Exposure to war-related trauma and symptoms of complex posttraumatic stress disorder among children and adolescents in Gaza.

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Learn more: PMC Disclaimer | PMC Copyright Notice Eur J Psychotraumatol . 2026 Jun 2;17(1):2665509. doi: 10.1080/20008066.2026.2665509 Show available content in en es Exposure to war-related trauma and symptoms of complex posttraumatic stress disorder among children and adolescents in Gaza Basel El-Khodary a , Rawan Iriqat b, CONTACT , Abdallah Abo-Shamla c , Mahmoud Ali d , Wael Al-Delaimy b Author information Article notes Copyright and License information a Department of Psychology, Islamic University of Gaza, Gaza, Palestine b Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA c Techmed Gaza, Gaza, Palestine d International Committee of the Red Cross, Gaza, Palestine CONTACT Rawan Iriqat ririqat@health.ucsd.edu Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, 9500 Gilman Dr. MC 0628 La Jolla, CA 92093-0628, USA Received 2025 Dec 16; Accepted 2026 Apr 20; Collection date 2026. © 2026 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. PMC Copyright notice PMCID: PMC13231820  PMID: 42227268 ABSTRACT Background: The war in Gaza has exposed children and adolescents to extreme trauma, violence, and loss, yet little empirical data exist on its psychological impact. This study examines war-trauma exposure and associated mental health outcomes, including probable PTSD, probable complex PTSD (cPTSD), depression, anxiety, and stress. Objective: This study aimed to assess the psychological impact of prolonged and repeated war-related trauma on post-traumatic symptoms among children and adolescents in Gaza during the ongoing war, with the goal of informing public mental health and humanitarian interventions. Methods: A cross-sectional study was conducted with 250 participants aged 12–18 displaced into refugee camps during the war in Gaza. War-related trauma was assessed using the Gaza Traumatic Event Checklist (GTEC) . PTSD and cPTSD symptoms were measured with the International Trauma Questionnaire (ITQ) , and depression, anxiety, and stress were assessed using the Depression, Anxiety, and Stress Scale for Youth (DASS-Y). Results: The results showed that all participants are exposed to at least three war traumatic events. Males exposed to more war trauma compared to females. Exposure to war-related trauma has a positive significant correlation with PTSD, cPTSD, stress, anxiety, and depression symptoms. Furthermore, no gender differences were found regarding PTSD and cPTSD diagnosis. Older adolescents reported higher stress, anxiety, and depression, but age did not predict PTSD or cPTSD. Children and adolescents with greater trauma exposure had higher PTSD and cPTSD scores than those with lower exposure. Conclusions: Children and adolescents in Gaza experience extremely high levels of PTSD and cPTSD due to chronic war-related trauma. Both genders are affected, with older adolescents showing more internalizing symptoms. These findings underscore the urgent need for culturally sensitive, comprehensive mental health interventions to mitigate long-term psychological harm. KEYWORDS: Complex trauma, mental health, children and adolescents, PTSD, Gaza KEY POINTS Children and adolescents exposed to war trauma are at high risk of developing post-traumatic stress disorder (PTSD) and complex PTSD (cPTSD), which involves difficulties with self-concept, emotional regulation, and relationships. The study reports alarmingly high rates of both PTSD and complex PTSD among children and adolescents living in Gaza during the war and highlighting the profound psychological impact of living under repeated traumatic events and chronic war conditions. Findings underscore the need for comprehensive, trauma-informed, and culturally sensitive mental health services that include screening for both PTSD and cPTSD and address emotional regulation, identity, and relational functioning. 1. Background Experiencing trauma during adolescence can leave deep and lasting marks on mental health. Adolescents, whose brains and social-emotional skills are still developing, are particularly vulnerable to the impact of repeated or chronic trauma. Rapid cognitive, emotional, and social development during this period may amplify sensitivity to environmental stressors, increasing the likelihood of psychological difficulties following traumatic experiences. This heightened sensitivity often manifests as internalizing disorders, such as anxiety, depression, or post-traumatic stress, which have been linked to dysregulations in cortical maturation, particularly in prefrontal and temporal regions, and to maturational mismatches between earlier-developing subcortical regions and later-developing regulatory prefrontal regions (Fan et al., 2023 ; Yu et al., 2025 ). Trauma during this critical stage of identity and social growth can make it harder for children and adolescents to manage emotions, see themselves positively, build healthy relationships, and