Children are disproportionately affected by global conflict and displacement, comprising one-third of the world’s population yet accounting for half of all refugees. 1 Alarmingly, one in six children lived in conflict zones in 2020. 2 Armed conflicts cause severe mental health consequences in children, including trauma, post-traumatic stress disorder (PTSD), anxiety and depression, further exacerbated by displacement, loss of caregivers and exposure to violence. Reference Shenoda, Kadir, Pitterman and Goldhagen3 In conflict zones, mental health impacts include sharply increased rates of PTSD, anxiety and depression, with prevalence two to four times more than the global average, with women and children being disproportionately affected. Reference Bendavid, Boerma, Akseer, Langer, Malembaka and Okiro4 In addition to the direct effect of war, indirect effects, which are demonstrated in daily life stressors, such as poverty, family violence, famine and severe food insecurity Reference Khoodoruth and Khoodoruth5 often have a detrimental impact on children’s mental health. Reference Miller and Jordans6
The protracted Israeli-Palestinian conflict has caused significant Palestinian displacement and created enduring socioeconomic challenges. Reference Feliciana7 Recent escalations in violence, including airstrikes and ground operations, have exacerbated psychological distress, particularly among children. Violence, forced displacement because of military action and bereavement have substantially increased mental health risks for this vulnerable population. 8 Existing research has extensively documented the mental health burden among Palestinian children. Reference Mehmood, Faizan, Ullah, Shoib and Őri9,Reference Qamar, Hashmi, Sadiq, Aquil, Arshad and Jobran10 Epidemiological data reveal disproportionately high rates of PTSD and depression in this population compared with both global and regional benchmarks. As highlighted by Shukri and colleagues, while global prevalence estimates for depression and PTSD remain relatively low, Palestinian children demonstrated higher rates, underscoring the disproportionate psychological burden faced by youth in conflict-affected settings. Reference Shukri, Holmes, Mohd, Shukri and Saada11
This study aims to evaluate the rates of anxiety and depression in war-displaced Palestinian children and adolescents, who are affected by the current war and who reside in Qatar. As part of a humanitarian response, Qatar launched a programme in December 2023 to provide medical care and resettlement support to displaced Palestinian families, including plans to sponsor 3000 orphans and treat 1500 individuals requiring medical attention. 12 The psychological effects of chronic conflict on Palestinian children have been documented in multiple studies over the past two decades. In one of the earliest investigations, Thabet and Vostanis found that 21.5% of children in Gaza reported significant anxiety symptoms linked to social adversities and exposure to violence. Reference Thabet and Vostanis13 Building on this work, Thabet, Abed and Vostanis examined the mental health outcomes of Palestinian refugee children aged 9 to 15 years and reported that exposure to war-related trauma was significantly associated with elevated symptoms of both PTSD and depression, with trauma exposure emerging as a stronger predictor of depressive symptoms. Reference Thabet, Abed and Vostanis14 These studies identify the cumulative psychological burden faced by children living under occupation and repeated cycles of violence.
Despite the extensive documentation of mental health challenges among children in conflict zones, there remains a critical gap in understanding the psychological impact on Palestinian children recently displaced to host countries. This study seeks to address that gap by evaluating the prevalence and severity of anxiety and depression among war-displaced Palestinian refugee children and adolescents currently residing in Qatar.
Method
Study design and population
This study employed a cross-sectional design to assess symptoms of anxiety and depression among war-displaced Palestinian children in Qatar who had relocated from Gaza following the events of 7 October 2023. The study was conducted within the residential compound in Al-Thumama designated for the displaced Palestinian families. A total of 350 children aged between 8 and 18 years were recruited using convenience sampling. Participants were eligible if they were (a) of Palestinian descent, (b) currently residing in Qatar due to displacement from war zones and (c) able to provide assent along with parental/guardian consent. Exclusion criteria included cognitive impairment precluding valid questionnaire completion.
Informed written consent was obtained from the parents or legal guardians of all participants before enrolment. In addition to parental consent, informed written assent was sought from each child participant per ethical standards for research involving minors. The nature and purpose of the research were explained in detail, including the voluntary nature of participation and the right to withdraw at any point without consequence.
Participants were assured that their responses would remain confidential. No personally identifiable data were collected or linked to questionnaire responses. All data were anonymised using serial codes. These measures ensured that participants’ privacy and confidentiality were fully maintained throughout the study. Potential risks associated with participation, including psychological discomfort related to the trauma-related questions, were communicated to caregivers. Provisions were made to refer participants to mental health support services if distress arose during data collection.
