Fleeing the horrors of war, thousands of Syrian children have lost their innocence to violence, sexual abuse, grief and pain.
So, when they reach a place safe from the threats of conflict, the battle for their mental health is often just beginning.
Refugee children as young as 12, some of whom may have witnessed the slaughter of a relative at the hands of so-called Islamic State or their friend choked to death by a chlorine bomb, are perhaps unsurprisingly turning to self-harm and attempting suicide.
HuffPost UK has heard how boys and girls as young as six are fighting conditions such as toxic stress, depression and acute post-traumatic stress disorder (PTSD), that, without treatment, could plague them all their whole adult life.
A study by the Migration Policy Institute of more than 300 Syrian refugee children highlighted some other factors driving this mental health crisis.
It found:
79% of Syrian children experienced a death in the family
60% had seen someone get kicked, shot at or physically hurt
25% reported daily psychosomatic pain in their limbs, while one in five reported daily headaches
Psychologists at Unicef Makani (Arabic for ‘my space’) centres in Jordan face an uphill struggle on all fronts.
The level of demand for their services is staggering. Unicef staff are supporting 697,000 children and adults via child protection and psychosocial programmes - but they have identified at least another 812,000 who need their help.
Around 44% of Syrian children are showing signs of depression and 45% are thought to be suffering from PTSD (10 times the prevalence of children elsewhere in the world).
Makani workers must also win the confidence of families who so distrust authorities that, to give just one example, they initially refused their children life-saving vaccinations from the Jordanian Government for fear they would be poisoned.
But time is of the essence, as early intervention is a vital component of mental health recovery.
Anoud Attieh, a child protection psychologist at the Unicef Makani centre at Jordan’s Azraq camp, an area home to around 30,000 Syrian refugees, admits the job she has been doing for the last four years is incredibly difficult, adding: “But I need to focus on these children, they need help and I’m here for them. This is what’s important.
“I do a lot of the time feel compassion but also bad that sometimes I cannot help all of them all the time.
“But what I can do is provide this service and make the children feel that they have this safe space and that they can talk to us any time, no matter what has happened to them.”
She says PTSD is common.
“Children keep having flashbacks to what they saw,” she says. “It also comes with nightmares and they are very isolated from others.
“They have a lot of trouble sleeping and will be frightened of anything that comes near them, like a plane or any loud voices or any aggression they may encounter.
“For example, if they saw a plane, they would start screaming and put their hands on their ears to hide. They will get his hands sweaty and their breathing would be heavy.
“Most of the kids here have PTSD or an anxiety disorder. Most of the kids presented as quite aggressive because they thought ‘I need to be aggressive to protect my little brother or protect my mum’ and they had these helplessness feelings all the time.”
Helping a child who has experienced sexual abuse is much more complex, said Anoud. Countless young females have confided in her about what they have suffered at the hands of the civil militia, during the terrifying journey from Syria into Jordan and, even, within the chaotic, almost-ungovernable camps.
“With the sexual abuse cases, they need long-term help. They have often built walls around them.
“Most of them will usually be afraid and they do not trust anyone. They want to isolate themselves.
“These are the hardest cases to deal with. Sexual abuse is a hard experience for a child to face, but when children do face this they lose all trust in everyone.
“And when they lost all trust in everyone, it is very hard for us to rebuild the relationship with them. It takes time and many sessions with the child to build trust with them.
“The mental health of kids who were sexually abused, they face a lot of fear about their future.
“What has happened to them is abnormal and they are facing abnormal symptoms. They need this psychological intervention, especially if the abuse comes from a member of the family.”
While the psychosocial programmes run by Unicef are providing vital assistance, their future is not certain.
With other global crises grabbing the attention of the public, many fear the needs of Syrian children are falling off the agenda.
As Ettie Higgins, deputy representative for Unicef in Jordan told HuffPost UK, the organisation faces a catastrophic funding shortfall, which means the organisation will have to face tough choices about what services it can and can no longer support.
This is hard for Anoud to hear, when some of the children she provides therapy for were so traumatised that they were initially unable to speak at all.
She said: “I had a child who came to me and he didn’t want to speak to anyone, not even his family. He was seven years old.
“He hadn’t spoken to anyone for three months. He would say small words to his father. He was one of our hardest cases and he needed behaviour therapy.
“He was separated from his mother.”
She also spoke about another child - a 10-year-old boy. “He came from a place where so-called Islamic State were.
“He was so afraid and so isolated. He didn’t want to speak, play or do anything. He just used this violent and aggressive language, even with his parents and his siblings.
“He was afraid that he could see any man who could harm him and his family.”
Depression is almost extremely common, said Anoud.
“With one of my depression cases, I was working with her inside her caravan,” she said. “She was and lost her grandmother in the war.
“She didn’t want to do anything at all. she stayed in the caravan sleeping, not eating and crying most of the time.
“We tried to convince her to come over here but she refused so we brought all of the toys and the games into the caravan, and we tried to play with her.
“We tried to make the caravan inside more colourful. We brought papers and we cut out butterflies and flowers and stuck them up.
“Then one day, she came here and decided she wanted to register in our art class. Now, she is much improved. She has a healthy pattern of sleeping, she’s back at school and she eats well and has a lot of peer support.”
As well as art classes, they offer sports facilities, games, drama classes, techlabs and IT training.
Halaf is 14 and fled Aleppo the day after an Assad bomb hit the nearby countryside town of his home.
A wall the teen was taking shelter behind collapsed on top of him breaking his hand.
When he arrived in the Azraq camp 18 months ago, he was gripped by a constant fear, he said.
“I was nothing, I used to stay at home and not go out and I did not know how to
write or read and when I came here everything bloomed. Here, I felt like I was reborn. My life was renewed.”
He added: “I was afraid and used to hide in the house to not see the plane, because when you see one, they usually bomb the house.
“The Makani centre helped me to learn, read and write and get knowledge, I benefited from the centre a lot, it opened my mind.
“They offered me psychological help and they talked to me calmly and comforted me.
“Here they enlightened me. I used to be afraid, they told me here there is no
fear, after that I’m not afraid of anything.”
Anoud sees mental health problems at their most acute among Syrian teens.
She said: “Let’s say from 13 to 18, most of them face a lot of psychological disorders.
“It is a hard job, but it is so satisfying when you see at the end of your sessions how improved the kids are.
“They get to a stable place and are living almost in a healthy way, especially psychologically.”
There are 236 Makani centres in Jordan, where they are being trialled by Unicef.
There are 39 in camps, 69 in settlements and 128 in host communities. They focus on child protection, psychosocial support and education, but Anoud admits the impact they can have is limited.
“Eventually, let’s face it, they are in the camp,” she said. “They left everything that they love behind, the relatives.
“They left their toys, their places, their comfort zones and they come over here. No matter what, they miss home, they miss their town, they miss their families back in Syria, so we are just helping them to adapt.”
To help the children of Syria this winter please donate to the HuffPost UK Christmas Appeal at unicef.uk/huffpost
Useful websites and helplines: Samaritans offers a listening service which is open 24 hours a day, on 116 123 UK and ROI (this number is FREE to call and will not appear on your phone bill).