Invisible Wounds by Save the Children
Photo by Save The Children
Save the Children and its Syrian partners interviewed more than 450 children, adolescents and adults across seven regions in Syria for “Invisible Wounds,” the largest and most comprehensive study undertaken inside Syria to examine children’s mental health and wellbeing.

For six years now, children in Syria have been living with the constant fear of being killed and, according to a report released today by Save The Children, the psychological toll has sparked a growing mental health crisis.

The report Invisible Wounds: the impact of six years of war on the mental health of Syria’s children finds that roughly two-thirds of children in Syria have lost a loved one, had their house bombed or shelled, or suffered war-related injuries. For the 3 million born since the start of the war, the only reality they have ever known is one wherein they cannot safely attend school or play outside for fear of shelling and mines.

“I’m afraid of going to school because a plane will bomb us,” said Rihab, a little girl between 8 and 11 years old interviewed by Save the Children. Nour, a 5-7-year-old, also confided: “My heart hurts because it beats too hard because I am scared.” That feeling of not ever being safe is especially acute among the 600,000 people still living under siege. In those areas, the report states, “The associated sounds alone — of people screaming and shouting or aeroplanes circling overhead, even without bombing — were enough to trigger extreme levels of fear in children.”

Consequently, a Save the Children estimates that a quarter of Syrian children suffer from “toxic stress,” a dangerous condition caused by excessive or prolonged activation of stress response systems in the body and brain. According to Harvard University’s Center on the Developing Child, “When toxic stress response occurs continually, or is triggered by multiple sources, it can have a cumulative toll on an individual’s physical and mental health—for a lifetime.” If untreated, it puts children at greater risk of developmental delays and future health problems including heart disease, diabetes, substance abuse, and depression.

The underlying cause is trauma, like 3-year-old Saeed witnessing the beheading of a fellow child and 9-year-old Mohammad losing one of his legs and two of his siblings when a bomb struck while he was out buying some chocolate.

Yet the children also face subtler, more persistent threats to their security that stem from soaring poverty rates (85 percent today compared to 28 percent before the war) and plummeting school attendance (4,000 schools have been bombed and 150,000 teachers have fled, leaving a third of children out of school and almost as many at risk of dropping out soon). The physical devastation of their country and the wreckage of its economy leaves many children to contend with insufficient food and medical care, rising rates of domestic abuse, girls as young as 12 being forced to marry, boys taking jobs cooking for armed groups or manning their checkpoints, families separating as some members die or flee the violence, and parents who admit they are too exhausted and stressed by the lack of money and jobs to adequately support their traumatized children.

Hisham*, a school teacher from Deir Ezzour in Syria, arrived in Al Hol Camp with his wife and five children in February 2017. Hisham says his children have witnessed violence one wouldn’t even see in a film. He worries that the lack of schooling will have a disastrous effect on younger generations. Image by Save The Children.
Firas* and his family have been displaced twice by ISIS. They eventually attempted to go back to their hometown, Tel Abiad, but when they reached their homes they found them in unliveable conditions. They therefore found an abandoned petrol station nearby and decided to live there until they figured out what to do. Firas says one of his children witnessed the death of an unrelated child. His sleep is now affected with nightmares that the same will happen to him. He wakes up screaming. His child now tries to stay awake during the night and sleeps during the day. Image by Save The Children.

Based on 458 interviews of children, teens, and their caregivers**, Save the Children found the majority of Syrian children exhibit symptoms of toxic stress, including: bedwetting or involuntary urination (71 percent), stuttering or losing the ability to speak (48 percent), increasingly aggressive behavior (80.5 percent). Furthermore, they found that, in an attempt to cope with their stress, about half of the youth have turned to hashish, opium, and other substances. Psychosocial workers in Syria are also reporting more and more instances of self-harm and suicide attempts.

