Gaza City – As another Israeli air raid thundered, eight-year-old Pretty Abu-Ghazzah stood shell-shocked, while her five-year-old twin brothers rushed to their mother Esraa’s arms. Pretty’s youngest sibling, aged two, cried loudly.

To escape the heavy bombardment in their neighbourhood of Deir el-Balah in the central Gaza Strip, Esraa brought her children to her in-laws’ house in a less-targeted area. But there is no escaping the mental health effects of the raid.

“I can’t bear to see my children trembling and their faces pale with terror. It’s too painful. Pretty vomited several times today due to panic and fear,” the 30-year-old mother said.

Making up nearly half of the 2.3 million people trapped in Gaza, children are suffering from the mental and emotional fallout of years of blockade and violence. According to a 2022 study by the non-profit Save the Children, four out of five children in the enclave grapple with depression, grief and fear.

Israel’s ongoing assault on Gaza, which it launched following the October 7 attacks by the armed wing of the Palestinian group Hamas, has killed at least 2,382 Palestinians and wounded 9,714 others so far. Hamas’ attacks on Israel killed more than 1400 people.

The conflict has also left parents in Gaza scrambling to keep their kids alive and mentally healthy through what they describe as the fiercest attack they have faced in years.

After Israel cut off the electricity in Gaza last Monday, residents now live in the dark amid dwindling fuel supplies, which are needed to operate generators. Many parents use what limited internet access they have to seek advice for comforting their children on platforms like YouTube and WhatsApp support groups.

Esraa has been observing her children’s reactions to the air attacks with growing concern. In addition to vomiting, they have been suffering from involuntary urination, a symptom she said is recent and highlights heightened fear.

“None of my children had faced issues with involuntary urination before,” she said.

In the 2022 Save the Children report, 79 percent of caregivers in Gaza reported an increase in bedwetting among children, compared with 53 percent in 2018. The last Israel-Hamas war was in 2021. Symptoms like increased difficulties in speech, language and communication as well as an inability to complete tasks also increased in children since 2018.

“I found a lot of helpful YouTube videos during the last war on how to talk to children. It was important to engage in a conversation with them and discuss what was happening in their surroundings,” Esraa said, adding that the impact of such strategies remains limited given the gruesome circumstances they are living through.

A Palestinian boy watches news on his phone at his house in Khan Younis in the southern Gaza Strip, May 10, 2023 [Bassam Masoud/Reuters]

Engaging their minds

From the online resources, Esraa learned

about keeping children entertained and engaged during conflict. One way was easing restrictions on screen time. “I usually limit my children’s iPad usage but given these distressing circumstances, I allow them to watch cartoons to keep themselves entertained. I make sure to keep my iPad or cellphone charged while they watch [in case of an emergency],” she explained. Esraa also reads stories to her children.

According to Palestinians in Gaza and sources at the United Nations Relief and Works Agency — the UN agency for Palestinian refugees — and Red Crescent, the Israeli Air Force has not been issuing warnings before shelling residential units, unlike during previous attacks sending families racing for their lives.

In its Humanitarian Needs Overview 2022, the United Nations Office for the Coordination of Humanitarian Affairs estimated that 678,000 children across Palestine need mental health and psychosocial support services. More than half of the children in Gaza are in need of such support. However, available mental healthcare has not been sufficient to address the significant need, especially during recurring times of distress. This leaves parents – who are facing their own mental health and emotional issues – to find ways to soothe their frightened children.

Esraa recalled that her children’s playtime now often revolves around war and imitating their mother’s phone calls to loved ones. “My children look up to me and pretend to have phone conversations, asking each other: ‘What’s happening in your area?’ They mimic me when I call my family members who live in different parts of Gaza, just to make sure they are okay,” Esraa explained.

Palestinian children look at the building of the Zanon family, destroyed in Israeli air attacks in Rafah, Gaza Strip, October 14, 2023 [Hatem Ali/AP Photo]

Expressing themselves

Rawan, another mother in her 30s, said her three daughters are struggling with the reality of the violence they are confronting.

“This is the fifth war I’ve experienced as a mother and each time, I turn to YouTube and online articles to enhance my understanding of how to support my daughters during times of conflict,” Rawan said.

