Focusing on the quality of family life in a war zone may seem futile, but one woman is doing just that. Juliet Rix meets Aala el-Khani, who is reaching out to traumatised parents trapped on the frontline in order to help thousands of children

Fatima, a jolly-looking woman in a sparkly grey jumper and tightly wrapped headscarf that accentuates her round, smiley face, laughs as she shows me into her living room in Manchester, which is comfortable even though the family moved in just a fortnight ago. She offers me nuts and biscuits, but then her demeanour changes. She shifts in her chair; the laugh is gone. She looks down. She starts to talk about her life in Syria.

“We moved and moved,” she says, “trying to find somewhere safe, but each time the bombing was as bad as before.” By the end, she says, they were semi-conscious, living only in that they were not dead.

“We forgot everything. We forgot our kids. All we could think was that we did not want to die,” she says.

“I will never forget the airstrikes. The children were terrified … And the things they saw … their grandfather’s dead body after he had been tortured … their uncle taken away with his T-shirt over his head [he has not been seen since] … The house hit by a barrel bomb. We were out, but the neighbour and her child were killed.”

Fatima’s daughter became racked with fear, her son a shadow of his former self. So when, newly arrived in Manchester, two years ago, she was approached and asked to help with a parenting project that would be delivered to Syrian families still in conflict zones and camps, she leapt at the opportunity. “It was perfect timing,” she says, “Finally, we were safe and I could focus on the children.”

But would parenting advice have been any use to her in the dark days in Syria? “Yes,” she says, without hesitation. “If I had been reminded what I should be doing, taught how to help … oh, yes.”

The woman behind the project is Aala el-Khani. She is sitting with us, translating Fatima’s Arabic. El-Khani, mother of two young children and a parenting trainer, had just started a PhD in psychology at the University of Manchester when the Syrian conflict began.

El-Khani’s parents are Syrian, and although she was born and raised in the UK, she still has family there. Her husband, Ammar, an NHS surgeon and also of Syrian descent, was soon travelling regularly to Syria with humanitarian organisations such as the David Nott Foundation, returning “numb” with stories and photographs.

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“One picture was of a little boy who looked so sad,” she says. “His father had been killed. His mother was caring for her two children and her elderly parents. My husband was staying with colleagues in the bottom of the building. One morning they heard screaming and rushed out. The mother had gone in a taxi to buy bread and been shot by a sniper. They couldn’t save her … I just kept thinking about that little boy. That could have been my son – or yours.”

Aid to Syria and to the refugee camps focuses on primary needs – food, shelter, medical supplies. But watching the horrors in Syria unfold night after night on television, El-Khani kept thinking about the children. How would her two children be changed if they had such experiences? How would she cope if faced with them seeing such things?

Mental health, she says, is as important as physical health, and research confirms that family support has a big psychological impact on a child’s wellbeing. One study found that the quality of family relationships was a better predictor of children’s mental wellbeing than their wartime experiences. If warm, secure parenting – or caregiving – could be that powerfully protective, thought El-Khani, then help to achieve it must be delivered to those who needed it most.

She changed her PhD subject to exploring ways to support families and children in the war zone and nearby refugee camps and headed out to Syria and Turkey to talk to refugee parents: “Every parent I met was struggling with emotional or behavioural changes in their children.” Some had gone looking for advice, asking camp doctors, teachers and NGOs, “but these people were too overwhelmed with their own roles or didn’t have the knowledge to help”.

Back in the UK, El-Khani worked with Rachel Calam, professor of child and family psychology at the University of Manchester, and psychologist Dr Kim Cartwright to produce a leaflet explaining to parents that bedwetting, nightmares, withdrawal and even aggression are normal responses to childhood trauma, and offering basic reminders and suggestions for looking after themselves and their children.

“When you become focused on survival,” says El-Khani, “you forget to praise your children, play, cuddle, or talk to them.” One young mother, after meeting El-Khani, later told her she had gone back to her tent and read her child a bedtime story for the first time since arriving in the camp.

To test the leaflet, El-Khani and her colleagues recruited a group of recently arrived Syrian refugee parents in Manchester, including Fatima. They read and approved the leaflet, but how was it to be distributed on almost no budget to thousands of families in a chaotic environment? An NGO worker had the answer: this “psychological first aid” should be delivered with the refugees’ bread. Two sheets of paper (the leaflet and a feedback form) and a pen were tucked inside the wrappers of 3,000 flatbreads and delivered to families and caregivers in northern Syria. Sixty per cent responded, a high figure anywhere, let alone in a conflict zone.

El-Khani remembers the excitement of opening the feedback forms. More than 80% of those displaced families who responded said the leaflet was useful; 400 had added comments. Most were positive remarks about the leaflet, some were prayers for better times, others asked for more information, particularly about bereavement and anxiety. The leaflet had hit a nerve.

When you become focused on survival, you forget to praise your children, play, cuddle, or talk to them

So the Manchester team has put the leaflet online (in English and Arabic) for anyone to use and distribute, along with a version (in various languages) adapted to refugees already in Europe. When a Swedish version was put on the Swedish health website, it was downloaded 343 times in the first 45 minutes, the largest response the website has ever had. The leaflet has just been translated into Urdu and Pashto, and is about to be distributed with newspapers in Pakistan, with the hope that it will reach more than a million families.

Taking on board the Syrian refugees’ requests for more information, an expanded booklet and two-hour seminar will be trialled with Syrian refugees in Europe this year, and the Manchester team is also working on a new version of an established evidence-based programme for children with post-traumatic stress disorder. Teaching Recovery Techniques, created by the British-Norwegian charity Children and War, has been used successfully with children who have faced traumatic situations, from war zones to the Zeebrugge ferry disaster.

El-Khani and her team have created a five-week course for children and carers and piloted it successfully in a school for refugee children in Turkey. All 13 eligible families attended every session and the results showed significant improvements in the children’s wellbeing and behaviour.

“We are developing video and Skype training that will allow us to reach many more families in places we cannot visit,” says El-Khani.

The primary purpose of this work is to help the families, but, she points out, it is also in the interests of their host countries. Without help, children with psychological problems become adults with problems.

Fatima is cheerful as we collect her children from school. Ten-year-old Khalid and nine-year-old Mariam skip and jump ahead. They like school and have made friends. Khalid is slight and considered; Mariam bubbly, chattering away in a mix of English and Arabic.

Back at home, the children are asked to tell me what they remember of Syria. Khalid claims not to recall that he used to recognise all the different threats from the sky by their sound. Mariam, however, points straight to the scar across her arm and tells me, haltingly, how she was hit by a car in post-airstrike chaos and nearly died. She mentions a dead aunt and the dangers of going outside, then a minor family disagreement leaves her suddenly tense. She puts her face in her hands and freezes, before bursting into disproportionate tears. El-Khani hugs her, and her mother says simply: “She remembered something.”

With both children smiling once more, we tuck into a selection of Syrian flatbreads. Fatima is pleased to be able to help El-Khani in her work, believing parenting advice – in a bread wrapper or by any other means – would have made things just a little less awful for her and her children. “It would have changed the way I was with them. We needed it.” The children are recovering now, she says. “We have a life again, not just a lack of death.”

Some names have been changed.

• The leaflet and more information about the Manchester group’s work can be found at research.bmh.manchester.ac.uk/pfrg/resources