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Six months after an 11-day conflict ravaged Gaza, Palestinian children remain burdened by trauma while their parents struggle to gain access to urgently needed care.
Sitting beside her father, eight-year-old Suzy Ishkontana wears a T-shirt with the slogan: “Girls are always strong."
She talks in a whisper about life at school, where she likes to play on the swings and has a handful of friends.
“One is called Salma, one is called Nour, one is in the 10th grade,” she said, perched on a brown sofa in her grandmother’s apartment.
During the violence in Gaza, Suzy spent hours trapped under the rubble of her home. Her brother died beside her.
Israeli air strikes on the centre of Gaza city killed her mother and four siblings. Her father, Riad Ishkontana, survived.
“They would get up at six in the morning and play as a group,” he said, remembering his children. “They loved each other and would even share a packet of crisps among themselves.”
Mr Ishkontana has videos on his phone of his children dancing, while portraits printed since they died rest against a wall.
A few metres from the apartment block is a vast empty space. Piles of concrete and rebar from destroyed homes once lay there, but the debris has since been cleared.
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Mr Ishkontana said he and his neighbours are scarred by the air strikes, which killed more than 40 people in one night.
“The grief remains, the place is gloomy because, regardless of the days passing, people remember,” he said.
“Because the people who died and were martyred, they’re the people of the neighbourhood.”
Across Gaza, 67 children were among 261 Palestinians killed during the conflict. Two children and 11 adults were killed in Israel, UN figures show.
While Suzy has been able to return to the classroom, her father said she was suffering from the loss and trauma.
“She stopped laughing and stopped being happy. She wants little kids in the house because she used to be with her younger siblings," he said.
He said she once joined a children’s trip to the seaside, which was aimed at improving her mental health.
But the family does not know exactly how to help her.
“Sometimes I sit and cry about Suzy’s condition, but I don’t let her see me,” said her grandmother, Samira Al Dora.
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Gazans reported incessant bombing throughout the conflict, during which the Israeli military said it struck more than 1,000 targets.
At least 4,000 rockets were fired by Hamas, the group that controls Gaza, the Israeli military said in May.
A fragile ceasefire has been pockmarked by outbreaks of violence, such as the numerous Israeli air strikes on Gaza in recent months.
The Israeli military said the strikes were a response to Palestinians flying incendiary balloons into Israeli territory, while rockets have been fired from Gaza on five occasions.
Such incidents increase fears of another conflict, hampering residents’ chances of recovering from the trauma they experienced in May.
“In the border areas it could be like a flashback to the same event every day, hearing the sound of [Israeli] drones and seeing the flare of bombs,” said Rania El Soussi, a psychologist at the Gaza Community Mental Health Programme (GCMHP).
“All this recalls the painful situation of living through the war, or the 2014 war, or before it, if they were older."
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Gazan teenagers have experienced four wars fought with Israel since 2008.
In recent months, psychologists have reported an increase in symptoms related to post-traumatic stress disorder.
Children have suffered from symptoms such as wetting themselves, having nightmares and becoming aggressive or anxious.
Nour Abdel Wahed, a psychologist with the GCMHP, treats families who called its helpline or were referred by other organisations.
“I’m seeing a child who has post-traumatic stress disorder, then discover that his mother and father also have it,” she said.
“A lot of our cases were exposed to instances of direct bombardment … the whole family saw people killed and wounded."
The programme has 200 families on its waiting list. Staff have already treated hundreds more people this year than in 2020, when they dealt with 3,200 cases.
While many Gazan families are seeking to overcome their trauma six months on, some are still dealing with the physical effects of the conflict.
About 685 children were wounded in the war, along with more than 1,500 adults, UN records show.
One of the most seriously injured was four-year-old Sara Al Metrabei, whose spine was impaled with shrapnel in an Israeli air strike on her home.
Her father, Zaher Al Metrabei, recalled his daughter’s confusion in hospital as she asked: “Why did they burn my back, daddy? Why did they burn me?”
He broke down in tears as he showed photos of Sara’s wounds taken in May.
Days after the ceasefire, she became one of the few Gazan children to be granted permission to leave the Palestinian enclave for treatment in Jordan.
She screamed as she was lifted on to a trolley bed and wheeled out of hospital, her head resting on a pink pillow.
Mr Al Metrabei has not seen his daughter since, because he has been unable to obtain the necessary paperwork to travel with his son to be at her bedside.
Sara’s mother, Lina, is heavily pregnant and has been with her daughter throughout the treatment. Sara has undergone about 10 operations so far and remains unable to walk.
The uncertainty about whether her condition will improve, coupled with the family separation, has taken its toll on her father.
“I’m not able to do anything, neither taking any decisions or work in my life, because things for me are at a standstill,” he said.
