teenager says that they have experienced difficult life events within the family, but those who remain in school do the same. The difference between the two groups could lie in the young people who remain in school maintaining social ties outside their family or from the energy they still find to try and create them. If these social ties fades they no longer have anything to hold onto and the possibility of hospitalisation rises.’

The psychologist is also interested in another question: what happens to depressed teenagers, but who are not hospitalised, and who do not manage to get through their illness? Certain of them, she thinks, could take a path leading towards delinquency, in turning their aggressiveness against others. Yet, particularly as far as boys are concerned, it is not necessarily thought that depression can be externalised towards delinquent behaviour. ‘I would like to begin a new study with the following theme: does depression precede delinquency and, if it is the case, in what percentage of cases?’

In awaiting such further studies the highlighting in the thesis of two important variables – judgement and perceived pubertal timing – should allow depression amongst teenagers to be better understood. ‘This research has shown that exclusion, verbal attacks and the feeling of being judged by one’s peers play a major role in the wellbeing of the teenager, who is thus often isolated. In addition their depressive mood gives off signals of weakness conducive to attacks and the establishment of harassment situations which, added to minimal social relations, are strongly linked to depressive feelings and thoughts of suicide (above all amongst girls),’ points out the psychologist. Put in that way, one can understand why Aurore Boulard talks of the presence of a genuine depressive spiral.

As in the Titanic, which the water invades deck by deck, progressively causing the shipwreck, the young are caught up in a vortex within which, little by little, it become one thing after another and leads them towards depression: they go through family difficulties or life events which lead to a depressive mood and behavioural changes, with irritability, instability or aggressiveness. Often they then try to cling onto their schooling and prosocial and reassurance seeking behaviour. But that does not prevent – on the contrary, at times – problems with peers which in their turn are at the root of exclusion and school failures. Added together, these elements act as extra vulnerability factors. One deck after another, everything ships water before sinking. Aurore Boulard’s thesis should provide weapons to all those who refuse merely to be a part of the orchestra, waiting for the shipwreck...

(1) Doctoral thesis defended on December 14, 2012, before a jury consisting of Professors Jean-Marie Gauthier (supervisor), Michel Born (ULg), Etienne Quertemont (ULg), Luc Goossens (KUL) and Jean Dumas (University of Geneva).