A qualitative study of coping strategies and resilience in the aftermath of childhood adversity in first‐episode psychosis

Abstract

Aim

Exposure to adversity during childhood is associated with elevated risk for commonly occurring forms of psychopathology, especially psychotic disorders. Despite the noteworthy consequences associated with adverse childhood experiences, an inconsistent and unpredictable number of at‐risk populations present with remarkably good physical and mental health outcomes that can be attributed to resilience. This study aimed to qualitatively explore the experience of childhood adverse events and coping strategies employed by individuals that promote resilience and better mental health outcomes.

Methods

Fourteen individuals with a history of childhood adversity were recruited to participate using a case‐study approach. A semi‐structured interview guide was developed based on empirical evidence and theoretical background, and the interviews were analysed using a reflexive thematic approach.

Results

Our findings showed that the type of adversity impacted the experience of trauma, for example, the death of a caregiver versus emotional abuse or witnessing violence at home. Five coping strategies were identified (social support, religious coping, problem or emotion‐focused coping, and meaning‐making), with healthy controls found to identify and use these resources more than the psychosis group to promote individual well‐being and better mental health outcomes.

Conclusions

Our findings provide insights into experiences in the aftermath of childhood adversity, emphasising the need to assess the history of trauma systematically. They further underscore the importance of mental health prevention programmes bolstering individual‐level coping strategies and the resources available within our environments to help them manage adversity, improve overall outcomes, and promote resilience.

1. INTRODUCTION

1.1. Background

Trauma is described as a perceived experience that threatens injury, death, or physical integrity, causes feelings of fear, terror, and helplessness, and may occur as a single event or as a result of repeated exposure (American Psychiatric Association, 2013; Dye, 2018). Exposure to traumatic experiences is widespread, and does not discriminate against gender, age, or ethnicity. Childhood trauma includes a broad range of childhood experiences of societal, familial, and individual stress or mistreatment before the age of 18 (Rosenfield et al., 2022). Although earlier research tended to focus on single forms of adversity, such as child physical abuse, more recent work has taken a broader perspective and considered the intersecting effects of multiple adversities, including multiple forms of child maltreatment (Turner et al., 2012). Without intervention, adverse childhood events (ACEs) can result in long‐term disease, disability, chronic social problems, and early death (Boullier & Blair, 2018). Increasing evidence has illustrated the substantial adverse effects of exposure to childhood trauma linked to psychopathology in childhood, adolescence, and adulthood (Dye, 2018), with mood, anxiety, substance use, and disruptive disorders commonly occurring (Green et al., 2010; Kessler et al., 2010). Of recent interest is the association between ACEs and psychosis. Different meta‐analyses have revealed that individuals with psychotic disorders have significantly increased rates of childhood adversities compared with controls (Bebbington et al., 2004; Matheson et al., 2013; Varese et al., 2012).

Despite the significant sequelae associated with adverse childhood experiences, scholars have observed that an inconsistent and unpredictable number of at‐risk populations do not present with poor mental and physical health outcomes (Condly, 2006; Khanlou & Wray, 2014; Ungar, 2006, 2013; Ungar et al., 2013). This could be attributed to resilience. Resilience refers to the capacity of a dynamic system to adapt to disturbances that threaten its function, viability, or development (A. S. Masten, 2014; Rutter, 2012; Southwick et al., 2014). Resilience develops in response to challenges, not in their absence, and the person (or system) become stronger than before the adversity, that is they function as well as before and then move forward, better prepared than they were before to face challenges that lie ahead (Barankin & Khanlou, 2007; Khanlou & Wray, 2014). Adaptive behaviours and life patterns demonstrate resilience in response to different developmental demands and the current environment. This adaptation is relevant to acquiring coping capacities and drawing upon environmental resources (Yates et al., 2003). Research suggests that the ability to cope with stressful events and circumstances may play a primary role in the development of resilience and in reducing the risk of psychopathology during childhood and adolescence (Compas et al., 2017).

Given the potential to inform our understanding of risk, resilience, and intervention processes, research on coping during and after exposure to adverse events during childhood is of considerable importance. This study explored adverse childhood events among patients diagnosed with first‐episode psychosis and healthy controls. We also document coping strategies within individuals and consider how they may inform adaptation trajectories to promote resilience, impact well‐being, and improve mental health outcomes.

2. METHODOLOGY

2.1. Study design and participant recruitment

This paper is part of a larger study which aimed to explore the role of resilience in individuals exposed to adversities in childhood to understand how they integrated traumatic experiences within their personal narratives. It also aimed to understand the coping efforts they employed to facilitate their adaptation to the challenges and losses brought about by these experiences within their context. Adverse events at a single level do not necessarily condemn children to poor developmental outcomes, specifically psychopathology, but there are protective factors at various levels that influence the child's overall adaptation (Cicchetti & Lynch, 1993; Kohrt et al., 2004; Lynch & Cicchetti, 1998). Therefore, to better understand the circumstances surrounding individual coping patterns, we used a case study methodology that aimed to study an integrated system with interactions within and across cases (Merriam & Tisdell, 2015). The case of interest in this study was the experience of adversity in childhood and to understand how individuals integrate traumatic experiences within their personal narratives to facilitate psychological well‐being. In addition, the literature highlights that it is imperative to understand the dynamic transactions between risk and protective factors to create developmentally informed prevention models that promote resilience and well‐being. That being the case, a mixture of individuals with first‐episode psychosis and those without any psychopathology (healthy controls) was deemed to be suitable to comprehensively understand the differences in transactions and compare adaptation to such adversities.

The study was conducted in Nairobi, Kenya. We enrolled participants with a diagnosis of first‐episode psychosis (FEP) within the first year of diagnosis (not actively psychotic) or healthy controls (HC, without FEP or history of mental disorder). Using patient files, participants with FEP diagnoses were recruited from inpatient wards at the Mathari National Teaching and Referral Hospital (MNTRH). Simultaneously, healthy controls were identified from the community with the help of volunteers. Fourteen participants were recruited for the interviews: six with an FEP diagnosis and eight healthy controls (HC). The first author screened all potential participants with the Adverse Childhood Experiences International Questionnaire (ACE‐IQ), which sorts out childhood experiences into 13 categories: emotional abuse; physical abuse; sexual abuse; violence against household members; living with household members who were substance abusers; living with household members who were mentally ill or suicidal; living with household members who were imprisoned; one or no parents, parental separation or divorce; emotional neglect; physical neglect; bullying; community violence; collective violence (World Health Organization, 2018a).