As compensation, each participant received a 50 Qatari Riyal (approximately 13 USD) grocery voucher. This was intended purely as a humanitarian gesture to acknowledge the time and effort of Palestinian children and young people who had relocated to Qatar in extraordinary circumstances.
Measures
Psychological symptoms were assessed using validated self-report instruments: The Screen for Child Anxiety Related Emotional Disorders-Child Version (SCARED-C) and the Short Mood and Feelings Questionnaire-Child Version (SMFQ-C).
SCARED-C is a 41-item questionnaire that screens for childhood anxiety disorders, including generalised anxiety disorder (GAD), separation anxiety, social phobia, school phobia and panic disorder. Reference Birmaher, Khetarpal, Brent, Marlane, Balach and Kaufman15 Children rate each item on a 3-point Likert scale (0 = not true or hardly ever true, 1 = somewhat true or sometimes true and 2 = very true or often true). Total scores ≥25 suggest clinically significant anxiety, with subscale cut-offs applied for specific anxiety domains. The tool demonstrates high internal consistency (Cronbach’s α = 0.91) and is validated in Arabic-speaking populations. Reference Hariz, Bawab, Atwi, Tavitian, Zeinoun and Khani16,Reference Arab, El Keshky and Hadwin17
The original MFQ is a 33-item child self-report version of the MFQ used to assess depressive symptoms over the past two weeks. Responses are rated as ‘true’, ’sometimes’, or ‘not true’, with total scores ranging from 0 to 66. Scores ≥27 are suggestive of clinically relevant depressive symptoms. The MFQ has strong psychometric properties and has been validated for use in both clinical and research settings among Arabic-speaking children and adolescents. Reference Tavitian, Atwi, Bawab, Hariz, Zeinoun and Khani18 The SMFQ was developed to enhance clinical and epidemiological use. Reference Thapar and McGuffin19 It is a 13-item shortened version of the original 33-item version with parent and child versions. Reference Angold, Costello, Messer and Pickles20 In the present study, we used the child self-report version of the SMFQ, which offers the advantages of brevity, simplicity and ease of administration. Reference Fernández-Martínez, Morales, Méndez, Espada and Orgilés21 The self-reported and parent-reported versions of the MFQs both present a unifactorial structure and good psychometric properties. Reference Messer, Angold, Costello, Loeber, Van Kammen and Stouthamer Loeber22,Reference Fernández-Martínez, Morales, Espada and Orgilés23
To collect background information and assess resilience-related factors, our team developed the Resilience and Demographic Questionnaire (RDQ) in Arabic. Initially compiled in English by experienced bilingual Child and Adolescent Psychiatrists, the questionnaire was translated into Arabic and then reverse-translated by independent bilingual colleagues to ensure linguistic accuracy and contextual integrity. It included items on age, gender, education level, living arrangements, family structure and exposure to traumatic events such as witnessing death or bombings. Resilience was conceptualised through questions on perceived family support, emotional coping strategies and duration of conflict exposure. The tool was piloted with five participants to assess clarity and cultural relevance, with no modifications deemed necessary.
All instruments were administered in Arabic by trained bilingual research team members. Questionnaires were anonymised using coded identifiers.
Statistical analysis
Statistical analysis was conducted using SPSS for Windows, version 26.
For categorical variables, we calculated absolute and relative frequencies and the confidence intervals (for the prevalence of psychiatric disorders). For continuous variables, we calculated the mean, the s.d., as well as the confidence intervals of the mean.
To examine the factors associated with anxiety and depressive symptoms, we constructed multiple linear regression models with the SCARED-C and MFQ total scores respectively as dependent variables; and with the following variables as independent variables: age, gender, formal education, physical injury due to war, currently living with a parent, living with parents before the war, having witnessed the death of a first- or second-degree relative in Gaza, having witnessed the death of any person in Gaza, bombing in their living area and length of exposure to the war in Gaza ≥3 months.
For each of these multiple linear regression models, we determined the unstandardised regression coefficients (β), their confidence intervals, the partial coefficients (r) and the p values. Multiple linear regression assumptions (including linearity, normality of residuals, homoscedasticity and the absence of multicollinearity) were checked.
The defined significance level α was 0.05.