succeed in school (Gerasimos Cruz et al., 2022 ; Downey & Crummy, 2022 ; Kalogeratos et al., 2024 ). In contexts of armed conflict, youth may be exposed not only to family – or community-level trauma but also to direct threats and violence, which can amplify the severity and complexity of psychological outcomes (Bürgin et al., 2022 ). Globally, an estimated 473 million children live in conflict-affected areas, with adolescents disproportionately represented among displaced populations (UNICEF, 2024 ). Research from conflict-affected regions, including Syria, Iraq, Afghanistan, and the Democratic Republic of Congo, demonstrates that cumulative trauma in adolescence often produces disturbances beyond traditional post-traumatic stress disorder (PTSD), underscoring the relevance of complex PTSD (cPTSD) as a framework for understanding these effects (Kanan & Leão, 2024 ; Qamar et al., 2022 ; Veling et al., 2013 ). The situation in Gaza exemplifies such chronic and cumulative exposure. Children and adolescents in Gaza, who represent a substantial portion of the population, experience trauma due to repeated violence, displacement, and socio-political instability (Hamad et al., 2024 ). The current generation of adolescents, born between 2007 and 2013, has never known life outside blockade and conflict, growing up amid recurring bombardments and a collapsing healthcare system (Al-Jamal, 2024 ; Farajallah, 2024 ). Exposure to traumatic events include killings, injuries, home demolitions, imprisonment, and witnessing violence repeatedly over time (Kanan & Leão, 2024 ; Zughbur et al., 2025 ). Prolonged exposure to conflict, blockade, and insecurity places adolescents at high risk for psychological difficulties. Research shows that core features of cPTSD, such as affect dysregulation, negative self-concept, and interpersonal challenges, are commonly observed in this population (Daniunaite et al., 2021 ; El-Khodary et al., 2020 ; Giourou et al., 2018 ). In September 2025, the UN Independent International Commission of Inquiry determined that Israeli authorities have committed genocide against Palestinians in Gaza, highlighting the scale and systematic nature of the violence to which children and adolescents are exposed (United Nations, 2025 ). As of July 2025, the Gaza ministry of health reported the number of traumatic fatalities in people under the age of 18 to be around 20,000 (Crawford, 2023 ). According to Save the Children ( 2025 ), at least one Palestinian child has been killed every hour on average over nearly 23 months of war, with the total number of child fatalities now surpassing 20,000; at least 42,011 children have been injured, and over 21,000 have been left permanently disabled. UNICEF estimates that over 1 million children are in need of mental health support (United Nations Office for the Coordination of Humanitarian Affairs [OCHA], 2025 ). This violence happens amid fragile and under-resourced mental health services, leaving many adolescents without the support they need to cope with ongoing trauma (Farajallah, 2024 ). Limited access to mental health support, stigma surrounding psychological care, and insufficient trained professionals exacerbate the impact of trauma and hinder adolescents from receiving timely and effective interventions (Hamad et al., 2024 ; Qutishat, 2025 ). While PTSD is typically associated with single-event trauma and characterized by re-experiencing, avoidance, and hyperarousal, cPTSD includes these symptoms plus disturbances in self-organization (DSO), such as difficulties with emotional regulation, negative self-perception, and challenges in relationships (Giourou et al., 2018 ). In populations exposed to repeated and prolonged trauma, such as children and adolescents in Gaza, cPTSD may provide a more valid and clinically meaningful framework than PTSD alone (Daniunaite et al., 2021 ). Adolescents exposed to cumulative trauma often present with internalizing symptoms, such as anxiety and depression, reflecting the complex psychological burden of prolonged conflict exposure (Giourou et al., 2018 ). Recognizing cPTSD, rather than PTSD alone, is clinically important. Adolescents with cPTSD often struggle to manage their emotions and maintain healthy relationships, which means they need longer, more comprehensive care that blends skill-building and relational approaches, instead of relying on a single trauma-focused treatment (Rolling, 2025 ). Despite extensive research documenting PTSD prevalence and trauma exposure among children and adolescents in Palestine and in Gaza particularly (Agbaria et al., 2021 ), no studies have explicitly assessed cPTSD in this population. This critical gap limits understanding of the full spectrum of trauma-related difficulties in this extremely vulnerable population and hinders the development of interventions that address the unique needs of adolescents exposed to chronic armed violence. In this study we aim to systematically document the burden of probable cPTSD and probable PTSD during the war, to aid in the development of targeted mental health interventions fit for the unique situation in Gaza, by assessing trauma-related symptoms and associations among children and adolescents using standardized assessment tools. We specifically aim to: (1) describe the prevalence and severity of war-related trauma exposure, symptoms of PTSD, cPTSD, depression, anxiety, and stress among children and adolescents in Gaza; (2) examine gender and age differences in trauma exposure and psychological outcomes; and (3) explore associations and predictors of symptoms of PTSD, cPTSD, and emotional distress (depression, anxiety, stress) based on multiple factors. 