2.2. Ethical considerations

Ethical approval to conduct this study was granted by the University of Kwa‐Zulu Natal Research Ethics Committee (BE631/18) and Kenyatta National Hospital‐University of Nairobi Ethics Review Committee (P710/10/2018). Institutional approval from MNTRH was also granted during the study period. Before data collection, the participants were informed about the study aims and the voluntary nature of their participation. All participants provided written informed consent to participate in the study. The interview transcripts were anonymized to protect participants' confidentiality.

2.3. Data collection and procedure

A semi‐structured interview guide was developed based on the empirical evidence and theoretical background. The first author interviewed the participants. All interviews were conducted face‐to‐face at the hospital (MNTRH) and one of the primary health centres in Nairobi. The interviewer (GNW), a clinical psychologist, focused on creating a safe environment for the participants to share their experiences. Field notes were used to capture the key ideas during and after the interviews. They included summaries of general learnings from the interactions, identified possible themes, and as guides for future questioning. The interviews were conducted in Swahili and audio recorded. The interviews lasted from 30 to 90 minutes, averaging approximately 60 minutes. No repeat interviews were carried out. The participants received a small gift certificate as a token of appreciation for their time.

2.4. Data analysis

Transcriptions and translations of the recorded interviews were conducted by a trained transcriber and corrected for errors by the first author. The first author carried out all coding using the QSR NVivo software program (QSR International Pty Ltd, 2020). To address our study aims, our analysis sought to answer three research questions sequentially: (i) what are some of the adverse childhood events experienced by the participants, (ii) what coping strategies did participants utilise to help manage challenging events, and (iii) are there differences in the experiences and coping styles perceived and utilized by the groups? The analysis process was carried out using the reflexive thematic analysis developed by Braun and Clarke (2019) Clarke and Braun (2018), enabling the researcher to engage with the data flexibly in a less constrained manner. Braun and Clark outline 6 phases that guided the process: (i) familiarising yourself with the data—immersion in the data to the extent that one is familiar with the depth and breadth of the content; (ii) generating initial codes from the data (semantic or latent content); (iii) searching for themes—this phase re‐focuses the analysis at the broader level of themes rather than codes; (iv) reviewing themes—refinement into meaningful, clear and identifiable distinct themes; (v) defining and naming of themes—identify the essence of what each theme is about and determine what aspect of the data of each theme captures it and (vi) producing a report—involves the final analysis and write‐up of the report (Braun & Clarke, 2006). Additionally, this approach recognises and views the researcher's subjectivity as integral to the analysis process, organic and recursive coding processes, and the importance of deep reflection on and engagement with data (Braun & Clarke, 2019; Clarke & Braun, 2018). The data analysis began with a read‐through of the translated transcripts 3 to 4 times by the first author to familiarise herself with the content of the data. This read‐through led to the identification of potential themes and codes. The transcripts were re‐read to highlight codes from the data and group them into general themes. Braun and Clarke (2006) highlight that the analysis process is not linear but recursive throughout each phase. Using the field notes captured during the interviews, which highlighted key ideas, general learnings and possible themes, the generated codes and themes were refined and defined into meaningful themes that answered the study's objectives.

3. RESULTS

3.1. Participant characteristics

Fourteen individuals were interviewed in this study. Six patients were diagnosed with first‐episode psychosis (FEP), and eight were healthy controls (HC). Most participants had at least a form of primary education, with 43% having some form of casual employment. At least 64% (n = 9) of the participants experienced four or more adverse events during childhood, with the most common events being emotional neglect (92.9%), followed by parental death/separation (78.6%). Table 1 summarises participants demographic characteristics.

TABLE 1.

Participant demographics.

		N	%
Age		28.86
Gender	Male	7	50.0
	Female	7	50.0
Education	Some form of primary education	5	35.7
	Some form of secondary education	8	57.1
	No schooling	1	7.1
Work	Casual worker	6	42.9
	Employed/owned business	4	28.6
	Unemployed	4	28.6
Family history of mental illness	Yes	2	14.3
	No/unknown		0.0
Family history of suicide	Yes	3	21.4
	No/unknown	11	78.6
History of substance use	Yes	6	42.9
	No/unknown		0.0
Adverse events	Physical abuse	1	7.1
	Emotional abuse	4	28.6
	Sexual abuse	5	35.7
	Alcohol or substance use in household	6	42.9
	Family member with mental illness	2	14.3
	Household member treated violently	8	57.1
	Parental death/separation	11	78.6
	Emotional neglect	13	92.9
	Physical neglect	8	57.1
	Bullying	2	14.3

3.2. Early adverse experiences

3.2.1. Parent death/separation

The adverse experiences highlighted varied widely, with participants experiencing multiple adverse events during childhood. Many participants had lost at least one caregiver through death, with illness being the most common cause of death. Suicide, vehicle accidents and consequences of failed abortion were also highlighted as causes of caregiver death. Three participants whose caregivers had died due to illness pointed out that they had to act as caregivers to their ailing parents, which affected their childhood, especially their participation in school.

it is something that pains me, why did she decided to do such a thing! she did an abortion and in the process she died. I did not know (if the child was for the stepfather) because he was giving her a lot of stress so maybe she saw having the three kids and again adding another one might have added on her stress (FEP 4, male, 28 years)

I was around by the time my father was dying…I was at home with my father when he was taking the poison… I just saw everything, I was seeing but was not understanding, I was four years but I could do nothing …….I just remember in the morning they had disagreed and my mother left for job but my father did not go to job then we remained at home with him alone so while at home he told me to get out of the house and that is how he took poison while with him then thereafter, I do not know how somebody knew about it but he came and found out that he was dead. (FEP 3, male, 25 years)

