Aleppo, Syria - Eight months ago, Hala's mother was killed in front of her when a shell struck the family's home in rebel-held eastern Aleppo.
"Whenever I remember this moment, my tears just fall by themselves," Hala, 14, told Al Jazeera.
"Even after we moved to another house, I have been having nightmares, and I awake suddenly in the middle of the night and I just can't sleep again," she said. "I feel very exhausted."
Regardless of how many civilians manage to leave besieged Aleppo in the coming days or weeks, the psychological scars left on the city's children will take much longer to heal, doctors say.
The Russian and Syrian governments announced last week that civilians and any fighters who surrendered would be allowed to leave the city via humanitarian corridors, but Amnesty International expressed scepticism, noting that even if safe routes were provided, this "will not avert a humanitarian catastrophe".
John Kahler, a paediatrician from Chicago who recently visited Aleppo on a voluntary medical mission with the Syrian American Medical Society - one of the biggest organisations still providing healthcare inside the country - said the situation has become increasingly dire.
"It was powers of 10 worse than what I expected. You can't expect it if you haven't seen it - whole blocks were bombed out," he told Al Jazeera.
Civil wars are deeply traumatic for children, Kahler said, noting that to be happy, children must feel secure and comfortable.
"[In a civil war], it's not just an external aggressor. These are foes from inside," he said, noting the degradation of cultural security can leave children feeling extremely vulnerable, affecting their ability to trust others and to find comfort.
"[In Aleppo I saw] kids who couldn't be comforted … At the least provocation, they would break down," Kahler said, citing temper tantrums and signs of "significant anxiety disorder".
Um Hanan, a mother of five children whose husband was killed three years ago when a shell hit his carpentry workshop in Aleppo, said she was at a local market last year with her daughter Basma when two barrel bombs fell nearby.
While Basma, now 11, quickly recovered from her light wounds, the psychological trauma has lingered, her mother told Al Jazeera. Ten days after the incident, she began wetting her bed at night, and her hands shake while she eats. She no longer seems to enjoy socialising, her mother added: "She goes to school but she doesn't play, and she is not very interactive in classes or in the free time between the lessons."
[Children need] safety, comfort, protection, room to play. I don't mean physical room, but psychological space. But if you don't know when a barrel bomb is going to fall next, there's only so much you can do.
Um Hanan, however, says she has struggled to find support for her daughter.
"I really don't know what to do," she said. "I visited and asked many doctors and pharmacists about her situation, but they all said she can't be treated because it is a psychological issue."
Abdulkarim Ekzayez, a doctor with Save the Children, expressed concern that children have not been receiving sufficient psychosocial support in many areas of Syria.
"We do have a lot of cases of mental health and children really badly affected, psychosocially, by the conflict," said Ekzayez, who heads the organisation's health and nutrition programme for northwestern Syria. He said that he has seen children exhibiting anxiety-related symptoms, often after having left besieged areas.
"You can see the child is isolated. In the child-friendly centres, a lot of children are not engaged with other children; they do not play, they prefer to be alone, they do not laugh at all," he said. "Such symptoms are really common."
Kahler says this type of anxiety can manifest as bed-wetting and having difficulty eating, a situation that has been exacerbated in Aleppo as families have been repeatedly internally displaced, with their everyday routines torn apart.
Jamila's 16-year-old son, Ahmad, has displayed many of these symptoms, his mother told Al Jazeera. Five months ago, he was at school when the building was hit in a regime air raid. He managed to escape serious injury as he was in an underground classroom at the time, but he has not been able to forget that day.
"This is not the first time he has survived a bombing from a jet, but this one truly had a bad effect," Jamila said. "He has lost his appetite and has been eating a small amount of food." He has also been wetting the bed and stammering, she said, noting she has tried in vain to find appropriate support for Ahmad.
"There are no psychological doctors or specialists in the rebel-held part of Aleppo, but I asked and visited many pharmacists, and they gave me some medicines to help my son," she said, noting the drugs have helped somewhat, but not enough.
She lamented the gradual exodus of doctors from Aleppo in the years since Syria's civil war broke out.
"Why they have abandoned the city? We suffer from constant sickness … All of those who have left will never be forgiven by those of us who have had to survive with basic treatments in order not to die," Jamila said. "Doctors' work should be here on the ground, which is what they had an oath to do."
While life in a warzone is unpredictable, Kahler said, it is crucial for parents to impress upon their children the message that life goes on.
"[Children need] safety, comfort, protection, room to play. I don't mean physical room, but psychological space," he said. "But if you don't know when a barrel bomb is going to fall next, there's only so much you can do."
Source: Al Jazeera