2. Methods 2.1. Study design This cross-sectional study was conducted in August 2025 among children and adolescents residing in three refugee camps in southern Gaza (Rafah, Al-Zawayda, and Al-Bureij). The study aimed to assess the prevalence of trauma exposure and related mental health symptoms among youth living under prolonged conflict conditions. 2.2. Participants Eligible participants were: (1) aged 12–18 years, (2) displaced and directly affected by the war, (3) currently residing in one of the three camps (4) provision of written informed parental/guardian consent and child assent. Exclusion criteria included: (1) active psychosis or severe developmental delay impairing participation, (2) currently undergoing a psychological treatment, (3) non-consent or inability to provide assent, or (4) physical impairments (e.g. amputations, blindness) to maintain a relatively consistent sample, allowing for accurate comparisons across participants. 2.3. Recruitment and screening procedures Participants were recruited through TechMed Gaza, a local team delivering mental and physical therapy support through virtual reality. TechMed psychologists collaborated with camp clinics and outreach teams to identify eligible participants for recruitment. Screening was conducted in person by trained psychologists from Gaza. Each participant completed structured questionnaires assessing exposure to war-related traumatic events and psychological symptoms. Responses were recorded on paper forms and later entered into a secure Google Form database. To maintain confidentiality, participants were assigned unique identification codes, and identifying information was stored separately from questionnaire data. Although participants were recruited from three refugee camps in southern Gaza, the majority of Gaza’s population has already been displaced, and the camps included children and adolescents originally from across the region. At the time of data collection, northern Gaza was under complete siege, limiting recruitment from that area. Thus, while some geographic variation is not captured, the sample reflects a broad cross-section of youth exposed to conflict and displacement throughout Gaza. 2.4. Measures and variables 2.4.1. Demographic data The main questionnaire consisted of a consent form to be signed by the participant and a caregiver. Age and gender were recorded for each participant. 2.4.2. The Gaza traumatic event checklist (GTEC) This 20-item checklist assesses participants’ exposure to war-related traumatic events and was developed for the Gaza context (El-Khodary et al., 2020 ; Hein et al., 1993 ). It was selected for this study due to its strong cultural and contextual relevance, as it captures the types of traumatic experiences that are common in Gaza, such as witnessing bombings, loss of family members, home destruction, displacement, or injury due to shelling. Each item is scored dichotomously (0 = No, 1 = Yes) to indicate whether the adolescent has experienced a particular event. Total scores range from 0 to 20, representing the cumulative number of traumatic events experienced or witnessed. Higher scores reflect greater cumulative trauma exposure. For descriptive purposes, exposure levels were categorized as low (0–6 events), moderate (7–13 events), and high (14–20 events) based on the distribution in prior studies with Gazan youth (El-Khodary et al., 2020 ). 2.4.3. International trauma questionnaire (ITQ) The ITQ assesses symptoms of PTSD and complex PTSD (cPTSD) according to the International Classification of Diseases, 11th Revision (ICD-11) (Cloitre et al., 2018 ). Probable PTSD is measured using six items across three symptom clusters: re-experiencing, avoidance, and sense of current threat (hypervigilance). cPTSD is distinguished by an additional Disturbances in Self-Organization (DSO) subscale, which includes six items assessing affective dysregulation, negative self-concept, and relational difficulties. In this study, PTSD and DSO symptoms are reported separately. This allows for examination of distinct symptom patterns, such as gender differences within the self-organization component of cPTSD, while remaining consistent with ICD-11 scoring guidelines. Each subscale also includes associated functional impairment items. Items are rated on a 0–4 Likert scale (‘not at all’ to ‘extremely’), and scoring follows ICD-11 criteria: participants meeting PTSD symptom criteria alone are classified as probable PTSD, whereas those meeting both PTSD and DSO criteria are classified as probable cPTSD (Cloitre et al., 2018 ). 