It also became that mother was sick, I was also in school. At breaktime I run home and make for her porridge she drinks, I go back at lunch, I go and make for her lunch to eat…. I won't even go for preps because I have to go farm so that I could get something (money) to support us. It continued like that until mother passed away. (HC 8, male, 32 years)

Mother, she became sick, it was stress because you come back from school then you are the one to go and find a way in which you can eat; for three to four months, it was so difficult to me…. she cannot move, I have to wake up at four to wash her, make her porridge and leave for her there then go to school. I used to run away from school to look at her and take care of her in the same way then the following day, that is how I used to do it. (HC 1, female, 28 years)

Some of the participants were left with grandparents or extended family members. The reasons varied, with caregivers lacking funds to support all children when the child was born to an adolescent mother or in the case of death. Experiences varied, with some having stable home environments while others experienced emotional abuse, neglect, and exploitation at the hands of the extended family.

I can say that I lacked that motherly‐ love from parents because now you know somebody else is the one raising me; yes she was like mother to me and my grandfather was also like my father, they loved me like their last child; but now I was‐ I knew my mum as my elder sister, I didn't know her as my mother, only when I reached class five is when they told me, “this one is not your sister, she is your mother,” so that thing used to stress me until students at school, in fact students at school are the ones who made me to know. (HC 4, female, 22 years)

At my grandmother's is where I was suffering because she wasn't treating us well. She used to wake us up early, me and my cousins, forcing us to hard labor of farming, which was a lot. We have a big farm. When we go to school, when we come back, she gives us work, she quarrels us, talks bad to us about our parents, she was not a good person. (FEP 3, male, 25 years)

3.2.2. Neglect

As often seen in African communities, when families struggle with poverty or caregivers have passed away, the extended family will support the family. This would sometimes be in the form of providing money/in‐kind support to help meet their needs. For children, this would sometimes look like ‘adoption’ of the children into their homes, with the intention of giving them some stability. Our participants pointed out that they were always hopeful in this situation because it meant an opportunity to continue with school, only to find that there was no intention to provide the promised support. Many of the women pointed out that they were put to work as unpaid domestic workers in the homes of family members. However, sometimes, it was covert, like one participant who was living with an elder brother and his family. For the men whose mothers had remarried, their stepfathers started off well and supported them, but this soon stopped, with the stepfathers often abandoning the mothers and their children. For one participant, the extended family chose to take her and her siblings to a children's home after the death of their parents.

…maybe she saw there was nobody that would stay with us because even the other family members were also struggling with raising their kids helping to pay bills and taking them to school so that they can work hard so even me with my younger brother we could not be helped while the others had not completed school so that is how she decided to look for a children's home for us to get help (FEP 5, female, 18 years)

They were making me to feel neglected; because if you could go to live with somebody then that person considers you as a house help yet at that place where you live there is no money that you are given; you hustle so that to get a garment, it's only food that you can be given (HC 4, female, 22 years)

Another commonly reported adverse event was economic hardship, often in response to other adverse events. Participants noted that the home situation often changed after a parent's death or separation, especially if the paternal figure was the breadwinner. Often, the mothers would have to look for work to take care of the children and meet the needs of the home. In some cases, the participants engaged in some income‐generating activity to help meet their needs.

sometimes it used to force me to burn charcoal and sell then I go to the market and buy, and grind be it two tins of flour then we eat, the rest of the money I tell dad, “I am going to use this to buy a book, a pen.” Sometimes mum fails to send me the required fees for like exams, I could take some little money from charcoal since we had a lot of wood before; whenever I could burn about two, three, four, or five sacks I buy books and save money for exams even if it is eight hundred I just know that this is eight hundred for exams; you know dad doesn't have a job. (HC 5, male, 33 years)

when they were still together life was so good, we were eating well dressing well, we were learning well. …Father was the one paying, … when they divorced and life got bad even my elder sister dropped out and went to work as a house girl so she was the one who was helping us… we remained with our mother with all the suffering then now our father abandoned us for good, we suffered a lot and that is why we did not get enough education (FEP 6, female, 33 years)

3.2.3. Emotional/physical abuse

Children born out of wedlock were often at the mercy of the new family and experienced bullying from the children, stepparents, or extended family. One participant shared that she heard about not “belonging to” the family from an aunt as they played or snickered behind her back. Two participants reported significant experiences of victimisation during their childhood. One describes an incident that occurred on his way to school, which affected his daily ritual of going to school. The other participant reported experiencing a pervasively hostile environment throughout his childhood, characterised by on‐going threats and victimisation from his stepfather, and is still perpetuated to date. One of the male participants also pointed out that he experienced bullying and abuse from his stepfather, who also noted to frequently mention that he (the participant) was not his and should leave his home, especially after the mother passed away. Participants also highlighted the poor relationship they had with their mothers.

Exactly it's aunt; there is one aunt who used to tell me to my face whenever we were playing. Now perhaps you are playing then you disagree in the game, she says “in fact‐ after all you don't belong to this family, you are supposed to go to your home.” So, you start questioning yourself yet you don't have answers, yet you cannot face your mother while you are a young child. (HC 3, female, 39 years)

they were brothers from different mothers so when they spotted me going away from my sisters they decided to take rods and they pulled me and threw me when my head was upside down and they had beaten a lot, from there i was taken to the hospital where i was admitted even though i bled profusely, they caned somewhere here and at the same time somewhere here so i bled profusely, when they left me, then it reached now where they were telling me enough is enough you have done it and they are near with me [Inaudible] me to get into class and study mathematics which was to be taken from (FEP 2, male, 30 years)

Now the insults that she used to insult me whenever I just make a small mistake; you know when you are a child you just have to make a mistake; whenever I make a mistake she insults me, “a fool, go away, a fool like your father.” (HC 4, female, 22 years)

my biological father I did not know him because he died before I saw him, the one who showed me showed the one I am staying with (stepdad) and he always says I am not his son so that is always a big issue… he is the issue and he has given me so much stress because if I try to stay well, he just come to distract me—when he comes while drunk, he tells me “you go away I do not know where you came from you are not my son” so such like things depresses me so much (FEP 4, male, 28 years)

3.2.4. Witnessing violence

Another common theme was the experience of domestic violence between parents. Participants explained that poor caregiver relationships, often characterised by violence and sometimes heightened by substance use, impacted family stability, with some parents separating. One participant mentioned that his father had committed suicide after quarrelling with his mother. Domestic violence significantly negatively impacts the entire family's health and economic stability.