One 12-year-old hung himself with a scarf after his father died in a car bomb. “They tried to explain to the child that now your dad is a martyr and he is going to paradise, so the child thought that if he died he would see his dad,” explained Sharif, the psychosocial worker in Southern Syria who reported the incident to Save the Children. Another child expressed wanting to be hit by a sniper in order to be brought to a hospital so he could get something to eat.

At a UN press briefing on Monday, representatives from Save the Children shared some of their concerns based on the report’s findings.

Syria Director Sonia Kush warned that the children’s constant exposure to violence and death could desensitize them to the point where they become emotionally numb. She explained, “They could grow up to lack empathy and be indifferent to violence, which is very dangerous to Syria’s future society.”

Already children are showing signs of desensitization according to Rolla H, a representative of the UK-based organization Syria Relief, which partners with Save the Children in Syria. She recalled how Mohammad, the same little boy who got caught in a bombing attack while out to buy chocolate, smiled as he told her about losing his leg and his two siblings. When children speak about death with smiles on their faces, it signifies that death has become “something totally normal” for them, Rolla says, stressing that just because a child smiles “does not mean he is okay.” She further explains, “Our children in Syria are not crying anymore when they should be crying. They are just getting through the day and [wondering] if they will make it to the day after or not.”

Whether or not this “broken generation” recovers psychologically will determine Syria’s future as these are the children who will one day face the Herculean task of rebuilding their war-torn country. Studies show that toxic stress causes neurological damage that impacts a child’s ability to learn, so unless they get the care they need, they will be unlikely to benefit from any education that may be available to them down the road.

The report warns that after six years, Syria has reached a “tipping point,” where millions of children have been so consistently exposed to toxic stress that their chances of recovering fully are dwindling day by day. For the moment, there is still hope because the children interviewed continue to feel emotions including fear, anger, and hope. They still dream of a better future after the war ends, and they strongly desire to go back to school. According to Sonia, this means it is not too late to help them.

Not all children require professional help to cope with their experiences, but they all need to feel safe and loved and to go to school and have safe spaces to play to regain a sense of normality.

Carolyn Miles, President and CEO of Save the Children, stresses the importance of “stopping the bombardment of civilian areas and reaching [all 13.5 million people in need, including 5.8 million children] with lifesaving aid and psychological support.”

But achieving this is immensely difficult. Despite the relatively positive outcome of the most recent round of Syria peace talks, which concluded in Geneva last week, prospects for civilian protection, let alone peace and security in Syria, remain far off. As attacks on schools and hospitals continue, many humanitarian groups cannot reach people in government-held or ISIS-controlled areas. Those who do reach affected populations, do not always have the expertise or the funding to address mental health needs. Furthermore, a social stigma attached to seeking counseling and a dearth of child psychologists and mental health experts needed to help the most severely afflicted children present additional obstacles.

Save the Children has called on the UN and others to look at mental health challenges seriously and give it more prominence in their response plans. Sonia also noted that funding needs to be longer-term, explaining, ”A lot of donors will fund programs for six months at a time, but that doesn’t work for mental health programs because when children start going through this treatment, they actually get worse first as they process what happened to them and then they get better over time.” If the funding stops mid-treatment, it can be very dangerous and harmful for the children.

Of course, what Syrian children need even more urgently than funding for mental health programs, is to stop living under the constant threat of being attacked. They need compliance with several UN Security Council resolutions to ensure their protection. They need their government (which is responsible for 80 percent of civilian deaths in the war) and all opposition parties to stop targeting their schools and hospitals, to refrain from using explosives in widely populated civilian areas, to stop recruiting child soldiers, and to allow full humanitarian access. They need the world to care enough about them to muster the political will to end this madness.

**Save the Syria conducted these interviews between December 2016 and February 2017 across seven out of Syria’s 14 governorates. It is the largest study to date of the mental health toll that war has taken on Syria’s children. They are “confident” that their sample is representative of children across Syria’s opposition-held areas, which are the only territories they could access. Although they were barred from entering government-controlled areas, they spoke to a mental health expert working there who reported similar findings.