Results
Sociodemographic characteristics of participants (Table 1)
We included 350 participants with a mean age of 12.3 ± 2.9 years, with a gender ratio close to 1:1 (52% males, n = 182). The majority (98.3%, n = 344) had a formal education, and most (95.4%, n = 334) were living with their parents prior to the war. At the time of the study, around two-thirds (66.9%, n = 234) were still living with their parents. Around one third (33.7%, n = 118) sustained a physical injury during the war. Most (80.9%, n = 283) witnessed at least one death in Gaza, including the death of a first- or second-degree relative (67.4%, n = 236). Virtually all (99.4%, n = 348) respondents experienced bombing in their living area, and most were exposed to the war in Gaza for longer than one month (Table 1).
Table 1 Sociodemographic characteristics of participants
Anxiety and depressive symptoms
Figure 1(a) presents the mean rating scale scores and s.d. for various anxiety subtypes and depressive symptoms, as assessed by the SCARED-C and the MFQ, respectively. The mean total SCARED-C score, reflecting overall anxiety symptoms, was 36.3 ± 18.0 (95% CI: 34.4–38.2). The mean MFQ score, indicative of depressive symptoms, was 11.0 ± 6.9 (95% CI: 10.3–11.7).
Fig. 1 (a) Anxiety and depression scores. (b) Prevalence of anxiety disorders and depression. MFQ, Mood and Feelings Questionnaire; SCARED, Screen for Child Anxiety Related Emotional Disorders.
As shown in Fig. 1(b), 70.9% (95% CI: 65.9–75.4%) of participants had a total SCARED-C score above the clinical threshold for an anxiety disorder, while 46.0% (95% CI: 40.8–51.2%) had MFQ scores suggestive of clinically significant depression. Among the specific anxiety subtypes, separation anxiety was the most prevalent, observed in 79.7% of the sample (95% CI: 75.3–83.7%).
Factors associated with anxiety and depressive symptoms (Tables 2 and 3)
Anxiety symptoms were higher in females (β = 4.980 (1.258; 8.702); p = 0.009; r = 0.142) and those who witnessed the death of any person in Gaza (β = 7.400 (1.969; 12.831); p = 0.008; r = 0.144).
Table 2 Multiple linear regression analysis: factors associated with anxiety symptoms
VIF, variance inflation factor. Model: R 2 = 0.087; Adjusted R 2 = 0.060; p < 0.001.
Bold indicates statistically significant findings.
Table 3 Multiple linear regression analysis: factors associated with depressive symptoms
VIF, variance inflation factor. Model: R 2 = 0.161; Adjusted R 2 = 0.136; p < 0.001.
Bold indicates statistically significant findings.
Depressive symptoms were higher in those with a formal education (β = 7.489 (2.127; 12.851); p = 0.006; r = 0.148), those who had a physical injury during the war (β = 1.980 (0.384; 3.576); p = 0.015; r = 0.131), those who used to live not with their parents before war (β = −4.655 (−8.049; −1.262); p = 0.007; r = −0.145) and in those who witnessed the death of any person in Gaza (β = 4.310 (2.307; 6.313); p < 0.001; r = 0.224).
Discussion
This cross-sectional study demonstrates the psychological impact of war-related trauma on the displaced Palestinian refugee youth. Of the participants, 70.9% had clinically significant anxiety symptoms, while 46% had signs suggestive of depressive disorders. These findings align with previous research conducted in Palestinian territories, Reference Elbedour, Onwuegbuzie, Ghannam, Whitcome and Hein24–Reference Kolltveit, Lange-Nielsen, Thabet, Dyregrov, Pallesen and Johnsen26 where depression prevalence has been reported between 40 and 55.6%, and anxiety prevalence has ranged from 33% to as high as 94.9%, the latter reflecting particularly high variability. Such variability may be attributed to differences in trauma type and severity, methodological approaches, the circumstances of the participants at the time of the study and the varied use of assessment tools.