…it was not good because my mother was still not in good terms with him because of the beatings….she would go to rent with the three of us and he would also come and then they go back and that is how it was. She was renting and she could stay there for some months or a year and she comes back so that is how it was from the past. The alcohol caused them to quarrel, he was not understanding and I had told you he was always drunk in 24 hours and did not even wanted to contribute to the family (FEP 4, male, 28 years)

My father used to drink alcohol and my mother never liked it, so whenever he got drunk he could come to the house and never left money for food so they used to fight, so on the last day they fought and poured paraffin on each other and all of us were locked in the house; they wanted to burn each other. (HC 1, female, 28 years)

they (parents) were not relating well because sometimes they were quarreling and my mother could go and come back … she was going back at her home place. All of this would happen when father was at home. When he was in Nairobi it was always good because my mother was working up and down to make sure we have eaten. Our father was sending and food was being prepared for us so that we can get what to eat. My father he was a drunkard so when he was at home he would bring problems. He starts harassing my mother, fighting…. you just know how people behave while drunk; sometimes he would beat her, not all the time, so after beating her is when she was going back to her home. (FEP 3, male, 25 years)

Although some participants highlighted that their caregivers had mental health/substance use issues, these were identified as secondary stressors. In households where substance use was identified as a primary cause of strife and instability, the participants were said to have experienced abuse and neglect at the hands of the users or extended family members who chose to take advantage of them. One participant shared how he nursed his father to health after an alcohol‐related illness, only for the father to return to use.

Life at home was somehow difficult because you know whenever somebody is a drunkard all his/her mind is on alcohol… mum does not mind, whatever she sees in front of her is alcohol. Then sometimes when she buys food you will eat late; you just understand the kind of life in an alcoholic household where the dad is drunk‐ I mean when he comes back, he is drunk, when mum is here, she is drunk, you see? Now such kind of things; it used to be problematic over and over again. (HC 7, female, 43 years)

One week he is fine then the next week he is sick. I came and sat with him down and told him, “Father if you know that this is what is affecting your health, even if it is alcohol, it is not mandatory that you take, just deal with the drugs that you have been told to take.” It compelled me to just stay with him and persevere, I change his clothes…. when his time for medicine is due, I give him the drugs, I give him food to eat so that he is fit. He began to recover; after recovery and getting well again he forgets and goes back to alcohol. (HC 5, male, 33 years)

3.3. Coping strategies

Aldwin and Yancura (2004) highlighted five general types of coping strategies: problem‐focused coping, emotion‐focused coping, social support, religious coping, and meaning‐making. The participants described strategies that fit into these five categories which helped them cope with the difficult experiences.

3.3.1. Religion

A commonly mentioned strategy identified by participants was their belief in God. Religion is an important aspect of Kenyan identity, and most participants highlighted that when faced with difficult situations, they would call God in prayer. Prayer was identified as a way to cope with challenging events and feel hope for the future. One participant also mentioned seeing God transform her once‐alcoholic mother after many of the family members died from substance‐use‐related illnesses. This belief in God was also mentioned as a coping strategy still utilized by the participants in their adulthood.

Life is not all about taking it fast, it is slow [Inaudible] God is the one who understands, we leave everything to God, because without the almighty God; he is the creator and owner of everything, if you ask him he will give you. If you ask Him today but He fails to give you, but He has heard your prayers. (HC 5, female, 33 years)

I believe in God and I believe so much in Him because if it were not for Him I would not be the way I am…in life because if I would be a weak person I would have even committed suicide but because I believe in God and I know that life will change that makes me firm. (FEP 6, female, 33 years)

3.3.2. Family support

Despite mixed responses, participants highlighted the importance of social support systems to help them cope with the traumatic events. For those who had lost one caregiver through death, they pointed out that the remaining caregiver—often the mother—provided much needed support and comfort. As mentioned earlier, the loss of fathers in this case often meant a loss of income, especially as the father was the primary breadwinner, with mothers often playing the role of homemaker. Participants highlighted that their mothers met this challenge head‐on, going above and beyond, to ensure that their needs were met. As is similar in the African context, older siblings, in some cases, were also a source of support for the participants, especially if they were employed, as they would support their mother in taking care of the needs of the young ones.

You know the other ones knew that I am their sister's child, so I am the one who used to call them sister‐sister…They used to support me in terms of school fees whenever grandmother doesn't have, she could make a call and one could buy me a book, a biro, another one pays school fees; that's how I used to survive. My uncle used to make sure he has bought me pads, that was the best thing he could do because maybe he could find me standing with a man, it's the pad that's causing me to stand with him perhaps I don't have; he used to make sure that he buys me pads. (HC 4, female, 22 years)

when my dad passed away everything became a mess……it means that we started experiencing some difficulties of life, we could not now eat and my mum could not even pay this normal fees in primary school but she just used to go to the hill and come and bring the firewood to take them to the lake where she could get some money and sometimes she could come with dagaa (fish) and she used to be a good farmer, getting flour was not that tough but she could manage life that way. (FEP 2, male, 30 years)

in fact, when my father died, my elder sister had been employed as a teacher in rural secondary school so she took from there helping us in bits… she could at least chip in. Nobody else was working, it was just my sister and in fact she took us from far in fact that is why everyone else gives her respect. (FEP 2, male, 30 years)

In some cases, extended family would offer much‐needed support, with grandparents often taking over the caregiving role. For some participants, siblings to their parents often came in to support them. For example, one of the female participants pointed out that an uncle stepped in to pay school fees and meet her needs out of fear that their dire situation would force her to sleep with men for money.

