When Iman Farajallah was growing up in Gaza, she says she witnessed the first and second intifadas — Palestinian uprisings against Israel's occupation of Gaza and the West Bank — and subsequent wars with Israel.
"The experience was so vicious, so scary, so harmful that there are no words that you can actually describe it," says Farajallah, a psychologist who now lives in the United States and works with refugee children at a community clinic in San Francisco.
"How can you describe when [an] Israeli soldier comes and jumps from the walls into our home, beating up my brothers, beating up my mother?"
Yet, as a child, she says, she wasn't able to talk to anyone about how terrifying those experiences were. "Nobody ever talked to me about my trauma," she says.
Now there is new trauma for children in Gaza.
The current conflict began on Oct 7, when Hamas attacked parts of Israel, killing 1,400 people and kidnapping more than 200, including 32 children. In response, Israel began bombing Gaza and launched a ground invasion.
The children in Gaza, including the hostages, are trapped in a war zone.
According to Palestinian health officials, of the more than 10,000 Palestinians killed in Gaza in the past month, about 4,000 were children. Gaza is becoming a "graveyard for children," U.N. Secretary-General António Guterres said on Monday.
And even as the World Health Organization warns about the spread of infectious diseases in Gaza, some researchers are concerned that those children who do survive might be scarred for the rest of their lives.
Researchers say the cumulative trauma of chronic ethnic-political violence has a profound and lasting impact on children's mental health and development, affecting their functioning and outlook on the world as young adults. Studies show that even youth who seem to become desensitized to the violence around them remain deeply scarred — unless, that is, they are given a chance to recover.
This is especially a concern for children in Gaza, who were already struggling with significant mental health issues well before this conflict. For years, numerous studies have documented unusually high rates of mental and behavioral health issues among Gaza's youth, who make up nearly half of the population in the territory. Most of them have never known a life without the threat of violence and conflict.
Mental health of children in Gaza before the current conflict
In recent years, Farajallah returned to Gaza to talk to kids and their families, and document how violence has affected their physical and mental health.
Many children struggle with symptoms of physical trauma, says Farajallah. "A lot of them have been impacted by the bombs," she says. "So they have scars. They have splinters and fragments in their body. Some of them [have] lost their limbs, some of them have lost their eyesight."
She also saw a whole range of mental and behavioral health symptoms among children in Gaza, like "fear of darkness, general tension, flashback, nightmares, avoidance, difficulty sleeping and a recollection of their trauma."
Many other studies have documented high levels of emotional distress and mental illness among children in Gaza and the West Bank. A review study in 2011 found high rates of post-traumatic stress disorder among Palestinian children, with estimates in various studies ranging from 23% to 70%.
According to UNICEF, before the previous conflict in 2021, one in three children in Gazaneeded care for conflict-related trauma. In a study in 2022, the nonprofit Save the Children interviewed nearly 500 children and 160 parents in Gaza. It found that 80% of children in the study showed symptoms of emotional distress. About half of them there reported having contemplated suicide, and three out of five kids were self-harming. Four in five children reported they were living with depression, grief and fear.
Studying how violence affects Israeli and Palestinian children
A series of international studies following both Israeli and Palestinian children over several years have documented how exposure to high levels of ethnic and political violence not only hurts children's mental health but also makes it more likely for some to become aggressive toward others.
Back in 2007, a team of American, Israeli and Palestinian researchers began following hundreds of children in Israel, the West Bank and Gaza to understand how much political and ethnic violence they were exposed to and how that was affecting them in the long run.
"We were able to look at exposure to violence from middle childhood, around age 8, all the way through late adolescence, emerging adulthood," says Eric Dubow, professor of psychology at Bowling Green State University.
They looked at a range of exposures to political and military violence, from having family members or friends and acquaintances die to seeing someone held hostage, tortured or abused to witnessing the destruction of buildings, buses or properties.
While both Israeli and Palestinian children were exposed to relatively high levels of violence, Dubow says Palestinian children's exposure was significantly greater than for Israeli children on all measures they looked at.
For example, they found that 55% of Palestinian children reported having at least one friend or acquaintance die due to political or military violence. In comparison, 13% of Israeli Jewish kids and only 3% of Israeli Arab kids had the same experience. While 43% of Palestinian children had witnessed someone being held hostage or tortured or abused by Israelis, 14% of Israeli Jewish kids said they had witnessed such violence by the other side.
