Post-Traumatic Stress and ADHD Symptoms Among Children in the Gaza Strip Since 2023: A Cross-Sectional Study

Post-Traumatic Stress and ADHD Symptoms Among Children in the Gaza Strip Since 2023: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Post-Traumatic Stress and ADHD Symptoms Among Children in the Gaza Strip Since 2023: A Cross-Sectional Study Abdalrahman Ajjur, Younis Elijla, Aya Abu Samak, Shayan Ali, Afnan Alsadoni, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8941410/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Armed conflict exposes children to repeated traumatic events that may substantially increase the risk of psychological disorders. In the Gaza Strip, prolonged hostilities since October 2023 have resulted in widespread displacement, physical injury, bereavement, and severe socioeconomic disruption. Post-traumatic stress disorder (PTSD) and attention-deficit/hyperactivity disorder (ADHD) are among the most commonly reported psychiatric conditions in conflict-affected children. However, few studies have directly compared mental health outcomes between physically injured and non-injured children within the same war-exposed population. This study aimed to assess the prevalence and severity of PTSD and ADHD symptoms among children in Gaza and to examine associations with injury status, socioeconomic factors, and maternal mental health. Methods A cross-sectional study was conducted between April and October 2025 across four governorates in the Gaza Strip. A total of 603 children and adolescents aged 1–17 years were recruited using convenience sampling from schools, hospitals, clinics, and displacement shelters. ADHD symptoms were assessed using the Arabic version of the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS), and PTSD symptoms were measured using the Arabic Child PTSD Symptom Scale for DSM-5 (CPSS-V). Descriptive statistics, t-tests, non-parametric tests, ANOVA, and correlation analyses were performed using R (version 4.3.1). Statistical significance was defined as p < 0.05. Results Among 603 participants (median age 9 years; 52.1% male), 45.4% had sustained conflict-related physical injuries. Injured children had significantly higher PTSD symptom severity compared to non-injured children (median 30 vs 17; p < 0.001). Lower socioeconomic status and poorer maternal mental health were strongly associated with higher PTSD severity (p < 0.001). ADHD symptom scores were significantly higher in males (p < 0.001) and were inversely associated with parental education. A moderate positive correlation was observed between ADHD and PTSD symptom severity (ρ = 0.54, p < 0.001). Conclusions Children in Gaza exposed to armed conflict demonstrate substantial PTSD and ADHD symptom burden, particularly those with physical injuries, lower socioeconomic status, and maternal psychological distress. The coexistence of ADHD and PTSD symptoms highlights the need for integrated, trauma-informed mental health interventions in conflict settings. These findings underscore the urgent necessity for targeted psychological screening and support services for war-affected children. Figures Figure 1 Figure 2 Figure 3 Introduction The mental well-being of children is influenced by a number of factors, including socio-economic status, family environment, and education. 1 Such influences may however dramatically change in contexts of war and armed conflict. Armed conflict can disrupt the social, economic, and environmental conditions necessary to healthy well-being, and often weakens or even reverses the protective effects of factors that typically support children's mental health. 2 Children living in conflict zones are often exposed to prolonged stressors and repeated traumatic events that can affect their physical and psychological state and health. The escalation of armed hostilities in the Gaza strip since October 2023 that has lasted well over two years has resulted in extensive destruction of civilian infrastructure, including schools, shelters, tents, and homes, and has led to widespread forced displacement, loss of life, and left children particularly vulnerable to a wide range of mental health disorders. 3 – 8 Among the most common disorders observed among children in conflict-zones are post-traumatic stress disorder (PTSD) and attention-deficit/hyperactivity disorder (ADHD). 9 – 13 PTSD is a psychiatric disorder that can arise after direct or indirect exposure to traumatic events. 14 – 16 Symptoms can include intrusive memories, flashbacks, nightmares, avoidance behaviors, hyperarousal, and emotional numbing, which can impact developmental stages, cognition, and daily life. 17 , 18 ADHD on the other hand is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity, which often has reported to result in academic underachievement, interpersonal difficulties, and increased vulnerability to further psychological stressors. 19 – 22 Children exposed to prolonged conflict may experience PTSD and ADHD symptoms either independently or concurrently, thus making diagnosis and treatment more challenging. The mechanisms through which war can contribute to PTSD and ADHD in children are multifactorial. Direct exposure to life-threatening events, witnessing death or injury of family members, destruction of homes, and forced displacement can overwhelm a child’s coping capacities, thus triggering chronic stress responses. 23 , 24 Prolonged exposure to such stress can disrupt neurodevelopment, impair executive functioning, and sensitize the brain to hyperarousal, increasing vulnerability to both PTSD and ADHD. 25 , 26 Additionally, chronic stressors that often arise as a consequence of armed conflict, such as poverty, interrupted schooling, and lack of social support, could worsen psychological vulnerability and may affect the severity and expression of symptoms. 