My uncle used to make sure he has bought me pads, that was the best thing he could do because maybe he could find me standing with a man, it's the pad that's causing me to stand with him perhaps I don't have; he used to make sure that he buys me pads (HC 4, female, 22 years)

in fact, when my father died, my elder sister had been employed as a teacher in rural secondary school so she took from there helping us in bits… she could at least chip in. Nobody else was working, it was just my sister and in fact she took us from far in fact that is why everyone else gives her respect. (FEP 2, male, 30 years)

3.3.3. Community support

In instances where family was unavailable or unwilling to provide support, the community, teachers, and friends supported the individuals. The participants who had worked as house helpers mentioned that some of their employers offered support, even during this exploitation.

You know now you had been used to somebody…, you get lonely, you feel that now everybody has discriminated you since you are left alone yet it is not supposed to be that way. By good luck by the way what I came to realize is that having friends was a very good thing; friends used to come and encourage me, “don't lose hope that you are alone,” even if it is slashing they help me to slash the homestead, even when a visitor comes h/she tells me, “sorry, that is life and that's how it is, take this one for sugar you can help yourself with it,” I pushed on well. (HC 5, male, 33 years)

I was just praying to God while I was in school because sometimes‐ we usually have a nurse at school, so I used to share the story with him/her; so as we share h/she also gave me guiding and hopes, h/she is the one who helped me a lot of which at form four third term at least I studied. (HC 2, male, 18 years)

3.3.4. Emotion focused and problem focused strategies

Emotion‐focused refer to a wide range of strategies that are directed toward managing one's emotional response to a stressor. The coping strategies identified by the participants included the use of substances, especially by male participants. The women would run away from home to marry or sleep with men for financial support. They discussed how they thought marriage would solve these challenges, only to experience abuse at the hands of their partners.

After the funeral took place, people went away and I was left in the homestead alone, so it came that I don't have any other option and that's where I met with friends who would say, “come let me help you remove stress.” So, then we would drink alcohol, the local brews at home. (HC 8, male, 32 years)

there is a friend of mine who called me at his place and we started using bhang, cigarette and from there we were going daily and because I was having stress they were relieving me (from stress at home). I had those things in mind so I saw that the drugs will help me forget about them. (FEP 3, male, 25 years)

I was born then left with my grandmother when I was six months; grandmother has raised me until I reached sixteen years while she was just struggling with me to get educated but when it reached sixteen years I felt that life had become hard and it compelled me to look for how I can survive that's when I decided to get married. (HC 4, female, 22 years)

Problem‐focused strategies. This strategy involves behaviours and cognitions aimed at solving the problem, such as taking direct action seeking, information seeking, breaking down the problem, or delaying or suppressing action. Our participants shared that they would often engage in income‐generating activities to help support the family or even their schooling.

sometimes my mother used to send us something little whenever she could get; sometimes it used to force me to burn charcoal and sell then I go to the market and buy and grind be it two tins of flour then we eat, the rest of the money I tell dad, “I am going to use this to buy a book, a pen.” Sometimes mum fails to send me the required fees for like exams, I could take some little money from charcoal since we had a lot of wood before; whenever I could burn about two, three, four, or five sacks I buy books and save money for exams even if it is eight hundred I just know that this is eight hundred for exams; you know dad doesn't have a job. (HC 5, male, 33 years)

so after him passing it was a major problem because he was the main pillar in the family. After him passing, my stepmother also ran away, so it used to force us to sometimes go and do these hard jobs until we got used to digging for people, slashing, drilling pit latrines, boreholes and such things, boreholes so that at least we can support mum…The twin sister too felt that that life has become a bit difficult and she ran away and got married, so I remained ‐two people; mum and I, so I am the one who used to support mum. (HC 8, male, 32 years)

3.3.5. Meaning making (cognitive reappraisal)

Park & Folkman described meaning‐making as how individuals interpret, understand, and make sense of life events, enabling them to cope with stressful situations by reappraising the situation and seeking a more positive understanding of the situation and its impact on their lives (Park & Folkman, 1997). Our participants appraised the events that they went through as a failure or let down by the caregivers/adults in their lives. For example, for those whose parents had separated, or those with stepparents, they wished that their caregivers would have separated their feelings or thoughts toward their partners from how they went on to treat them (the children).

Yes, I mean, I feel that if they could have stayed together because the whole of these things I can say occurred as a result of the separation, if they could have stayed together, we couldn't have gone through such and then at right now let me say that if my mother could have been available and got a job I could have gotten educated and I couldn't have been married, … I can say that if my mum could have been available even if they could have separated but she was available I couldn't have done these other things such as house help, I mean certain things couldn't have befallen me because my mother was trying so that she can settle and take us to stay, but it wasn't maturing, because my mother is also somebody who reached class four, so she didn't also go to school so what she could do was maybe in the bar or hotel, just that. (HC 1, female, 28 years)

about my parents, I saw that my father was the bad person because he should have not involved us in his issues with my mother; instead treated us as his own children and educate us. He shouldn't have involved us in that fight. He should have taken care of us so that we can know that he was our father. Even when he died we did not attend his burial because we knew he was not our father. He rejected us and also refused to educate us. (FEP 6, female, 33 years)

they have affected because now if your parent fails to take care of you and they are the parent, what is that? You see now you get stressed because you do not have support from both sides, not the father not the mother. When you go to your mother she does not want you. Sometimes I just feel like I don't have parents so I prefer to stay without parents. (FEP 6, female, 33 years)

4. DISCUSSION

Our results demonstrated that by the age of 17 years, majority of our participants had experienced multiple adverse events. Emotional neglect was the most common adverse event, followed by divorce or caregiver death. Physical neglect and experiencing a family member's violent treatment were the third most common events experienced by the participants. Physical abuse was the least common adverse event. These findings align with local and global quantitative findings that showed that the most commonly reported ACEs were death/loss of a parent, followed by violently treated household members (Kessler et al., 2010; Kiburi et al., 2018; Oladeji et al., 2010). We noted increased vulnerability to being exposed to an additional category after a report of any single category of adversity (Kessler et al., 2010), echoing research that suggests that childhood adversities often co‐occur (Armour et al., 2014; MacLochlainn et al., 2022) (see Appendix 1). Our findings were similar to those reported by Oladeji et al. (2010), suggesting that the chance of experiencing multiple adverse childhood experiences was higher among individuals who reported neglect. We found no difference between the number of ACEs experienced by the different groups (FEP or healthy controls), (see Appendix 1). These findings, although like other studies carried out in Africa (Kilian et al., 2018), are unusual in the global literature context but perhaps not surprising as we have such high rates of trauma on the continent (Ng et al., 2020).

