Left speechless

Most children say their first word between the ages of 12 and 18 months. But Fatehy, a Palestinian boy living in Jabalia City in Gaza, is four years old and is still barely talking. 

When he does speak, he says the same words over and over again - "scared", "bomb" and "fighters". While he used to say words such as "mumma" and "bubba", his language progression has reversed, and now he is mostly silent. 

He has been displaced roughly 15 times and experienced several close family deaths, including those of his mother and sister. At one point, he was discovered on a pile of bodies and was presumed dead. He was rescued purely by luck when a family member saw that he was still gently breathing. 

His cousin, Nejam, is three years old. His speech is also very limited, and is mostly reserved for the names of tanks, drones and rockets. He has been pulled from rubble several times. 

Neither child has access to school, nursery or social activities with friends. Medical treatment is severely limited, and they have been unable to access any of the few speech therapists available. Food scarcity also means they have been unable to learn basic vocabulary about ingredients or meals. 

Dalloul Neder, a 33-year-old Palestinian man living in the UK since 2017, is their uncle. 

"The only thing they've been listening to is the bombing," he told Index. "That's why they are traumatised. 

"They miss their families, grandparents, mums and family gatherings around the table. They realise something is not right but they can't express their pain." 

Psychological trauma is extremely common for children living in warzones. This can cause mental health issues such as depression, anxiety and panic attacks, but also communication problems, such as losing the ability to speak partially or fully, or developing a stammer. For younger children such as Fatehy and Nejam, war trauma can impact cognitive development, causing language delays and making it hard to learn to speak in the first place. 

In December, the Gaza-based psychosocial support organisation Community Training Centre for Crisis Management published a report based on interviews it had conducted with more than 500 children, parents and caregivers. Nearly all the children interviewed (96%) said they felt that death was "imminent" and 77% of them avoided talking about traumatic events. Many showed signs of withdrawal and severe anxiety. Roughly half the caregivers said children exhibited signs of introversion, with some reporting that they spent a lot of time alone and did not like to interact with others. 

Katrin Glatz Brubakk is a child psychotherapist who has just returned to Norway from Gaza, where she was working as a mental health activities manager with Médecins Sans Frontières in Nasser Hospital, Khan Younis. Her team offers mental health support to adults and children, but mainly to children dealing with burns and orthopaedic injuries, mostly from bomb attacks. 

She told Index that children tended to present with "acute trauma responses", while the long-term impacts on their psychological wellbeing were yet to be seen. 

In her work, she typically sees two types of responses - either restlessness and being hard to calm down, or becoming uncommunicative and withdrawn. She believes the latter is significantly harder to spot and therefore under-reported. 

"We have to take into account that it's easier to detect the acting-out kids, and it's easier to overlook the withdrawn kids or just think they're a bit shy or quiet," she said. 

She commonly saw children experiencing extreme panic attacks due to flashbacks, where any small thing - such as a door closing or their parent leaving a room - could trigger them. She noted they would often let out "intense screams". 

But some children have become so withdrawn they do not scream or cry at all. Some have even fallen into "resignation syndrome", a reduced state of consciousness where they can stop walking, talking and eating entirely. 

Brubakk recalled one "extreme case" of a five-year-old boy who was the victim of a bomb attack and witnessed his father die. He fell completely silent and did not want to see anybody, and also hardly ate. 

"When children experience severe or multiple trauma, it's as if the body goes into an overload state," she said. "In order to protect themselves from more negative experiences and stress, they totally withdraw from the world." 

Living in a warzone can also mean that children's "neural development totally stops", she said, as they lose the opportunity to play, learn new skills, learn language and understand social rules. "The body and mind use all their energy to protect the child from more harm," she said. "That doesn't affect the child only there and then, it will have long-term consequences." 

This is made worse by a lack of "societal structures", such as schools. "[These offer a] social arena, where they can feel success - there's no normality, there's no predictability." 

Therapy can be used to encourage children to speak again, particularly with creative methods such as play and   drawing therapy. Brubakk explained how through "playful activities" and "small steps", her team were able to encourage children to communicate. 

Recently, she managed this through the creation of a makeshift dolls house. A young girl had been burnt in a bomb attack. Her two brothers had been killed and her two sisters injured, with one of them in a critical state. It was uncertain whether her sister would survive. 

The girl wasn't able to speak about her experiences until Brubakk helped her create a dolls house using an old box, some colouring pens and tape, plus two small dolls the girl had kept from her home. She named the dolls after herself and her sister, and was able to start expressing her grief and fears, as well as her hopes for the future. 

"So through a very different type of communication, she was able to express how worried she was about her sister, but also process some of the experiences she had," said Brubakk. 

A report published by the non-profit Gaza Community Mental Health Programme (GCMHP) includes success stories of children who have benefited from creative communication. Alaa, a 12-year-old boy who sustained facial injuries after a bombardment and then later experienced forced evacuation by Israeli forces from Al-Shifa hospital, developed recurring nightmares, verbal violence, memory loss and an aversion to talking about his injuries. A treatment plan of drawing therapy and written narrations of the events helped him to become more sociable, and now he visits other injured children to share his story with them and listen to theirs. 

Sarah, meanwhile, is a 13-year-old girl who developed post-traumatic stress disorder and traumatic mutism after having an operation on her leg following a shell attack. She didn't speak for three months and would use only signals or write on pieces of paper. The GCMHP worked with her on a gradual psychotherapy plan, including drawing and play therapy. After three weeks, she started saying a few words, and she was eventually able to start discussing her trauma with therapists. 