2.4.4. Depression, anxiety, and stress scale (DASS-Y) The DASS-Y is a self-report instrument measuring the severity of depression, anxiety, and stress over the past week (21 items; rated 0–3: ‘did not apply to me at all’ to ‘applied to me most of the time’) (Szabo & Lovibond, 2022 ). Scores are calculated separately for each subscale, allowing differentiation between depressive symptoms, anxiety symptoms, and stress. Each subscale score is then categorized into normal, mild, moderate, severe, or extremely severe symptom ranges using established cut-offs. Both the ITQ and DASS-Y were administered using previously validated Arabic-language versions. While the Arabic DASS-Y has shown promise for clinical use in Arab populations, it has not been directly validated in youth populations in Gaza (Obeid et al., 2025 ). Therefore, symptom classifications in this study should be interpreted as probable rather than diagnostic. Similarly, this study represents, to our knowledge, the first application of the ICD-11 ITQ framework among adolescents in Gaza, highlighting the importance of future validation work in this population. 2.5. Statistical methods We first calculated descriptive statistics, means, standard deviations, and frequencies, to summarize demographics, war-trauma exposure, and mental health outcomes and symptoms of (PTSD, cPTSD, depression, anxiety, and stress). To examine differences by gender, we used t-tests for continuous variables and Chi-square tests for categorical variables (probable PTSD and probable cPTSD). Pearson correlations were conducted to explore relationships among age, trauma exposure, symptoms of PTSD, cPTSD, and emotional distress. We then ran hierarchical linear regression models to see how age and cumulative war-trauma exposure predicted PTSD and cPTSD symptoms, as well as stress, anxiety, and depression. Age was entered in the first step, followed by trauma exposure in the second step. Standardized (β) and unstandardized (B) coefficients, along with 95% confidence intervals, were reported. A significance level of p < .05 was used for all analyses. 2.6. Ethical information Written informed parental or guardian consent and child/adolescent assent were obtained prior to participation. The study protocol was approved by the ethics board at the Islamic University of Gaza (IUG) on 20 July 2025 under reference number (2025/11). 3. Results Data were available for N = 250 participants recruited from refugee camps in southern Gaza. Below we report sample characteristics, prevalence of exposure and mental health outcomes, group comparisons (gender; exposure by diagnosis), correlations, and regression models predicting symptoms. 3.1. Sample characteristics A sample of 250 participants (145 females (58%) and 105 males (42%)); aged 12–18 years (M = 14.2, SD = 1.68) were recruited from refugee camps in southern Gaza. All participants had been exposed to war-related traumatic events. There were no missing data to handle. 3.2. Prevalence of mental health outcomes As shown in Table 1 , all participants in the study had been exposed to at least three war-related traumatic events. A high prevalence of mental health conditions was found within the sample. Specifically, 128 participants (51.2%) met the diagnostic criteria for probable PTSD, while 73 (29.2%) met the criteria for probable cPTSD according to ICD-11. Furthermore, 171 (68.4%) reported moderate to extremely severe stress symptoms, 89 (35.6%) reported moderate to extremely severe anxiety symptoms, and 158 (63.2%) reported moderate to extremely severe depression symptoms. Table 1. Descriptive statistics and frequencies of trauma exposure and mental health outcomes among refugee children in Gaza. Frequency Percent Mean Median Range Exposure to war trauma 13.72 14 17 PTSD (continuous) 13.24 14 24 cPTSD (continuous) 9.52 9 24 PTSD (Categorical) Probable PTSD 128 51.2 cPTSD (Categorical) Probable cPTSD 73 29.2 Stress Normal 134 53.6 Mild 27 10.8 Moderate 41 16.4 Severe 28 11.2 Extremely severe 20 8 Anxiety Normal 46 18.4 Mild 33 13.2 Moderate 76 30.4 Severe 44 17.6 Extremely severe 51 20.4 Depression Normal 60 24 Mild 32 12.8 Moderate 74 29.6 Severe 46 18.4 Extremely severe 38 15.2 Open in a new tab 3.3. Gender differences in trauma exposure and diagnosis Chi-square analysis was used to investigate potential gender differences in probable PTSD and cPTSD diagnoses. The results indicated no significant difference in probable PTSD diagnosis (χ 2 (1, N = 250) = .004, p = .52) or probable cPTSD diagnosis (χ 2 (1, N = 250) = .435, p = .30) regarding gender. However, a significant gender difference was found for exposure to war trauma ( t (248) = 3.57, p < .001). As shown in Table 2 , males had a higher mean exposure to war trauma (M = 14.56, SD = 2.77) compared to females (M = 13.11, SD = 3.64). Conversely, gender was not significantly associated with PTSD, DSO, stress, anxiety, or depression symptoms scores ( p > .05) Table 2. Mean differences in trauma exposure and mental health symptoms by gender. Male Female P M (SD) M (SD) War-trauma 14.56 (2.77) 13.11(3.64) < .001 PTSD 13.04 (5.65) 13.39 (5.59) .63 DSO 9.23 (5.33) 9.73 (5.23) .46 Stress 11 (4.57) 11.69 (5.13) .26 Anxiety 10.16 (5.16) 11.06 (5.15) .17 Depression 10.46 (4.94) 11.06 (5.11) .35 Open in a new tab Note: DSO = Disturbances in Self-Organization, a core component of ICD-11 complex PTSD (cPTSD). 