However, her eldest daughter is experiencing accentuated symptoms. “My daughters, Aysel, 9, Areen, 6, and Aleen, 4, are profoundly affected by the terrifying sounds of bombings, especially Aysel. She’s now old enough to understand the implications of war. She has stopped eating and drinking. I’ve also noticed an increase in her heart rate,” she said.

Aleen, too, has displayed signs of food aversion and frequent trembling due to fear, Rawan said.

To ease their anxiety, Rawan tries to engage her daughters in group games and activities.

For guidance, Rawan has been turning to YouTube and awareness messages sent by her daughters’ teachers to help mothers support their children’s mental well-being. Among such advice is to monitor children closely for signs of anxiety that they may have difficulty expressing verbally. In this situation, mothers are advised to encourage their children to express themselves creatively, through writing stories or drawing as an outlet to process their feelings.

Like many people in Gaza seeking a safe haven from the shelling, Rawan and her family spent the first three days of the Israeli attack in their home in the al-Nasr neighbourhood of Gaza City. However, after the bombings intensified near their residence, they relocated to the Nuseirat refugee camp near Deir el-Balah in the heart of the Gaza Strip.

As with Esraa’s children, the relocation has not eased the mental unrest of Rawa’s children. “They stick close to me at all times, even when I’m preparing meals. I constantly embrace and comfort them,” she said in a helpless tone.

When her daughters ask about the ongoing war, Rawan tries to divert their attention by showing them photos and videos of happier times or engaging them with games, reading together and cuddling.

Unlike Esraa, Rawan feels compelled to limit her kids’ use of mobile phones and iPads for entertainment, since these devices are essential for emergencies. She has also tried to restrict their exposure to news by turning off the television during war-related coverage.

Mental health support

Some mental health professionals have been providing free resources on social media. In a Facebook post, the Palestinian Counseling Center announced the formation of a national emergency team to provide “free psychosocial support via phone calls and WhatsApp” to those who need it. The post includes a list of names and contacts of professional mental health and social work specialists across Palestine who are available to jump on calls. The page has shared a number of tips on how to assist children under fire.

Palestinian children, who fled their houses due to Israeli attacks, play as they shelter in a United Nations-run school, in Gaza City, October 12, 2023 [Arafat Barbakh/Reuters]

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A man takes a solar panel from a mosque destroyed in an Israeli air strike in Khan Younis in Gaza Strip on Sunday. [Yousef Masoud/AP Photo]

Palestinians inspect the rubble of a building after it was struck by an Israeli air raid in Gaza City. [Fatima Shbair/AP Photo]

 A Palestinian man reacts next to the ruins of a house destroyed in Israeli strikes in Khan Younis, in the southern Gaza Strip. [Ibraheem Abu Mustafa/Reuters

Israel struck 426 targets in Gaza, its military said, flattening residential buildings in giant explosions. [Fatima Shbair/AP Photo

People scour the debris of a building in Gaza City. [Fatima Shbair/AP Photo

 People gather next to the ruins of al-Watan Tower, destroyed in an Israeli attack in Gaza City. [Mohammed Salem/Reuters

People remove debris at a mosque destroyed in Israeli raids in Khan Younis.

[Ibraheem Abu Mustafa/Reuters

 Rescuers search through the rubble of a house destroyed in Khan Younis. Medical teams have difficulties arriving safely to tend to wounded people in Gaza. [Ibraheem Abu Mustafa/Reuters

Palestinians search for people trapped under the rubble of a house destroyed in an Israeli strike in Khan Younis. [Ibraheem Abu Mustafa/Reuters]

 A man sits amid the rubble of a building after it was struck by an Israeli air raid in Gaza City. [Fatima Shbair/AP Photo]

 A man carries his belongings next to the ruins of al-Watan Tower, destroyed in Israeli strikes. [Mohammed Salem/Reuters]

 Gaza City residents sit on a debris-strewn street. [Mohammed Salem/Reuters]

Palestinians react as they search through the rubble of a house destroyed in Israeli attacks in Khan Younis in the southern Gaza Strip. [Ibraheem Abu Mustafa/Reuters]