The adolescent stage is one of the most challenging developmental stages. During this stage, it is normal for teenagers to feel upset, confused, or angry. However, when these emotions cause concerns and mental problems such as psychosis (a phenomenon where one has impaired thoughts and emotions, delusions and hallucinations, and thus loses contact with the reality), it is important to seek professional assistance. Psychotic phenomena can occur to seemingly very healthy youngsters. However, some can be vulnerable due to potential underlying issues in their development and a psychosis can be triggered by prolonged stress. This story pictures a girl who experienced psychotic phenomena and was referred for mental health care.
Nacho’s story
Nacho’s mother was shocked when she received a call from her daughter’s headteacher informing her that her daughter was unwell and seemed to be having a mental health problem “mwenda wazimu”. She panicked and swore that could not be her daughter. She explained to the principal that Nacho had never had such a problem and she did not understand what the headteacher was talking about. Nacho’s parents went to pick her from school and sought mental health care from one of the hospitals. In the course of her treatment, her psychiatrist nurse referred her to me for further psychological assessments and diagnosis as she was not responding well to the medications. Her mother had accompanied her to the appointment.
Nacho (not her real name) is a 15-year-old girl who is a third born girl in a family of five. She has four sisters and a brother. She is a brilliant form two student (second class in secondary school) in a national boarding school. Since childhood she has been a bright, talented, all-round girl whose talent attracted the director of her primary school who offered to sponsor her primary education since she was 10 years old.
When I meet her on our first interview, she looks calm and collected. She is, however, very soft spoken but confident. During the interview she tells her life story that is replete with events and conditions that made her vulnerable despite her apparent talents.
When Nacho was 5 years her second last born sister was sponsored by a well-wisher to go for an open-heart surgery in Israel where her mother accompanied her. Fortunately, the surgery was successful and after some time they came back home. Unfortunately, while her mother was away, her last-born sister suffered severe malnutrition and developed rickets. Her mother had to focus on treating her last-born sister immediately she arrived from Israel. These were difficult moments for Nacho as her sibling’s ill-health caused a lot of financial constraints, stress, and worry to the family.
When Nacho was about 10 years old, her father had problems securing a job in the hotelier industry. He could only manage to get short contracts which never lasted for more than 3 months and became jobless again. From this moment, Nacho never understood why her family had to go through a lot of problems. She kept thinking and wondering why her family had to suffer this much.
However, this became her motivating factor to work even harder in school so she could one day have a brighter future. With the sponsorship from the director of her primary school, she was assured of school fees at least for her primary school education. True to her vision, she scored very high marks in her final primary school exam and got an admission in one of the best secondary national schools in the country.
The family was happy to have their daughter in the national school, little did they know that this could have been the beginning of Nacho’s problems.
Nacho reported to her new school which is approximately 850km from her home and settled down to start working hard as she had done in her primary school. Within no time, she became her classmates’ and teachers’ favourite student who quickly gave her a leadership role – a class prefect.
However, after a while, with extreme weather change and strict school rules and more responsibility and expectations as a student and a leader she started becoming overwhelmed. As a student she is expected to wake up at 4:30am to go for her morning preps until 7:20 am, as a prefect she is to supervise the other students while doing daily school cleaning and prepare herself for school by 8:00am. During lunch hour they take lunch while having group discussions. They then proceed for afternoon classes and are all expected to go for games from 4pm to 5pm. After this, dinner is served, and they go back for evening preps until 10pm. By 10:20pm all students are expected to be deep asleep. Obviously, 6 hours of sleep are way too little for a teenager, and chronic lack of sleep is known to be related to a number of mental health problems.
When school closed for second term she talked to her father about her new school. Being a very supportive father, he carefully listened to her and advised her to focus on the bigger picture as sometimes as humans, conditions and situations might not be favourable as we might wish but we have to adjust accordingly. She promised her father that she would try to adjust accordingly and continue with her studies. Fortunately, since the teachers realized that most students always sleep during class time, the school schedule was changed to allow students more time to sleep. However, this was only favourable to the rest of the students but not to prefects. While the rest of the students were busy finishing their homework during the evening preps, all prefects were expected to attend school meetings to discuss the new schedule. The meetings could last until 10pm when students are expected to sleep, and none is supposed to be awake. Since the prefects should be leading by example, they too are expected to adhere to these rules. However, Nacho was not able to do her homework since during the time scheduled for the homework, she was supposed to be attending the prefect meetings. When she went to class without the homework, the teacher questioned her and wondered why she was not performing as expected and moreover as a prefect she should be an example to the rest of the students.
Nacho then decides to speak to her class teacher to step down as a class prefect so she can have ample time to complete her assignments and attend to her school. However, her classmates and her class teacher say she is best suited for her position so she cannot step down. Supervising the other students and doing her duties as a prefect becomes a challenge and a huge burden to Nacho. She quickly gets irritated when a student does not follow her instructions. The students start becoming rude to her and she feels pressured to the wall. Nacho started feeling no one understands her.
Fortunately, the schools close and Nacho is happy to be back at home. She pours her heart out to her father who promises to get her to another school at the beginning of her second year in school. Despite how difficult it is to get a transfer to another school; Nacho passes her exam and qualifies for her transfer. Unfortunately, Nacho’s father is not able to pay the required new school fee and the transfer charges, and he convinces Nacho to try and go back to her old school while he continues to secure another job and save enough money for the transfer.