3.4. Correlation among variables Pearson's correlation analyses were performed to assess the relationships between age, war-trauma, and various mental health outcomes. The findings, detailed in Table 3 , showed significant positive correlations between age and symptoms of stress ( r = .17, p < .01), anxiety ( r = .19, p < .01), and depression ( r = .23, p < .01). Additionally, war-trauma was significantly and positively correlated with symptoms of PTSD, DSO, stress, anxiety, and depression. Similarly, probable PTSD showed significant positive correlations with symptoms of DSO, stress, anxiety, and depression. All mental health outcomes were found to be positively correlated with one another. Table 3. Correlations between age, war-trauma exposure, and psychological symptoms (PTSD, DSO, stress, anxiety, and depression). 1 2 3 4 5 6 7 1. Age – 2. War-trauma .10 – 3. PTSD .08 .35** – 4. DSO .12 .30** .51** – 5. Stress .17** .35** .56** .63** – 6. Anxiety .19** .35** .55** .55** .75** – 7. Depression .23** .30** .55** .64** .81** .70** – Open in a new tab ** Correlation is significant at the 0.01 level (2-tailed). 3.5. Exposure to war-trauma and probable PTSD and cPTSD cases Exposure to war-related trauma was significantly associated with both probable PTSD and probable cPTSD cases. Children with greater war-trauma exposure had a significantly higher mean number of probable PTSD cases (M = 14.68, SD = 3.26) compared to those with less exposure (M = 12.70, SD = 3.20), with this difference being statistically significant ( t (248) = 4.83, p < .001). Similarly, the data for cPTSD showed a significant effect of exposure to war trauma, with children who experienced more trauma having a higher mean number of probable cPTSD cases (M = 15.53, SD = 3.00) than those with less exposure (M = 12.97, SD = 3.25), a finding that was also highly significant (t(248) = 5.79, p < .001). 3.6. Prediction of complex trauma and mental health outcomes A hierarchical linear regression model was performed to assess the predictors of PTSD symptoms, cPTSD symptoms, stress, anxiety, and depression symptoms by age and exposure to war-trauma. Age significantly predicted symptoms of stress (F(1,248) = 7.85, p = .005), anxiety (F(1,248) = 9.32, p = .003), and depression (F(1,248) = 14.58, p < .001). Older children and adolescents were more likely to report stress, anxiety, and depression symptoms compared to younger ones. However, age did not significantly predict PTSD and cPTSD symptoms ( p > .05). Furthermore, exposure to war-trauma significantly predicted PTSD symptoms (F(1,248) = 34.92, p < .001), cPTSD symptoms (F(1,248) = 24.72, p < .001), stress (F(1,248) = 36.37, p < .001), anxiety symptoms (F(1,248) = 36.70, p < .001), and depression symptoms (F(1,248) = 25.74, p < .001). Participants who were exposed to more war-traumatic events were more prone to report symptoms of PTSD and cPTSD, stress, anxiety, and depression. Participants exposed to more war trauma also had more probable PTSD cases (M = 14.68, SD = 3.26) than those exposed to less (M = 12.70, SD = 3.20). Similarly, participants exposed to more war-trauma had more probable cPTSD cases (M = 15.53, SD = 3.00) compared to those exposed to less (M = 12.97, SD  = 3.25). A full summary of the regression model is shown in Table 4 . Table 4. Linear regression results for age and war-trauma as predictors of mental health outcomes ( N = 250). Age War-trauma 95% CI 95% CI B SE LL UL β p B SE LL UL β p PTSD symptoms .283 .21 −.132 .697 .080 .180 .583 .09 .389 .777 .350 <.001 DSO symptoms .387 .19 .000 .774 .120 .050 .469 .09 .283 .655 .300 <.001 Stress .510 .18 .151 .868 .170 .005 .519 .08 .350 .689 .350 <.001 Anxiety symptoms .583 .19 .207 .959 .190 .003 .549 .09 .370 .727 .350 <.001 Depression symptoms .703 .18 .341 1.06 .230 <.001 .457 .09 .280 .634 .300 <.001 Open in a new tab Note. PTSD = Posttraumatic Stress Disorder; DSO = Disturbance in Self-Organization; CI = Confidence Interval; LL = Lower Limit; UL = Upper Limit; B = Unstandardized Coefficient; β = Standardized Coefficient. All models were significant at p < .001. 