Our findings are also consistent with global data from conflict-affected regions, which similarly report elevated rates of psychiatric morbidity among war-exposed children. For instance, a systematic review and meta-analysis by Attanayake et al found pooled prevalence rates of 43% for depression and 27% for anxiety among 7920 war-exposed children, primarily from the Middle East. Reference Attanayake, McKay, Joffres, Singh, Burkle and Mills27 Kien and colleagues reported similarly high rates among young refugees and asylum seekers in Europe, Reference Kien, Sommer, Faustmann, Gibson, Schneider and Krczal28 while Henkelmann and colleagues found pooled prevalence estimates of 32% for anxiety and 28% for depression among refugee children and adolescents. Reference Henkelmann, de Best, Deckers, Jensen, Shahab and Elzinga29 More recently, in the context of the war in Ukraine, a study reported that 33.3% of adolescents in the conflict-affected Donetsk region exhibited anxiety symptoms, while 35.7% showed signs of depression. Reference Osokina, Silwal, Bohdanova, Hodes, Sourander and Skokauskas30 The study further demonstrated that adolescents in Donetsk were nearly three times more likely to experience severe anxiety and twice as likely to report moderate-to-severe depression compared to peers from non-conflict regions.
Among the various anxiety subtypes assessed, separation anxiety emerged as the most prevalent, affecting nearly 80% of the sample. This is consistent with prior literature showing heightened separation anxiety in children exposed to conflict-related displacement and disasters. Reference Hoven, Duarte, Lucas, Wu, Mandell and Goodwin31,Reference Dimitry32 Such symptoms likely reflect the significant attachment disruptions and instability associated with forced displacement, particularly when children are separated from familiar caregivers, communities and routines.
Girls reported significantly higher anxiety scores than boys, a trend echoed in other post-conflict contexts where girls reported higher levels of separation anxiety, Reference Farbstein, Mansbach-Kleinfeld, Levinson, Goodman, Levav and Vograft33 depression Reference Pat-Horenczyk, Abramovitz, Peled, Brom, Daie and Chemtob34 and general psychological symptoms. Reference Braun-Lewensohn, Sagy and Roth35 This gender difference may be partly explained by sociocultural norms. Boys are often socialised to suppress emotional expression and adopt stoic behaviour, thereby potentially leading to underreporting of distress. Reference Slone and Shechner36
Witnessing the death of any individual in Gaza emerged as the strongest predictor of both anxiety and depressive symptoms, exceeding the psychological impact of physical injury or length of exposure to the conflict. Witnessing violence during childhood has been associated with profound and enduring psychological sequelae, including regression, somatisation, self-blame and social withdrawal. Reference Knapp37 Recent evidence reinforces this, highlighting that exposure to death during war constitutes a severe early-life trauma with long-term consequences, including increased risk of suicidal ideation. Reference Kovnick, Young, Tran, Teerawichitchainan, Tran and Korinek38 The psychological toll of such visual trauma is particularly detrimental in children and adolescents, whose emotional regulation and coping strategies are still developing.
A noteworthy and somewhat counterintuitive finding was the positive association between formal education and elevated depressive symptoms. Several interrelated factors may help explain this relationship. Participants with access to education are typically older and more cognitively mature, and therefore more capable of processing loss, disruption and the existential implications of war. Educational aspirations may also be derailed by displacement, further contributing to feelings of hopelessness. Moreover, the prevalence of depression has been shown to increase with age, particularly during and after puberty, Reference Thapar, Collishaw, Pine and Thapar39 offering a developmental explanation for this association.
In interpreting these findings, it is also important to consider the role of resilience. Although the RDQ used in this study was not a validated resilience scale, it provided important protective contextual insights into pre-war support and chronicity of adversity. Further investigation should aim to validate resilience tools for displaced Palestinian youth, as resilience factors are known to buffer against adverse mental health outcomes in conflict-affected populations. Reference Tol, Song and Jordans40
These findings have important implications for clinical practice, humanitarian response and policy development. There is a clear need to implement trauma-informed, culturally adapted mental health services for war-displaced refugee children, with particular attention to bereavement, separation anxiety and the heightened vulnerabilities observed among girls. The justification for culturally grounded approaches lies in evidence that interventions ignoring sociocultural context often fail to engage communities, whereas culturally integrated models improve both acceptability and outcomes. Reference Miller and Rasmussen41 Integrating such services into schools, primary healthcare settings and community-based programmes may enhance accessibility and continuity of care. The host country context is also an important consideration. War-displaced children’s psychological outcomes are shaped not only by trauma exposure but also by the quality of education, healthcare and integration support available in the host setting. The post-war environment serves as a strong ecological context that can either support or hinder youth resilience by influencing access to protective resources such as community acceptance, family stability and educational opportunities. Reference Tol, Song and Jordans40
In Qatar, both governmental and non-governmental entities have initiated programmes aimed at supporting the educational and psychosocial needs of displaced children. However, sustained investment and targeted support are required to address the long-term mental health needs of displaced children, especially those separated from family or with relatives remaining in high-risk environments. Reference Hedaya42 Future research should prioritise longitudinal designs to clarify the trajectory and persistence of psychological symptoms over time, particularly in relation to time away from the conflict zone, as prior evidence in adults indicates that PTSD and depression can become chronic conditions, persisting for years or even decades, depending on ongoing stressors and length of displacement. Qualitative research may also enrich understanding by capturing children’s lived experiences, coping strategies and perceptions of care in culturally grounded terms. Finally, rigorous evaluations of intervention effectiveness and the development of context-specific, scalable mental health models are essential to inform evidence-based responses in similar humanitarian settings.