Trauma-related speech issues are complex problems that can be diagnosed as both mental health issues and communication disorders, so they often benefit from intervention from both psychotherapists and speech and language therapists. 

Alongside developing speech issues due to war, living in a warzone can worsen speech problems in children with pre-existing conditions. For example, those with developmental disabilities such as autism may already have selective mutism (talking only in certain settings or circumstances), and this can become more pronounced. 

Then there is behaviour that can become "entrenched" due to their environments, Ryann Sowden told Index. Sowden is a UK-based health researcher and speech and language therapist who has previously worked with bilingual children, including refugees who developed selective mutism in warzones. 

"Sometimes, [in warzones,] it's not always safe to talk," she said. "One family I worked with had to be quiet to keep safe. So, I can imagine things like that become more entrenched, as it's a way of coping with seeing some really horrific things." 

She described a "two-pronged" effect, with war trauma causing or exacerbating speech issues, and a lack of healthcare services meaning that early intervention for those with existing communication disorders or very young children can't happen. 

There is an understandable need to focus on survival rather than rehabilitation in warzones, she said, and a lot of allied health professionals, such as occupational therapists, physiotherapists and psychotherapists, are diverted to emergency services. 

This was echoed by Julie Marshall, emerita professor of communication disability at Manchester Metropolitan University and formerly a speech and language therapist working with refugees in Rwanda. Her academic research has noted a lack of speech and language therapists in low and middle- income countries (LMICs) in general. 

"In many LMICs, communication professionals are rare, resulting in reliance on community members or a community-based rehabilitation workforce underprepared to work with people with communication disorders," she wrote in a co-authored paper in British Medical Journal Global Health. 

For children who already have speech or language difficulties, losing family members who are attuned to their other methods of communication, such as gestures or pointing, can make the issue worse. 

"If you are non-verbal, you may well have a family member who understands an awful lot of what we would call 'non-intentional communication'," said Marshall. "If you lose the person who knows you and reads you really well, that's huge." 

In warzones, Marshall and Sowden both believe that speech and language therapy is more likely to be incorporated alongside medical disciplines dealing with physical injury, such as head or neck trauma or dysphagia (an inability to swallow correctly). This belief was mirrored by the work of Brubakk, whose mental health team at Nasser Hospital worked mostly with patients who had been seen in the burns and orthopaedics departments. 

One of the most valuable things that can be done is to train communities in simple ways to help children who may be living with a speech or language difficulty, Marshall believes, shifting away from treating a single individual to trying to change the general environment. 

"There are lots of attitudes around communication disabilities that could be changed," she said. For example, it is often misjudged that children with muteness may not want to talk, and they are subsequently ignored rather than patiently and gently interacted with. 

Despite a lack of healthcare provision, there are some professionals on the ground in Gaza. In 2024, the UN interviewed Amina al-Dahdouh, a speech and language therapist working in a tent west of Al-Zawaida. She said that for every 10 children she saw, six suffered from speech problems such as stammering. In a video report, al- Dahdouh held a mirror up to children's faces as she tried to teach them basic Arabic vocabulary and show them how to formulate the sounds in their mouths. 

But the destruction of medical facilities such as hospitals and a lack of equipment have made it difficult for professionals to do their jobs. Mohammed el-Hayek is a 36-year- old Palestinian speech and language therapist based in Gaza City who previously worked with Syrian child refugees in Turkey. 

"Currently, there are no clinics or centres to treat children, and there are many cases that I cannot treat because of the war, destruction and lack of necessary tools - the most important of which is soundproof rooms," he told Index. "Before the war, I used to treat children in their homes." 

Soundproof rooms can be used by speech and language therapists to create more private, quiet and controlled spaces that reduce distracting external noises including triggering sounds such as gunfire or bombs. 

The most common issue he has encountered is stammering, which he says becomes harder to tackle the longer it is left untreated. 

"Children are never supported in terms of speech and language," he added. "[It is] considered 'not essential' but it is the most important thing so that the child can communicate with all their family and friends and not cause [them] psychological problems." 

For many of these children, the road to recovery will be long. Mona el-Farra, a doctor and director of Gaza projects for the Middle East Children's Alliance, told Index that the "accumulation of trauma" caused by multiple bombardments meant that even those receiving psychological support were offered little respite to heal. 

One glimmer of hope is that cultural barriers around trauma appear to be lifting, which has encouraged people to stop self-censoring around their own mental health. 

"There is no stigma now [around mental health]," said el-Farra. "The culture used to be like this, but not anymore. You can see that 99% of the population has been subjected to trauma. [People] have started to express themselves and not deny it." 

At the time of publishing, the ceasefire between Israel and Hamas had broken down and bombardment had restarted. When a permanent ceasefire is finally established and healthcare provision in Gaza can be rebuilt, there will need to be a concerted effort to support children with their psychological and social rehabilitation as well as their physical health. Hopefully then they can start to come to terms with their experiences and tell their stories -otherwise, they could be lost forever. 

- Sarah Dawood is editor at Index on Censorship. 
This article was first published by Index on Censorship on 10 April 2025. It appeared in Volume 54, Issue 1 of Index on Censorship's print magazine, titled: The forgotten patients: Lost voices in the global healthcare system. Read more about the issue here.