With the war in Syria about to enter its seventh year, the mental and physical suffering of children is laid bare in these pictures and statements gathered by Save The Children.
They live in fear of being killed or maimed by bombs. They have seen loved ones die.
They suffer from nightmares and stress. Some of them stutter or wet their beds. Others have amnesia, headaches and chest pains.
These are Syria’s children - haunted by the sights and sounds of six long years of conflict.
“I feel depressed and as if I’m in another world. When I wake up I realise that I’m still here and then I cannot move my body,” said 15-year-old Mohammed from Eastern Ghouta.
A teacher in the town of Madaya said the children there are "psychologically crushed and tired", adding: "When we do activities like singing with them, they don’t respond at all. They don’t laugh like they would normally.
"They draw images of children being butchered in the war, or tanks, or the siege and the lack of food.”
These awful descriptions have emerged in a research project by Save The Children that found widespread evidence of "toxic stress" and mental health issues among children inside Syria.
It comes soon after Theirworld produced a briefing document about how toxic stress - prolonged exposure to high levels of stress from trauma, violence, neglect or deprivation - is affecting the development of children under five in humanitarian emergencies like the Syrian conflict.
Millions of children around the world have spent their whole lives in a war zone - more than 3.7 million of them in Syria.
Save The Children’s Invisible Wounds report, which interviewed more than 450 children, found that:
- 84% of adults and almost all children believe ongoing bombing and shelling is the main cause of psychological stress in children’s daily lives
- 50% of children say they never or rarely feel safe at school
- 40% of children say they don’t feel safe to play outside, even right outside their own home.
- 89% of adults said children’s behaviour has become more fearful and nervous as the war goes on
- 71% said children increasingly suffer from frequent bedwetting and involuntary urination
- There has been a rise in self-harm and suicide attempts among children as young as 12
Children, parents and caregivers said the lack of schools and education is taking an enormous toll on children and leaves them fearful for their future.
There have been almost 4000 attacks on schools in Syria and about 150,000 teachers and education staff have fled the country.
Zeinab, a 12-year-old living at a displaced persons camp in Hassakeh in the north-east of Syria, said: “When the war came, all the Syrian children forgot everything they learned and now know nothing else except war.
"I feel like I’ve seen so many terrible things. I lost out on two years of school - and my brother has grown up and has hardly studied at all. What if I get old and I continue on this same path and I lose out on my entire future?”
The Save The Children report said: "For 12 to 14-year-olds in the focus groups, the thing that makes them most sad or angry is when their schools are bombed or they can no longer attend school. Even for children who do attend school, almost 50% said they rarely or never feel safe there."
It said efforts to provide education must go hand-in-hand with increased efforts to provide children with mental health and psychosocial support, including training and equipping teachers to respond effectively to the anxiety and trauma that children are living through.
“The children are always stressed. Constant anxiety," said Ahmed, a reactional coordinator from Idlib.
"We notice that Syrian children, through our work with them, they are not like other children. They’re always stressed.
"Any unfamiliar noise, if a chair moves, or if a door bangs shut, they have a reaction. This is the result of their fear - of the sound of planes, of rockets, of war.”
With many doctors and health professionals having fled the country - and the relentless bombing and blocks on aid workers reaching the worst-hit areas - there is little official provision for mental health services, said Save The Children.
Dr Marcia Brophy, Save the Children Senior Mental Health and Psychosocial Support Adviser for the Middle East, said: “We are failing children inside Syria, some of whom are being left to cope with harrowing experiences, from witnessing their parents killed in front of them to the horrors of life under siege, without proper support.
What this research shows is that we are witnessing a mental health crisis among children brought about by six years of war in Syria.
"We risk condemning a generation of children to a lifetime of mental and physical health problems - we need to ensure that children who have already lost six years of their lives to war don’t have to lose their whole future as well.”
Theirworld's #5for5 campaign has been calling on world leaders to invest in early childhood development.
That includes ensuring humanitarian emergency responses cover the need to care for, nurture and protect babies and toddlers - and particularly those with disabilities and the most marginalised groups of children.
Without early interventions, young children living in war zones may never reach their full potential.
They will have an increased risk of illness, depression and substance abuse - and their future behaviour and relationships could be affected.