MacLochlainn et al. (2022) proposed that the original ACE categories did not encapsulate the full spectrum of ACEs one can experience. We agree with including economic hardship or deprivation as an ACE (Braveman et al., 2018). Researchers suggest that strong links between poverty and ill health can lead to a lack of community resilience to protect children from adverse events (Boullier & Blair, 2018; Braveman et al., 2018; Liming, 2019). At the same time, Pelton (2015) argues that poverty reinforces high‐risk environments, leading to conditions that may endanger children by increasing opportunities for adversity. Most participants mentioned the impact of economic difficulties, with children's basic rights, such as going to school, neglected. In agreement with previous literature, our findings emphasise that economic hardship and its associated problems (food insecurity, impaired access to services) are hard on children, increasing their vulnerability to other adverse events and impacting their coping abilities (Braveman et al., 2018).

The findings of this study present notable divergences from the literature in high‐income countries (HICs), shedding light on the unique challenges and experiences within a low‐resource setting. Several key differences emerge when compared to HIC literature, for example: while a few participants highlighted issues of bullying, these were few in contrasts with literature from high‐income countries (HIC) where these factors are more prevalent. In HICs, issues of bullying have been extensively documented, with a paucity of reports on adolescent bullying in low‐ and middle‐income countries (LMICs) (Arseneault, 2018; Biswas et al., 2020). Another study found bullying victimisation is prevalent among adolescents globally, particularly in the Eastern Mediterranean and African regions (Biswas et al., 2020). The scarcity of these findings in the study's context suggests distinct societal dynamics and challenges, in need of further evaluation. In addition, caregiver incarceration was not cited as an adverse event among our participants. While our sample size was limited by the study design, we cannot suggest that there were low rates of caregiver incarceration in our context, particularly when compared to HICs. Where increased criminal activities may be found in poor economic conditions, rural–urban differences coupled with strong community and family support structures, common in many LMICs, may influence the prevalence of incarceration in our context (Arisukwu et al., 2020; Miruka Daniel, 2020). In addition, our findings revealed low rates of community violence, which diverge from some HIC literature where urban violence and community safety concerns are more prominent (Sharkey, 2018). The differences may reflect variations in social structures, cultural norms, and community dynamics that influence the prevalence of violence. The discrepancy in community violence rates between LMICs and HICs can be attributed to a complex interplay of socio‐economic, cultural, and environmental factors. These differences underscore the importance of understanding the socio‐cultural and economic context when interpreting findings related to adverse childhood experiences (ACEs). The variations may be influenced by factors such as cultural norms, legal frameworks, and societal structures that differ between low‐resource settings and HICs. Moreover, economic hardships in low‐resource settings can contribute to distinct challenges, impacting family dynamics and the overall well‐being of children (Braveman et al., 2018; Pelton, 2015). Another finding from our work showed that at least half of our participants had parents who had separated/divorced. This finding was surprisingly high for communities in LMIC which traditionally have lower divorce rates due to strong family ties, communal support systems, and cultural values often contribute to the stability of marriages. A review by Clark and Brauner‐Otto found urbanisation and female employment to be associated with higher levels of divorce, while age at first marriage and female education corresponded to lower rates in similar contexts (Clark & Brauner‐Otto, 2015).

Exposure to stressful situations at any level (individual, family, or community) necessitates strategies to manage tension. Coping responses refer to intentional physical or mental actions that react to a stressor and are directed toward the environment or an internal state to manage this tension (Compas et al., 2001). This dynamic process changes in response to changing demands of stressful encounters (Compas et al., 2001; Folkman & Moskowitz, 2004). As highlighted by Aldwin and Yancura (2004), we identified five general coping strategies used by our participants: social support, religious coping, problem‐focused coping, emotion‐focused coping, and meaning‐making. These strategies can either support the individual in dealing with the stresses brought about by the events or cause further harm to the individual and their well‐being. The strategies identified in this study varied across individuals and genders. Some of the strategies utilized by the participants included engaging in self‐harming behaviours. The men reported using substances to help ‘forget’ the challenges faced, with women using relationships with the opposite sex as a way out. Literature suggests the need for disengagement, avoidance, and emotional suppression (Compas et al., 2017).

In children exposed to adversity, social support can buffer stress caused by exposure to adverse events and prevent the development and maintenance of psychopathology (Nelson et al., 2020; Pinto et al., 2021). Social support was identified as a coping strategy employed by the participants in this study. This study found family and community support to be protective factors, with the literature showing that secure attachment relationships, especially those with parents/caregivers, act as a buffer for children from the psychological distress associated with traumatic experiences (Dye, 2018; Turner et al., 2012). Evidently, support from mothers or mother figures (often maternal grandmothers) provided a safe base for the participants to navigate the challenges. Those who lacked this support had to go within themselves. Research has found that increasing strength at the community level is a way to improve an individual's functioning following adverse events, suggesting that the collective efficacy of the community augments the adaptive capacity of the individual, thereby improving their well‐being and resilience (Ireland & Thomalla, 2011; Murray & Zautra, 2011; Zautra et al., 2008). Our findings showed conflicting reports, with some participants highlighting the support of the community during challenging events, while others did not. Those who expressed having received support were also more open to supporting others in difficult situations, as they were appreciative of the support accorded to them.