Thus, Nacho’s dreams of changing her school are shattered. Since she understands the situation at home, she agrees to go back to her old school in January. When Nacho goes back to school, she feels too much pressure and helpless. She has too many responsibilities and expectations that she cannot meet. The school environment is not favourable, yet her family cannot afford to change her school. She has problems both at home and school. She becomes inactive in class; teachers get concerned about her situation but cannot understand her point of view. Instead they keep telling her that she cannot drop being a class prefect duty and as a leader she needs to lead by example. She loses her class concentration; her mind starts wondering and she starts overthinking.
Just when the students are about to start the exams, Nacho and other students get admitted to the hospital due to food poisoning. It is during this time that the doctors realized Nacho is not only suffering from the food poising but might be having a mental problem as she is talking alone and seeing things that other people are not seeing.
Just when we are about to end this interview, Nacho mentions that when her parents came to pick her up and took her home, her mother listened to her and recalled that while she was about 4 years, she had a similar situation and could talk and hear things others were not hearing.
Her parents then took her to a mental health facility where she was given drugs and for 3 weeks was on treatment. Since she was not responding well to the medication the psychiatric nurse had to refer her for further psychological assessments and diagnosis. Nacho’s greatest fears at the moment is feeling that her neighbours are always talking about her condition. Whenever she sees a group of people, she thinks they are talking about her condition.
I later brought her mother on board so we could talk about Nacho’s childhood and the mother confirmed that when Nacho was about 4 years she was admitted to hospital with severe malaria and she could talk to herself and see things that the rest of them could not see. Luckily, she was treated and discharged from the hospital and since then Nacho has never been sick until when the mother received the call from the principal.
Her mother confirms that since Nacho came back from school, she had an obsession with cleanliness and neatness. She gets frustrated when the other siblings cannot perform their duties on time e.g., she wants them to take a bath on time despite that sometimes they have to finish doing their homework etc. She, however, thinks that Nacho learned this behaviour from her father as whenever the mother and children see him, they get busy and have to ensure everything is at its place and clean. Failure to which the father will get angry and start an argument with the mother while the children are listening. Nacho’s mother always advises her telling Nacho’s father that it is not a good idea for them to argue while the children are listening. However, since he does not get her point, she finds herself shouting back at him. She then says, “actually now that we are talking about this, I feel the home environment might have contributed to Nacho’s condition”.
I finalize the interview and the mental health assessments and give them my feedback. Both Nacho and her mother feel better and hopeful for better days.
Fortunately, Nacho’s parents found a neighbouring boarding school for Nacho and now she can go to school while on treatment. With the permission of the new headteacher, she will be able to come back for treatment and assessments as needed.
Each year about 100,000 young people experience a first episode of psychosis globally. This means that 3 in every 100 people experiences psychosis. Psychosis is a phenomenon where a person has sensory experiences that is, they hear or see things that do not exist or believe in things that are not real.
Early stages of psychosis may include difficulty in concentrating, poor school performance, poor personal hygiene, irritability, feelings of anxiety, displaying strong emotions or not showing emotions, and social withdrawal as indicated in Nacho’s case. The behaviour of children with psychosis may change over time as psychosis can develop gradually or suddenly. Children or adolescents may begin talking about strange things or ideas that do not make sense for instance, they might talk about their ancestors who they claim has sent them with a special message to the family. Others may become withdrawn and seem to be in their own world. This is also apparent in Nacho’s case.
It is important to identify these signs and symptoms as early as possible and get treatment which improves the chances of full recovery. Treatment includes antipsychotic medication along with individual, family therapy, and specialized programs. Changes in lifestyles such as reducing stress, additional support e.g. from school and family can be helpful in reducing the symptoms. If a parent or guardian is concerned about their child’s mental health they should talk to a doctor and get a referral to child and adolescent mental health specialist who is trained at evaluating, diagnosing, and treating children with psychotic disorders. The parent/guardian should describe the behaviour of the child that concerns them and talk to other people close to the child e.g. teachers or close relatives to see if they have also noticed any changes in behaviour of that child.
There are several causes of psychosis in adolescents such as family history of psychotic disorder, pregnancy complications, chronic inflammation, medical illness, exposure to traumatic life events and stress, low-socioeconomic status, social isolation, use of cannabis. In Nacho’s case, there were several risk factors for her condition. First her medical condition-severe malaria- at age 4 triggered her first episode. Secondly, her family’s low-socioeconomic status, stressful home environment, and stressful school environment all contributed to her psychotic episode at 15 years.
How can a parent/guardian help their child to cope with mental illness?
During this moment your child will need your support the most. It may be difficult for the parent or guardian to cope with the feelings of hopelessness, anxiety or anger before your child gets a diagnosis. However, after a diagnosis, you can work together with the mental health provider to help you change how you interact with your child and how to handle their challenging behaviours. For instance, it may be important to praise your child often to encourage their strengths. It is also important to interact with your child often and have fun and play together. You may need to learn how to manage stress so as to respond calmly in stressful situations. Seeking family therapy and support groups and further understanding of your child’s condition may help you to cope better.
To help your child cope better in school, it is important to inform the teachers and school counsellor about her condition so that they can be supportive and offer a conducive school environment.