21 February 2019
How fear has stolen the childhood of a generation
Published online 7 September 2014
Across the Arab world many children are showing signs of severe psychological distress and support efforts are often futile in the face of continuing raging conflicts.
In Gaza, children play a game called “checkpoints and searches,” where they pretend to go through roadblock security checks and give each other pat-down searches. Another favoured pastime is the game of “martyr” where one child pretends to be dead, while the rest carry him or her in a mock funeral procession.
During art class in shabby, overcrowded classrooms, instead of trees, rainbows or butterflies some Syrian children draw the faces of the soldiers that make them wet their beds in fear. Instead of messages to friends and parents, they scrawl threats; “We will conquer,” “down with Bashar [El Assad],” or “Dictator, you killed my mother.”
Underlying these outward expressions of fear is mental distress wrought by conflict, which the Arab world is doing very little to ease.
Whether living in camps in Lebanon, Jordan or Turkey, or caught in the web of violence in Syria, Iraq or Gaza, children are exhibiting similar symptoms: depression, psychosomatic problems such as difficulty to sleep, anxiety, nervousness, fatigue or showing signs of grief and rebellious, aggressive behaviour.
On average, around 41% of teenage girls and boys who are now refugees have contemplated suicide, says Marta Passerini, a Save The Children child protection technical advisor based in Lebanon. “There’s also a lot of worry that adolescents will go back to fight,” she adds.
Even in the relative sanctuary of refugee camps, children “grow very fast in a world that is not kind to them,” explains Konstantina Bougonikolou, psychologist and medical coordinator with Doctors Without Borders. Theft, arson and murder are reported in some Syrian refugee camps. Children tell child protection experts they are scared to walk alone, scared of being bullied, scared of dogs and scared when an airplane flies by.
A preliminary report from the International Medical Corps’ Mental Health and Psychological Syrian response assessment, which has yet to be published, paints a clearer picture of the situation of Syrian refugees, including children.
“Based on a nearly 6,000-person caseload sampling from Syrians receiving mental health case management services both in the country and in neighboring countries, severe emotional disorders (31%) are the most common form of mental health disorders cumulative of the four countries (Lebanon, Jordan, Syria, and Turkey),” says an excerpt of the report, seen exclusively by Nature Middle East.
The kids have nightmares, they become clingy to parents, they experience separation anxiety, and they have difficulty concentrating and learning in school.
The Medical Corps, like other international groups including Doctors Without Borders and Save the Children, dispatch mental health experts and aid workers to either create support networks or work one-on-one with some of these children. They also provide training to healthcare practitioners in the area of mental health and trauma. They organize activities, like soccer games, conflict resolution exercises and awareness classes to help the children cope with their new reality.
The Medical Corps handle cases of children and young adults between the ages of 12 and 18. Within their sample group, the report found “a high prevalence of major depressive disorders (20%) and bipolar disorders (6%). Schizophrenia (10%) was the most prevalent form of psychotic disorder across the region.”
Effects on child development can also be significant; developmental disorders, autism, intellectual disabilities or enuresis are common. Risk factors for disorders like epilepsy increase during crisis.
Research about the extent of trauma in the region usually focuses on post-traumatic stress disorder (PTSD), immediately triggered by conflict and easier to diagnose. This places less emphasis on ensuing developmental disorders among toddlers and young children, and other long-term effects that are more subtle but just as crippling.
At a focus group by UNICEF and the International Medical Corps, the mother of an adolescent says: “Kids see weapons and can label them – they know the names of each weapon because they have seen so many.” Some internalize their problems – with boys finding it more difficult than girls to speak about their emotions or to speak at all, because of regional cultural conditioning on how boys should express themselves.
“The kids have nightmares, they become clingy to parents, they experience separation anxiety, and they have difficulty concentrating and learning in school. They sometimes isolate themselves,” says Inka Weissbecker, global mental health and psychosocial advisor at the International Medical Corps.
“These are not necessarily mental health disorders; they’re reactions to stressful environments. And some children of course develop more pervasive problems, like chronic bed-wetting and other regressions to earlier stages of development.”
In Iraq, a study of 10,000 primary school students by the Iraqi Society of Psychiatrists and the World Health Organization in the Sha’ab area of north Baghdad found that 70% of children were suffering from trauma-related symptoms.
Mental health services and practitioners have historically been sparse in Iraq and the exodus of doctors over the past decade has compounded this problem. There is currently only one psychologist for every million people in Iraq. As of March 2014, there were only three specialized child psychiatrists in the entire country, according to Child Victims of War, a charity that exposes the impact of modern warfare on children.
Generally, there are very few local psychiatrists or specialized mental health workers in affected countries, says Weissbecker. “A place like Gaza has only ten psychiatrists. And many who call themselves psychologists are not sufficiently trained.”
In the Palestinian territories, “acute stress” seems to be the norm, and specialised clinical attention is usually needed but rarely given. Yasser Jamei, head of Gaza’s Community Mental Health Center, says that during shelling, the tiny strip—one of the most densely populated in the world—experiences a significant rise in demand for mental health care.
Last May, Doctors Without Borders received 15 new Palestinian cases for counselling, but in June, during the height of the Israeli attack, they received 263 new cases.
What is most difficult in attempts to ease the fears and trauma of Gaza’s children, says Jamei, is the lack of a safe environment to ease the initial trauma and facilitate counselling. “There’s nowhere secure to shield them [from the stress of war]. Even UNRWA schools get directly hit by Israeli air strikes.” Public school-based mental health interventions are scarce or nonexistent.
The illusion of resilience
Not everyone will experience the psychological effects of war in the form of trauma or a disorder.
What could be mistaken for resilience among some children is usually them adapting to a new, skewed normal, says Bougonikolou, where it’s typical for neighbours and classmates to get killed or disappear, where homes are sporadically shelled, and disruptions of routine are frequent.
“When you watch news from Gaza where children describe the situation, ‘we were playing then three kids were killed,’ talking about death [nonchalantly], they’re describing a reality that they learned how to live with since they were born” she says.
For most 10-year-old Palestinian children, this year’s Israel-Gaza conflict is the third war they witness.
Palestinian children know from when they start school that they have to cross multiple checkpoints every single day in order to get there, says Bougonikolou, “so this becomes part of how they perceive the school experience.”
But this “adaptation” carries a hefty price tag. These children often adopt reckless or compulsive behaviour and don’t hesitate to throw themselves in dangerous situations. “They won’t be afraid to be engaged in situations that might lead to their death,” continues Bougonikolou.
She explains that the continuous exposure to violence and conflict can have a long-term damaging effect on the children, even if it does not show immediately. “Their life takes a wrong turn, and it’s very hard to take them back.”
Nature Middle East writer Kira Walker contributed to this report.