Some strategies could also be culturally influenced, with cultural distinctions known to occur in the perception and interpretation of traumatic experiences and the subsequent expression of the response to the event (Oladeji et al., 2010). For example, in this study, it was evident from the participants that speaking out about the stressful nature of events was not something that they thought was possible or available. This may be due to the cultural context in which the children are not encouraged to speak.

We also note that coping with adverse situations looks different at the different stages of life, with children seeking social support, often from caregivers. These findings echo attachment literature that underscores that caregivers act as a ‘secure base’ from which the child explores, and as a ‘safe haven’ for obtaining support and protection in times of perceived threat (Cassidy et al., 2014; Doyle & Cicchetti, 2017). It is also well documented that attachment in adolescence evolves with increasing reliance on peers for intimacy and social support, and consequently, weaker bonds with parents (Ferrajão & Elklit, 2021; Moretti et al., 2004). As adolescents, our participants showed that while they still acknowledged the supports available at home (within the family), they also identified that they had access to external supports including peers, teachers, community members. We also observed when they were older (adolescents), they utilized the other coping strategies, such as meaning making, emotion‐ and problem‐focused approaches. This is noted by Compas et al. (2001) who suggests that greater diversity and flexibility in the range of coping responses available to the individual develop as one gets older; with increasing metacognitive skills enabling a greater ability to match coping efforts to the stressful events.

Our study also described similarities or differences in the experiences and coping styles employed across the two groups. First, our findings showed that the way an event occurred impacted the individual's experience of the trauma. For example, the type of caregiver death influenced the experience of trauma, with healthy controls whose parents died of an illness were seen to navigate the death well, while FEP participants whose parents died through gruesome events (suicide, traffic accidents, or death by abortion), appraised them as causing significant trauma to self. Another difference noted among the participants was that the experience of intent to harm was more prevalent among our FEP cohort than among the healthy controls. Arseneault et al. (2011) found that maltreatment by an adult and peer victimisation (intention to harm experiences) were associated with a significantly increased risk for the development of psychotic experiences than those who experienced unintentional harm. Condly (2006) further suggests that traumatic events significantly damage the affected individual, not so much because of the immediate harm they cause but because of the lingering need to re‐evaluate one's view of oneself and the world.

Briere et al. (2009) point out that the major types of childhood maltreatment associated with lasting psychological impacts on adult women include sexual abuse, physical abuse, psychological abuse, and psychological neglect. Although our sample is inadequate for casual interference, our findings among the women concur, suggesting that their psychological well‐being is impacted by the trauma they experienced accompanied by supports at their disposal. Our participants with FEP were found to experience more severe trauma and lacked the necessary support to help them cope with the events, thus increasing their vulnerability compared to healthy controls.

Additionally, intense, prolonged, and cumulative trauma (extreme exposure to adversity) is associated with more problems and less favourable adaptation (A. Masten, 2011). Our findings showed that loss or injury, displacement or separation from the family, including exposure to destruction or violence, was associated with more symptoms and disturbances in functioning (A. S. Masten, 2021). This was more evident in our participants with psychosis, whose adverse experiences were prolonged and often occurred in the home. The experiences of adversity varied between the two groups, with our findings suggesting that adverse experiences that were prolonged, intense, and occurred at a younger age were associated with more problems and less favourable adaptation. Most participants identified social support as a resource, and the number varied among participants; however, we cannot conclusively suggest that those with an FEP diagnosis have less access to support systems. In addition, our patient population was found to experience more severe trauma, lacking the necessary support to help them cope with the events, thus increasing their vulnerability compared with healthy controls.

Traumatic events cause significant damage to the affected individual because of the lingering need to reevaluate one's view of oneself and the world (Condly, 2006). Additionally, it has been suggested that the ability of the individual to re‐evaluate adverse events and their impact and reframe them may lead to acceptance and eventual recovery (Iacoviello & Charney, 2014; Rosenberg, 2020; Rutter et al., 2006). From this perspective, the most notable difference in the coping strategies between FEP patients and healthy controls was observed in how they appraised the traumatic events. Our findings highlighted this, with healthy controls showing a better ability to reframe and incorporate the impact of traumatic events on subsequent functioning. Aldwin and Yancura (2004) suggest that simply asking “Why me?” may be associated with poorer outcomes, but realising how a problem fits into the larger pattern of one's life may be a painful process, but in the end, may be one way in which individuals grow from stressful or traumatic experiences. Our findings showed that both groups of participants often had a “why me” perspective to their previous adversity, with the psychosis group stuck in this phase, ruminating on the events. Findings from the controls showed that although they questioned the events, they reappraised the situation and made use of other strategies to cope with the adversities, such as substance use, running away to get married or going out to work to make money to buy food at home, as well as seeking support from others.

Resilience has been described as the ability to negotiate existing pressures using harnessed resources in an adaptable manner to maintain well‐being (Masten et al., 2021; Panter‐Brick & Leckman, 2013). Aldwin and Igarashi (2012) and Aldwin et al. (2009) suggest that the process of coping with stressful events can create resources for resilience, which may prove useful for future negative episodes. Our findings emphasised that participants attempted to manage negative experiences amid adverse situations using various strategies. Researchers have suggested that the ability to identify and (re)use these resources to effectively cope with stressful events makes the individual more adaptable, thereby promoting positive outcomes (Galletta et al., 2019; Idan et al., 2016; Langeland & Vinje, 2016). We observed that the healthy controls showed more resilience than the psychosis group, as they were better able to identify resources at their disposal and use them to promote well‐being.

Resilience‐promoting factors (also referred to as preventive/protective factors) and resilience‐challenging factors (risk factors) can be considered at the individual, family, and social‐environmental levels. These levels are not independent of each other. There are overlaps between different levels; they interact and depend on each other. Rutter (2007) suggested that the utility of these factors depends on the context and the child's individual situation. This indicates that children can be resilient in relation to some risks and not others; therefore, different risks and environmental changes can result in a child showing resilience or a lack of resilience at different points in time. It is also important to note that although protective factors help attenuate the effects of adversity, individuals are only resilient up to a point. Studies have shown that when risk factors outweigh the benefits of protective factors, adjustment deteriorates despite the presence of positive influences (Zielinski & Bradshaw, 2006). Therefore, it is important to consider the effects of adversity and resilience in multiple contexts and vulnerabilities.