"There's no question that the Palestinian kids are being exposed to a lot more political violence than the Israeli kids," says Dubow.
Dubow and his colleagues found that high levels of ethnic-political violence also increased the levels of violence in communities, and perhaps more important for kids, within families.
"When families are growing up in these conflict zones, it affects the parents," says Dubow. "The parents become more depressed, the parents become more aggressive toward each other."
So children in a conflict zone are more likely to experience violence at home and more likely to be harshly treated by their parents, he says.
His team found that overall exposure to violence affects both Israeli and Palestinian kids in a number of harmful ways.
"The more violence they see all around them in their broader social environment, the more likely they are to have higher levels of post-traumatic stress (PTS) reactions," says Dubow's colleague Paul Boxer at Rutgers University.
As the teamreported in a 2013 study, the Palestinian children had the highest levels of PTS symptoms, followed by Israeli Jewish kids and then, Israeli Arab kids. And these symptoms stayed with the kids through the seven years of the study, following the oldest cohort into adulthood.
Post-traumatic stress is debilitating for youth, says Dubow. "Their sense of the world is shattered," he says. "They don't feel secure in their families. They don't feel secure in their relationships with others. They're constantly on guard."
From pushing and shoving to more severe aggression
Dubow, Boxer and their team also found that greater exposure to ethnic-political violence was associated with more aggressive behaviors among children in all age groups they looked at.
The aggression starts out as "pushing and shoving other kids," says Dubow, "but by the time they're [in] adolescence and late adolescence and even into early adulthood, then we start to see more severe physical aggression and we also start to see more support for violent political demonstrations."
By the seventh year of the study, when the oldest kids were young adults, nearly 22% of Palestinian youth and 15% of Israeli youth said they had participated in at least one violent political protest in the past year.
He and his colleagues also wanted to know how these children who were seeing so much violence around them from a young age were reacting to violence. So they did an experiment and showed the kids a violent video to gauge their emotional reaction.
"We actually hooked kids to this machine that basically has little straps that go around the fingers and measures the amount of sweat under the skin," says Dubow. The amount of sweat is an indicator of emotional arousal – the more someone sweats, the stronger their feelings.
As the researchers reported in a study this year, one group of kids got sweaty and anxious after watching the video.
"Those kids actually show more post-traumatic stress symptoms because they are emotionally aroused by the violence," says Dubow.
But the other kids weren't aroused by the violence in the video – they were numb to it. And these are the kids, Dubow says, who had become aggressive toward others and were more likely to participate in violent political protests as young adults.
"Most of us, when we're exposed to violence, it's abhorrent to us," says Dubow. "We reject it. We think it's horrible."
But when children are constantly exposed to violence from a young age, some start to become desensitized to it. "By becoming numb to the violence we see, it makes it a lot easier to accept violence as a typical way of responding to a social situation," he adds.
These kids start to believe "that the world is a more violent place, that aggression is a good way to solve problems," says Boxer, "and [that] the world in the broader sense, is a very hostile environment where there may be others who are consistently out to get them."
For all the outcomes Boxer and his colleagues looked at, Palestinian children fared worse than Israeli kids.
Psychological 'first aid' and long-term healing
The ongoing conflict, he says, only makes things worse.
Both children in Gaza and the Israeli children directly exposed to the Hamas attacks are now at a greater risk of long-term post-traumatic stress and other mental health problems, says Dubow.
"It's almost unfathomable to think about what's happening to kids there," says Boxer.
What kids in Gaza need most urgently, he says, is to be safe. It's part of what's known as "psychological first aid," he says. "So making sure kids are warm and clothed and fed, kept physically safe."
Only then, he says, can they receive care to minimize the long-term mental health impacts of what they have been through in recent weeks.
But Iman Farajallah, the Palestinian-American psychologist, says mental health care alone can't heal children in Gaza.
"When you work with a child, he's going to ask you, 'but what if another war broke out? Can you protect me? Can you protect my parents?' " she says. "Our answer is 'no, we can't.' "
With violence spiraling in the war, she fears that the children in Gaza won't have a real chance to recover from their trauma.
You can find NPR's complete coverage of the Israel-Hamas war at Middle East Crisis — Explained,
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