3.7. Predictors of cPTSD symptoms A hierarchical regression analysis was conducted to examine whether symptoms of stress, anxiety, and depression mediated the association between war-related trauma and complex PTSD (cPTSD) symptoms. In Step 1, war-traumatic exposure significantly predicted cPTSD symptoms (B = .469, 95% CI [.283, .655], p < .001). In Step 2, war-trauma exposure significantly predicted all three mediators: symptoms of stress (B = .519, 95% CI [.350, .689], p < .001), anxiety (B = .549, 95% CI [.370, .727], p < .001), and depression (B = .457, 95% CI [.280, .634], p < .001). In Step 3, war-trauma exposure and the three mediators were entered together in the model. The overall model was significant, explaining 46% of the variance in cPTSD symptoms (R² = .462, Adjusted R² = .453, F(4, 245) = 52.57, p < .001). In this model, symptoms of stress (B = .270, 95% CI [.079, .462], p = .006) and depression (B = .380, 95% CI [.208, .552], p < .001) were significant predictors, whereas anxiety symptoms (B = .083, 95% CI [−.065, .232], p = .271) and war-trauma exposure (B = .109, 95% CI [−.046, .265], p = .163) were not, which suggests that symptoms of stress and depression partially mediate the relationship between war-related trauma and cPTSD symptoms (see Table 5 ). Table 5. Hierarchical regression analysis examining the effects of war-related trauma and psychological mediators on complex PTSD symptoms ( N = 250). Step 1 (trauma predicted cPTSD) Step 2 (trauma predicted mediators) Step 3 (trauma and mediators predicted cPTSD) B [ 95% CI] β B [ 95% CI] β B [ 95% CI] β cPTSD .469 [.283, .655]*** .301 Stress .519 [−.350, .689]*** .358 .270 [.079, .462] ** .252 Anxiety .549 [.370, .727]*** .359 .083 [−.065, .232] .082 Depression .457 [.280, .634]*** .307 .380 [.208, .552]*** −.963 War trauma .109 [−.046, .265] .070 R 2 .462 Adjusted R 2 .453 Open in a new tab *** p < .001, ** p < .01, * p < .05. 4. Discussion To the best of our knowledge, this study is the first to systematically document the burden of probable cPTSD using the ICD-11 framework among children and adolescents affected by the genocide in Gaza. The findings comprehensively address the critical gap identified in the literature, revealing a mental health crisis driven by collective exposure to chronic war-related violence. Specifically, the results show a devastatingly high prevalence of probable PTSD and cPTSD, underscoring the severe and complex psychological toll of living under protracted military assault. Our study confirms a devastating mental health crisis: all children and adolescents were exposed to severe trauma, which may have led to pervasive symptoms of PTSD, cPTSD, stress, anxiety, and depression. The reported rates of probable PTSD and especially cPTSD (29.2%) are among the highest globally, reflecting the chronic, repetitive, and complex nature of trauma in Gaza. In a recent study of Ukrainian students living in Kyiv during the ongoing war, the prevalence of probable PTSD was 12.4%, and probable cPTSD was 11.2% among those exposed to war-related stressors (Lotzin et al., 2023 ). The strong correlation between PTSD and DSO symptoms ( r = .51, p < .001) observed in our sample aligns with the ICD-11 conceptualization of cPTSD as a trauma-related disorder comprising both core PTSD symptoms and disturbances in self-organization. However, the chronic, repeated, and pervasive nature of trauma exposure in Gaza may blur the clinical and phenomenological boundaries between these symptom clusters in ways that differ from populations exposed to single-event trauma. For individuals exposed to a single traumatic event, PTSD symptoms often arise in direct response to that event, while DSO symptoms may be less apparent or emerge only in cases of prolonged or interpersonal trauma. In contrast, children and adolescents in Gaza are exposed to ongoing, multifaceted trauma, such as bombings and displacement. This results not only in classic PTSD symptoms but also in profound disruptions in identity, emotional regulation, and interpersonal functioning, which are core features of DSO. The high prevalence of both probable PTSD (51.2%) and probable cPTSD (29.2%) in our sample suggests that, for many children and adolescents, trauma exposure is not a discrete event but a continuous reality. This may lead to a symptom overlap in which hypervigilance (PTSD) becomes a persistent way of being, emotional numbing (PTSD) merges with affective dysregulation (DSO), and avoidance behaviours extend to relational withdrawal (DSO). Such entanglement supports the view that, in contexts of chronic adversity, trauma-related pathology may reflect a dimensional rather than purely categorical distinction between PTSD and cPTSD, consistent with empirical findings that cPTSD is associated with greater functional impairment and often follows prolonged or multiple traumas. This pattern aligns with the ICD-11 proposal that cPTSD captures a distinct, more complex symptom profile resulting from sustained or repetitive trauma. These findings emphasize the chronic and intense nature of trauma in Gaza, driven by repeated wars, prolonged blockade, and ongoing instability. We also found that increased war-trauma exposure strongly predicts all psychopathology and confirms dose–response relationship between trauma and mental health outcomes, a fundamental aspect of traumatology. This finding aligns with previous research indicating that exposure to three or more types of potentially traumatic events (PTEs) significantly predicted increased PTSD and depression severity, supporting the dose–response theory (Gerber et al., 2018 ). Such cumulative exposure is highly relevant in Gaza, where repeated and prolonged trauma compounds psychological risk. While early and ongoing trauma-focused care is important to support recovery, it is crucial to emphasize that stopping ongoing exposure to trauma and ensuring safety are the primary prerequisites for healing. In this context, advocacy for human rights and protection should be prioritized, with trauma-focused interventions serving as critical support in the aftermath of conflict. Another critical finding in this study was that while males may be more exposed to direct trauma, and violence, females' psychological distress is equally severe. This may be due to exposure to indirect trauma (loss, fear for family, domestic stress) or different cultural coping mechanisms, highlighting the need for gender-sensitive screenings that go beyond simple exposure counts, or the fact that all adolescents regardless of gender were exposed to displacement, starvation, and other stressful factors. In one study of adult survivors of the Croatian war, women who had been exposed to war trauma during childhood reported more severe PTSD symptoms and showed greater vulnerability to trauma exposure in conflict settings. The study also found that interpersonal violence and deprivation were key predictors of PTSD, highlighting notable gender differences in trauma experiences and outcomes (Ajduković et al., 2025 ). Similarly, Zona and Milan ( 2011 ) found that adolescent boys experienced higher exposure to violence, while girls, despite lower exposure, were more likely to exhibit dissociative symptoms. Together, these findings highlight that gender differences in trauma responses often reflect differences in symptom expression rather than exposure alone. Our findings also highlight that older adolescents (16–18 years) report higher levels of stress, anxiety, and depression, suggesting that the cumulative burden of prolonged conflict, combined with the developmental challenges of late adolescence, increases vulnerability to internalizing symptoms. Consistent with research on internalizing and externalizing symptoms, worsened mental health outcomes are more prevalent among youth exposed to multiple types of trauma (Darnell et al., 2019 ). These patterns may reflect both the repeated traumatic experiences over time and the heightened emotional and cognitive demands of late adolescence, such as identity formation, increased social awareness, and concern about the future. Supporting this, previous research found that self-concept clarity increases in a nonlinear way between ages 16 and 23 then stabilizes into adulthood (Branje et al., 2021 ). We also found that exposure to war-related trauma predicts higher levels of cPTSD symptoms both directly and indirectly through increased stress and depressive symptoms. This suggests that stress and depression play a key mediating role in the pathway from trauma exposure to complex PTSD, whereas anxiety did not significantly contribute once other factors were included. These results align with previous research showing that emotional dysregulation and persistent depressive symptoms are central components of complex trauma responses (Alpay & Celik, 2022 ; O’Shea Brown, 2021 ). The strong mediating effect of stress may reflect the cumulative psychological burden and ongoing sense of threat often experienced in war-affected environments, which can sustain trauma-related distress even after direct exposure ends. In contrast, anxiety may represent a more immediate or transient response to trauma rather than a long-term mechanism linking trauma to cPTSD. This distinction supports theoretical models that conceptualize cPTSD as characterized by enduring affective and stress-related dysregulation, rather than acute anxiety reactions (Gerrans et al., 2025 ; Martin, 2022 ). Collectively, these findings underscore the importance of ensuring safety and advocating for the rights of children as a foundation for interventions, while also addressing stress management and depressive symptoms to reduce cPTSD among war-affected populations. 5. Implications The main theoretical implication is that the high rates of probable cPTSD and the strong correlation between PTSD symptoms and DSO support the ICD-11 cPTSD framework for populations exposed to chronic and widespread violence. Previous research in the region focused only on rates PTSD (e.g. Agbaria et al., 2021 ) and missed the emotional, and self-regulatory difficulties captured by the DSO cluster associated with cPTSD. This suggests that PTSD diagnosis alone does not fully capture the psychological impact of protracted conflict, highlighting the need for a complex trauma approach in both research and clinical practice. Clinically, many participants in this study experienced multiple symptoms at the same time, including stress, anxiety, and depression. This means treatments that target only one