War compounds tough conditions in Gaza
Charles Nelson, a professor of pediatrics and neuroscience at Harvard Medical School, said parents and relatives were vital to helping children recover mentally from trauma.
“Do they have adults that are looking out for them, adults that are supportive and sensitive to their needs? For those that do, they will likely do much better than those who don't," he said.
But despite their best intentions, some Gazans will struggle to provide support to their relatives because they are traumatised themselves.
“This fundamentally shapes what kind of parents they are. Those kids are at much higher risk of long-term challenges,” said Prof Nelson, who has extensively researched the effects of early adversity on brain development.
The conflict compounded the pressure on families in Gaza, which has been under an Israeli-led blockade since 2007.
Few of Gaza’s nearly two million residents are able to leave the territory, while the arrival and departure of goods is also strictly limited.
“The alarming unemployment rate in Gaza is roughly 50 per cent and more than half of its population lives in poverty,” the World Bank said in July.
There are some community centres in the Palestinian territory where children and parents can receive private or group counselling.
At one centre in Gaza city, run by the Palestinian NGO Ma’an, children jump around and giggle while they play a game. A colourful picture on the wall shows different emotions, with tears rolling down one face.
“We teach the children a bit about things and behaviours, how to be able to deal with situations they face, how they can make friends, how they can overcome fear,” said counsellor Mayssa Rabi Al Tanani.
About two months ago, she noticed some of the children were showing symptoms of PTSD. They were suffering from nightmares and had become fearful, but avoided talking about the conflict.
“Yesterday when it rained a lot and there was the sound of thunder, my sisters thought it was bombing and were really scared,” she said.
A fear of loud noises has been widely observed in people by mental health experts and families in the months since the conflict.
Many of those at the Ma’an centre, which is funded by the UN children’s agency, had already sought support before the war.
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Tamam Al Akawi has been caring for her 14-year-old son, who has a heart condition. Although he was able to travel for treatment in Nablus in the occupied West Bank, Ms Al Akawi said they were struggling to afford the medical costs in Gaza.
“Our situation is really, really bad,” she said.
“I’m appealing for anyone to help us with my son’s treatment and to help me with my children’s mental state.”
While counsellors have helped, Ms Al Akawi said her six children were deeply affected by air strikes on their home district and footage of attacks.
“The children were always sitting in front of the TV and saw bombs coming down on the towers,” she said.
The Israeli military destroyed four high-rise buildings during the conflict in strikes that Human Rights Watch said could amount to war crimes. Israel refutes the allegations.
Severe shortages affect trauma treatment
While some children have started to recover from the war, the acute lack of resources puts the mental health of many at risk. Dr Yasser Abu Jamei, director of the GCMHP, estimates that there are 3,500 unemployed psychology graduates in Gaza.
“We need resources in order to train them. They need equipped places, they need salaries … and this is not available,” he said.
He said bringing in more psychologists from abroad was unlikely to help unless they were fluent Arabic speakers and stayed for more than a few months.
Administering treatment is also particularly complex in Gaza, because patients’ symptoms are often related to numerous traumatic events over the years.
“We were not fine before May, and we are not fine today,” Dr Abu Jamei said.
He pointed out of his office window at the various parts of the district that were bombed.
Mr Al Metrabei said his daughter's mental health had improved slightly in Jordan.
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“She has started to talk, started talking to people,” he said.
Opening his phone to show a video of Sara eating a pomegranate in her hospital bed, Mr Al Metrabei said he was in contact with his daughter every day.
In Gaza, he feels abandoned by those unaffected by the war.
“After a week, they were living their lives normally,” he said. “I’m not living, I’m just damaged.”
Mr Ishkontana has also expressed a need for more support.
The recovery of traumatised children will not only hinge on their long-term access to care, but also the treatment of their parents.
“Unless the dad gets access to resources that will help him, it is going to be hard for him to be a good dad,” Prof Nelson said.
“And worse yet, the one thing he’ll suffer from is guilt. He’ll think he’s not being a good dad.”
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Mr Ishkontana said his daughter was not receiving one-on-one mental health treatment and remained isolated from her peers.
“Suzy wants to live like any child in the world and see her psychological state improve,” he said.
As she grows up, there is a risk she will develop survivor’s guilt or become overwhelmed by grief.
“There are few things that are worse than what she experienced," Prof Nelson said.
“Her experience won’t go away. The only thing we can hope for is that she gets the kind of counselling or psychological care that will be maintained."
She sits quietly beside her father as he talks about her future. Mr Ishkontana said he wished for a foreign government to grant his daughter a new nationality so she can flee Gaza.
He fears he will be unable to protect his only surviving child if violence flares again.
“Because if she’s not wounded in the next war, the sound of the war will kill her," he said.