Invisible Wounds

Studies into the mental health of Syrian refugee children have shown staggering levels of trauma and distress. However, much less is known about the impact on children still inside the country, one in four of whom is now at risk of developing mental health disorders. To begin to further understand and address this urgent problem, Save the Children and partner organizations managed to speak with more than 450 children and adults inside seven of Syria's 14 governorates about how the conflict has affected children's daily lives, their main causes of stress and fear, who they turn to for help, and how they cope with constant war – a waking nightmare that seems to them as though it may never end. The research took place between December 2016 and February 2017 and consisted of:

• 313 individual questionnaires completed by 154 adolescents aged 13–17 (59 girls, 95 boys) and 159 parents and adult caregivers (61 women, 98 men).
• 17 focus groups with 125 children (56 girls, 69 boys) split into four age groups: 5–7, 8–11, 12–14 and 15–17 years. The older ages were divided into groups of girls and boys.
• In-depth interviews with 20 psychosocial workers, children, aid workers, teachers, parents and psychologists.

The research was carried out with trained practitioners who also offered psychological first aid to children involved. It took place in multiple locations in Aleppo, Damascus, Dara'a, al-Hasakah, Homs, Idlib, and Rif Damascus, with additional interviews with experts based in countries neighboring Syria.The prolonged exposure to war, stress and uncertainty, means that many children are in a state of ‘toxic stress'. This is having immediate and hugely detrimental effects on children, including increases in bedwetting, self-harm, suicide attempts and aggressive or withdrawn behavior. If left untreated, the long-term consequences are likely to be even greater, affecting children's mental and physical health for the rest of their lives.

Findings include:

• 84% of adults and almost all children said that ongoing bombing and shelling is the number one cause of psychological stress in children's daily lives.
• 89% said children's behavior has become more fearful and nervous as the war goes on.
• 80% said children and adolescents have become more aggressive, and 71% said that children increasingly suffer from frequent bedwetting and involuntary urination – both common symptoms of toxic stress and post-traumatic stress disorder (PTSD) among children.
• All groups said that loss of education is having a huge psychological impact on children's lives.
• 49% said children regularly or always have feelings of grief or extreme sadness and 78% have these feelings at least some of the time.
• 50% of children who are still able to attend school said they never or rarely feel safe there.
• 59% of adults know of children and adolescents who have been recruited into armed groups.