symptom are unlikely to be effective. Instead, interventions should follow a cPTSD-informed, step-by-step approach: first establishing safety and stability, then teaching emotional regulation skills, and finally helping adolescents process their traumatic experiences. Because all adolescents showed high exposure and symptom levels, regardless of gender, there is also a need for community-based prevention programmes in addition to individual therapy. Such programmes can reach more youth and provide support in a scalable, accessible way. Lastly, from a public health perspective, these findings show the urgent need for ongoing mental health support, screening that considers culture and gender, and mental health programmes integrated into schools and community centres in refugee camps. Older adolescents may be especially at risk from cumulative stress, so programmes should take their developmental needs into account. 5.1. Strengths & limitations This study is an important first step in understanding the psychological impact of chronic war-trauma, as it is the first to use the ICD-11 cPTSD framework with children and adolescents in Gaza refugee camps during the genocide. A major strength is the large, non-clinical sample ( N = 250), which gives a realistic picture of complex trauma in this highly vulnerable population. However, there are some limitations to be acknowledged. First, although mediation analyses were conducted to explore potential pathways linking trauma exposure with cPTSD symptoms, the cross-sectional nature of the data precludes causality. These findings should therefore be interpreted as associative rather than causal. In protracted conflict settings where trauma exposure is ongoing, psychological distress may function both as a consequence of trauma and as a factor that exacerbates trauma-related symptomatology, suggesting potentially bidirectional relationships. Longitudinal research is needed to clarify these temporal dynamics and better understand mechanisms underlying cPTSD in chronically trauma-exposed populations. Second, the study relied on self-report measures, which may introduce reporting bias. Future research incorporating clinical interviews or multi-method assessments would strengthen diagnostic validity. Additionally, because participants with severe physical disabilities were excluded, and given the high proportion of Gaza’s population affected by injury or disability (Boukari et al., 2024 ), these findings may underestimate the true burden of trauma-related symptoms among children and adolescents. The analysis was also limited by available demographic data, as factors such as frequency of displacement or prior trauma history were not assessed despite their potential influence on mental health outcomes. Finally, our sample may not fully represent all children and adolescents in Gaza. Most of the population had been displaced to the south, and northern camps were under siege, which limited recruitment. This introduces potential selection bias and may affect the generalizability and validity of our conclusions. Future studies should aim to include a broader, more representative sample to strengthen the validity of findings. 6. Conclusion This study provides compelling evidence of a severe and complex mental health crisis among children and adolescents who lived in Gaza during the genocide. This exposure to chronic, pervasive violence has left an entire generation at risk, with alarming and high rates of probable PTSD and cPTSD. Both boys and girls suffer equally, highlighting that no child is spared from the psychological toll of war. These findings are not just statistics; they reflect childhoods stolen, lives disrupted, and futures impaired. Immediate, sustained, and culturally sensitive mental health support is not optional, it is a moral duty. Without urgent response, the effects on this generation will last for decades, continuing cycles of suffering and loss. Author contributions BEK and RI conceptualized the study. BEK performed formal analysis and edited the final draft. AAS and MA were responsible for methodology, data curation, investigation, and project administration. RI conducted data visualization, validation, and drafted both the original and final drafts. WAD provided supervision, validation, and reviewed and edited the manuscript. All authors approved the final version of the manuscript. Disclosure statement No potential conflict of interest was reported by the author(s). Data availability Data not available – participant consent. The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. Abbreviations PTSD: Post-Traumatic Stress Disorder; cPTSD: complex Post-Traumatic Stress Disorder; DSO: Disturbances in Self-Organization; ITQ: International Trauma Questionnaire; DASS – Y: Depresison Anxiety and Stress Scale for Youth; ICD-11: International Classification of Diseases, 11th Revision; PTE: potentially traumatic events; UNICEF: United Nations International Children’s Emergency Fund. 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