Mechanisms of risk and resilience among war-affected adolescents in Gaza: the mediating role of posttraumatic stress and the moderating role of prosocial behavior.

Adolescents in Gaza have been repeatedly exposed to war-related trauma, mass displacement, and severe humanitarian crises, placing them at heightened risk of psychological distress. Drawing on cognitive-behavioral and social-ecological frameworks, this study examined how posttraumatic stress and prosocial behavior shape the relationship between cumulative trauma exposure and psychosocial functioning among war-affected adolescents. A cross-sectional study was conducted between July and August 2025 among 717 displaced adolescents (aged 12-17 years) and their caregivers living in shelters and tented camps across the Gaza Strip. Participants completed the Child and Adolescent Trauma Screen (CATS), Strengths and Difficulties Questionnaire (SDQ), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). Mediation and moderation analyses were used to examine posttraumatic stress as a mechanism linking cumulative trauma exposure to emotional-behavioral difficulties and to test prosocial behavior as a potential resilience factor. Nearly four in five adolescents (78.4%) met the CATS cutoff for probable PTSD, and almost half (48.5%) met full DSM-5 diagnostic criteria. SDQ assessments indicated that more than half of the participants were classified in the abnormal range for total difficulties on both self- and parent-reports (54.1% and 55.4%, respectively). Peer relationship problems and emotional symptoms were the most prominent, affecting 90.5% and 43.2% of adolescents, respectively. In contrast, prosocial behavior remained relatively preserved, with about three-quarters scoring within the normal range. Strong agreement between self- and parent-reported ratings (r = 0.63) supported the robustness of these findings. PTSD symptoms statistically explained roughly two-thirds of the link between cumulative trauma and emotional-behavioral difficulties, emphasizing posttraumatic stress as a key factor in psychosocial impairment. Conversely, higher prosocial tendencies appeared to buffer the effect of trauma on PTSD severity, suggesting that empathy, cooperation, and helping behaviors help reduce the psychological impact of war exposure. The findings reveal an alarming prevalence of posttraumatic stress and psychosocial dysfunction among Gazan adolescents amid ongoing conflict. Although the findings are cross-sectional and cannot confirm causal mediation, PTSD symptoms appear to represent a key pathway linking trauma exposure to emotional and behavioral difficulties, while prosocial engagement serves as a significant resilience factor. Trauma-informed, family-centered, and strength-based interventions are urgently warranted to address both psychological distress and the social capacities that foster recovery and resilience.