This study possesses several methodological strengths. It is among the first to examine the mental health of Palestinian children recently displaced to a host country, thereby contributing new empirical data to a critical yet understudied population. The use of validated and culturally adapted screening instruments (SCARED-C and SMFQ) ensures robust measurement of anxiety and depression symptoms. The large sample size enhances statistical power and allows for subgroup analyses across different age groups and trauma exposures. Furthermore, the inclusion of a comprehensive demographic and resilience questionnaire enabled a more nuanced examination of psychosocial variables relevant to mental health outcomes in war-displaced refugee children.
Nonetheless, a few limitations should be acknowledged. First, the cross-sectional design precludes any determination of causality and limits understanding of symptom progression over time. Longitudinal studies are required to assess changes in mental health status, treatment responsiveness and long-term adaptation. Second, reliance on self-report measures may be subject to bias, including underreporting of distress, particularly among boys, due to social desirability or internalised cultural norms regarding emotional expression. Third, the convenience sampling from a single residential compound may limit generalisability, as the experiences and access to services in this setting may not reflect those of displaced children residing in different host countries. Additionally, severely distressed children may have been less likely to participate, possibly leading to an underestimation of prevalence rates. Finally, while the RDQ provided valuable socioecological context, it has not been formally validated and requires further psychometric evaluation. Moreover, as a structured questionnaire rather than a qualitative tool, it cannot adequately capture the culturally specific concept of sumud, a form of steadfastness rooted in ideology, connection to the land and persistence in struggle, which is central to understanding resilience and well-being among Palestinian youth. Reference Steel, Chey, Silove, Marnane, Bryant and van Ommeren43
Future directions
This study reveals alarmingly high rates of anxiety and depressive symptoms among war-displaced Palestinian refugee children and adolescents resettled in Qatar, highlighting the profound psychological toll of armed conflict, forced displacement and exposure to death and destruction. Separation anxiety emerged as the most prevalent anxiety subtype, and witnessing death was the most significant predictor of both anxiety and depressive symptoms. These findings echo a consistent body of international evidence highlighting the elevated mental health burden borne by children and adolescents affected by war. While our research contributes valuable insights into the mental health needs of war-displaced Palestinian youth, its implications go far beyond clinical concern. The enduring and cumulative trauma experienced by these children cannot be addressed through mental health interventions alone. It demands urgent global action, most critically, an immediate end to the violence in the region. No amount of psychological support can substitute for safety and the right of children to live free from fear. Mental health professionals must advocate not only for trauma-informed care and psychosocial support but also for justice, protection and peace.
Data availability
The data that support the findings of this study are not publicly available due to ethical and privacy restrictions.
Acknowledgement
We thank all participants and their families for participating in this study.
Author contributions
M.A.S.K.: conceptualisation; data curation; formal analysis; methodology; writing – original draft. Y.A.: conceptualisation; data curation; methodology; writing – original draft. O.S.: conceptualisation; data collection, methodology; S.O.: data curation; data analysis. M.A.A.A.: methodology, data collection. A.H.M.E.: data collection. M. Abdelkader: data collection. T.T.: data collection. A.A.A.E.: data collection. A.W.K.: conceptualisation; methodology. M. Alabdulla: conceptualisation and supervision. Y.S.K.: conceptualisation; methodology; data collection; supervision; writing – review and editing, supervision. All authors contributed to manuscript revision and read and approved the submitted version.
Funding
We acknowledge the Medical Research Center (MRC) at Hamad Medical Corporation, for providing funding to cover the cost of 50 QAR grocery vouchers given to each participant as a token of appreciation. Qatar National Library funded the open access publication of this article.
Declaration of interest
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. All procedures involving human subjects were approved by the MRC at Hamad Medical Corporation (IRB-MRC-01-24-256).
Open access
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