Our study highlighted the impact of adverse events on the well‐being of individuals. The paucity of literature on ACEs and mental health from sub‐Saharan Africa might be indicative of the limited availability of mental health services, the lack of quality representative data, and the competing priorities of other health and development issues (Brown et al., 2023). Additionally, this work highlighted the presence of coping strategies that can be harnessed to promote well‐being in the aftermath of adversities. Our study findings might be crucial to policy change and continued awareness of the adverse outcomes of ACEs. The pervasiveness of ACEs requires strategies to promote prevention. There is a need for multi‐level approaches to addressing risk and protective factors at the individual, relational, community, and societal levels while identifying and promoting the utilisation of support within the community to promote well‐being. The Centre for Disease Control and Prevention developed a resource to help communities prevent and reduce child abuse and neglect—Child Abuse and Neglect Prevention Resource for Action (Centre for Disease and Control and Prevention, 2019; Fortson et al., 2016). In addition, the World Health Organization (2018b) developed an evidence‐based technical package (INSPIRE) to support countries in their efforts to prevent and respond to violence against children aged 0–17 years. These resources can be used to impact individual behaviours and the relationship, family, school, community, and societal factors that influence risk and protective factors for ACEs. From our findings, immediate support strategies can be tailored to the individual, family, and community settings to create safe, stable, nurturing relationships and environments (Centre for Disease and Control and Prevention, 2019), while challenging limiting practises, and societal norms that perpetuate ACEs within these communities. For example, strategies from the INSPIRE technical package to reduce harsh parenting practices and create positive parent‐child relationships could be adopted to prevent ACEs and equip caregivers to provide adequate support (World Health Organization, 2018b). Implementation of mental health literacy sessions in the school curriculum may provide the necessary coping skills to deal with the impact of traumatic events while providing a safe space for young people to seek help. Promoting safe environments and economic strengthening activities can also reduce ACEs' occurrence and negative consequences, subsequently improving well‐being across the lifespan (Centre for Disease and Control and Prevention, 2019; Fortson et al., 2016; World Health Organization, 2018b). We suggest the inclusion of routine clinical assessment of past experiences of adversities or trauma for persons seeking psychiatric care as this will impact the care they receive (Herzog & Schmahl, 2018; MacLochlainn et al., 2022; Sara & Lappin, 2017). Given the limited access to mental health services, strategies aimed at extending the accessibility of mental health services to young people who have experienced adverse events in childhood may help buffer against poor mental health outcomes in life. Adoption of evidence‐based interventions like the Trauma‐Focused Cognitive Behavioural Therapy (TF‐CBT), which has been extensively evaluated have proven effective at improving outcomes of children and caregivers who have experienced violence and other traumatic life events (Kliethermes et al., 2017). At the national/regional level, campaigns may be necessary to raise awareness, prioritise resource allocation, and destigmatize mental health problems.

4.1. Strengths and limitations

Our study illuminates the different perceptions of events and coping strategies employed by individuals during their experiences of adverse childhood events. The first limitation of this study is that the shared insights may not be transferable to other contexts, as the participants were recruited from urban areas despite having grown up in both rural and urban contexts. Participants represented middle‐lower socio‐economic brackets. In addition, coping strategies may differ, considering additional resources and support specific to an individual's environment. Future research should consider studying adaptive trajectories over time. A major strength of this study was the use of a qualitative approach which aims to understand everyday human experience in all its complexity to understand how the social world is interpreted, understood, experienced, or constructed (Cleland, 2017). This approach was excellent because it allowed for a deep exploration and understanding of ACEs, coping strategies and resilience in this context, adding much needed insights into the complex phenomena add knowledge to the field is heavily dominated by Western literature. While a qualitative approach using multiple case study design was beneficial, there is need for additional rigour in future research especially in similar contexts. First and foremost, it is essential to clearly define the research questions and objectives, ensuring they align with the overarching purpose of undertaking multiple case studies. Secondly, the selection of cases should be thoughtfully justified, emphasising their relevance to the research questions, and incorporating diversity to enhance the generalizability of findings. In addition, triangulating data from multiple sources, such as interviews, observations, and documents, adds depth and reliability to the findings, which in our case was not possible. Clear data analysis procedures, including systematic and transparent coding, also work to facilitate a rigorous analysis, coupled with involving multiple researchers to help ensure the credibility and reliability of interpretation of the findings. Finally, it is also important to maintain reflexivity throughout the research process which is crucial for acknowledging and addressing the researcher's biases and assumptions that may influence data collection and analysis processes.

4.2. Conclusion

This qualitative study provides a local portrait of childhood adverse events and coping strategies. The evidence suggests that the impact of early adversity is prevalent in our community and, unfortunately, largely normalised to the detriment of the well‐being of the individual and society. There is a paucity of local literature on ACEs, most of which is quantitative. This study makes a valuable contribution to the literature by providing a qualitative understanding of the role of early experiences and their subsequent impact on perceptions of oneself, others, and adaption. Although limited in scope, the coping strategies employed were related to risk and protective factors at the individual, family, and community levels, with relationships playing a significant role in providing stability and structure for well‐being and resilience promotion. In addition, the study's findings highlight unique patterns of ACEs in a low‐resource setting, emphasising the need to consider context‐specific factors for future research. Understanding these differences contributes to a more comprehensive global perspective on childhood adversities and informs targeted interventions that are culturally sensitive and responsive to the specific challenges faced by communities in low‐resource settings.

FUNDING INFORMATION

Funding to collect data for this study was provided through a University of Kwa‐Zulu National College of Health Sciences PhD Scholarship Grant.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

Supporting information

Data S1. Supporting Information.

Wambua, G. N. , Kilian, S. , & Chiliza, B. (2025). A qualitative study of coping strategies and resilience in the aftermath of childhood adversity in first‐episode psychosis. Early Intervention in Psychiatry, 19(1), e13551. 10.1111/eip.13551

DATA AVAILABILITY STATEMENT

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.