Six years of violence and bloodshed in Syria have spawned a mental health crisis among the country's children, says the international charity Save the Children.
In a report it called the largest mental health survey inside Syria during the war, the group found children increasingly affected by fear or anger.
"We've all witnessed from a distance how horrifying this war has been," Cicely McWilliam told CBC News, from Save the Children's Toronto office.
The research drew on interviews in seven provinces with more than 450 children, parents, teachers and psychologists, mainly in rebel-held areas including Idlib and Aleppo, and in Kurdish-controlled Hasaka.
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The conflict has killed hundreds of thousands of people, made more than 11 million Syrians homeless, and created the world's worst refugee crisis. Some children had been forced to join armed groups to survive, Save the Children said.
"They have seen their friends and families die before their eyes or buried under the rubble of their homes," the report said. "They are the next generation who will have to rebuild their shattered country."
Most of the children interviewed by the group — two-thirds of whom had lost a loved one, had their houses bombed, or been injured — exhibited severe emotional distress and lacked psychological support, it said, "with parents themselves struggling to cope."
The effects ranged from sleep deprivation and withdrawn behaviour to self-harm and suicide attempts. Some had lost the ability to speak.
Other findings include:
- 84 per cent of adults and almost all children believe bombings and shelling are the number one cause of psychological stress.
- 50 per cent of children say they never or rarely feel safe at school and 40 per cent say they don't feel safe to play outside.
- 71 per cent said that children increasingly suffer from frequent bedwetting and involuntary urination.
If left untreated, the report said, the daily trauma could have other consequences, disrupting the development of the brain during formative years and causing a rise in health problems into adulthood, including depression and heart disease.
Most children had become more aggressive, or showed some symptoms of post-traumatic stress disorder, the interviews revealed.
'The children are psychologically crushed and tired.' - Save the Children
"My son wakes up afraid in the middle of the night. He wakes up screaming," the report quotes Firas, father of a three-year-old boy. "A child was slaughtered in front of him, so he started to dream that someone is coming to slaughter him. When a child witnesses a beheading, how could he not get afraid?"
McWilliam said more focus is needed to provide mental health services for refugees. "Children are incredibly resilient, but they don't have the tools necessarily to know how to cope with the kind of stress that this report documents."
The lack of schools has worsened the crisis. One in three has been reduced to rubble, used to shelter displaced people, or turned into military bases or torture chambers, the charity said.
"Children in many communities in Syria have been going to school in basements for several years, essentially going to school in bomb shelters," said McWilliam.
One teacher in the besieged town of Madaya said in the report that pupils "draw images of children being butchered in the war."
The charity called for more mental health programs across Syria, adequate funding for psychological resources and training for teachers.
More than 25,000 Syrian refugees have already made Canada their new home, part of the Liberal government's resettlement plan. McWilliam believes Canada can take more, but is "encouraged by the fact that so many Canadians are clamouring to be supportive of Syrian refugee families.
"It's absolutely vital that we make sure that we support these families and support them in their mental health needs once they've arrived." But she adds, "There are millions of Syrians who are refugees or internally displaced who will never come to Canada, and we need to be supporting them as well."
McWilliam, who's the director of policy and government relations at Save the Children, believes there's too much focus on the geopolitical machinations of the Syrian conflict, and "not nearly enough on what's happening to the civilians on the ground, and in particular the children."
"The war has to stop", she said. "These kids are so forgotten right now."