Almost a decade of civil and military unrest has left Syrian children mentally scarred, angry and traumatised, according to new research.
In the largest such survey yet carried out, researchers questioned more than 1,300 secondary school children in the Syrian capital, Damascus, about the impact that nine years of exposure to the conflict has had.
They found negative impacts in more than half, with high levels of post-traumatic stress disorder (PTSD), problematic anger and other, significant mental health issues.
The impact appeared worse in girls, who reported a higher predominance of PTSD and a worse quality of life.
The report suggests that the longer the crisis continues, the more persistent the impact will be, making mental recovery even harder.
The study, Posttraumatic stress disorder (PTSD), anger, and mental health of school students in Syria after nine years of conflict: a large-scale school-based study, provides a detailed analysis of the mental damage caused by war, the disparities between girls and boys, and the overall condition of Syrian students.
Looking at the extent of the damage, the study involved a total of 1,369 students, in grades 10 and above, living and studying for the past nine years in the city of Damascus.
Published in the Cambridge journal, Psychological Medicine, it looks at children who have grown up during the war and experienced daily traumatic events from the conflict and a deteriorating economy.
The study was carried out in seven schools over 12 months, starting in March 2019. Questionnaires were distributed and completed in class, with experienced data collectors on hand to ensure anonymity and to explain if anything was unclear to the students.
The survey covered students' socio-economic status; their health-related quality of life, including general, physical and mental health; the kinds of social and emotional support available to them; whether they had been in danger or distress, or suffered other traumatic events like the loss of a home or people close to them; and questions designed to assess their levels of anger and the likelihood of PTSD.
The answers revealed that around half of the students had changed where they lived due to war, with 58% reporting that they had been directly endangered, 40% saying they had lost someone close, and 61% reporting distress from war noises.
Analysis showed more than half of the students, 53%, had probable PTSD, while 62% suffered from problematic anger. Around 46% declared having a fair or worse general health, and 61% moderate or severe mental health issues.
Dr. Ameer Kakaje, lead author on the paper, believes the true prevalence of these problems could be even higher, as the study was only in Damascus, not in areas where populations may be even more severely affected. It was also unable to reach children who had dropped out of school.
He said: "I am a Syrian who lived most of his life in Syria and witnessed most of the suffering in person, especially as my last three years at high school and all of my university studies were during the war.
"The critically high prevalence of PTSD and problematic anger shocked me. We are talking about young people who are 18 and under and who should be healthy. But these high numbers are just a glimpse of what is going on in the Syrian community and how much they are mentally suffering without any means of dealing with it."
Further analysis found girls reported worse mental and physical health than boys, had a higher probability of PTSD and a worse quality of life. Again, Dr Kakaje suspects the figures may hide the true scale of the problem.
He said: "When screening for problematic anger, there was no difference between genders, which could indicate that due to gender stigma, boys might have underestimated their symptoms when they filled in the self-reporting scales. As anger is not stigmatised, they were free to declare their problems and thus both genders might have been severely affected. This may also mean that both genders may suffer mentally, but boys might have not expressed these feelings in ways other than through anger."