27 – 29 If left unaddressed, PTSD can lead to chronic anxiety, depression, impaired social relationships, academic difficulties, and increased risk of substance abuse or behavioral problems in adolescence and adulthood. Untreated ADHD may persist, leading to continued academic underachievement, interpersonal difficulties, and higher vulnerability to additional stressors. The coexistence of PTSD and ADHD is particularly concerning, as several studies have reported an increased risk of developing PTSD in individuals already diagnosed with ADHD, which can sometimes complicate clinical presentation and treatment planning. 30 Research from occupied Palestine, including the Gaza Strip and West Bank, have shown a high rate of PTSD among children exposed to conditions of military occupation and armed conflict, ranging from 6% to 70% depending on exposure severity and timing. 31 , 32 Despite growing research into children's mental health in areas of armed, few studies have directly investigated whether war-related physical injuries contribute to higher rates or increased severity of PTSD and ADHD in children. Many existing studies focus either on the general population of children or on those with physical injuries, without necessarily comparing the two groups. This leaves a significant gap in understanding how physical trauma interacts with potential disability and psychological stressors amid conditions of armed conflict. Recognition and investigation of such differences is important for developing targeted interventions, informing mental health policy, and appropriately allocating resources to support the most at-risk children. Given the lengthy duration and scale of casualties during the Israeli military assault on Gaza, and the extensive exposure of children to both direct physical injuries and indirect trauma, this study aims to compare the prevalence and severity of PTSD and ADHD between physically injured and non-injured children. It also seeks to examine how injury severity, trauma exposure, and sociodemographic factors may impact mental health outcomes. Methods Study design and sample size A cross-sectional study was conducted in the Gaza strip between April and October 2025 to assess the mental health impact of the Israeli military invasion on children. The primary objective of our study was to assess the prevalence and severity of post-traumatic stress disorder (PTSD) and attention-deficit/hyperactivity disorder (ADHD) symptoms in physically injured versus non-injured children exposed to war related trauma. To determine a statistically robust sample size, the Raosoft online sample size calculator was applied as a reference. Assuming a 95% confidence level, a 5% margin of error, and a 50% response distribution for a large population, the calculated minimum required sample size was 385 participants. The study's initial target, as outlined in the proposal, was set higher at approximately 500 children to ensure adequate statistical power for comparing injured and non-injured groups. A convenience sampling method was utilized due to severe practical constraints and risks to personal safety within Gaza, which made random sampling methodologies infeasible. A total of 603 children were successfully recruited and completed the questionnaires, significantly exceeding both the calculated minimum and the initial target. All 603 responses were deemed complete and were included in the final analysis. The findings are therefore representative of the sampled population, though generalizability may be limited due to the non-probability sampling approach. Study population and sampling technique A convenience sampling approach was employed to recruit participants from accessible locations, including schools, hospitals, medical clinics, and temporary shelters across four governorates of the Gaza strip (Khan Yunis, Deir El-Balah, Gaza, and North Gaza). Rafah was not included due to most of its population having been displaced or ethnically cleansed by the time of this study. This method was chosen due to the urgent and unstable nature of population groups amid repeated displacement events, and the limitations on access to comprehensive population rosters that prevented the implementation of systematic random sampling. The study intentionally included two primary subgroups: children who had sustained physical injuries due to the recent armed hostilities and those who had not. This purposive aspect of the sampling was critical to achieving the study's primary objective of comparing mental health outcomes between these two groups. While convenience sampling can introduce selection bias, this approach was one of the only viable methods to gather timely data in such an acute humanitarian emergency. Recruitment and data collection This study targeted children and adolescents aged 1 to 17 years residing in the Gaza strip who had been exposed to conflict-related traumatic events. Informed consent was obtained from parents and/or legal guardians, and assent from included children whenever possible. Exclusion criteria included the presence of pre-existing health conditions or disabilities that were unrelated to the current war and could confound the assessment of ADHD or PTSD symptoms, such as intellectual disabilities, autism spectrum disorder (ASD), epilepsy, or severe neurological impairments. Data collection was conducted using a structured, interviewer-administered questionnaire. The survey was administered in Arabic by a trained team of seven medical students from the Islamic University of Gaza (IUG) and Al-Azhar University in Gaza. The use of trained interviewers helped ensure consistency and clarity, particularly given the sensitive nature of the topics and the wide age range of the child participants. At the beginning of each interview, the research team provided a detailed informed consent statement to the parent or guardian, explaining the purpose of the study, the confidentiality of responses, and the voluntary nature of participation. Only after written consent was obtained did the interview proceed. No personal identifiers were collected in the final dataset, and all responses were anonymized for analysis. Study tool A structured, multi-part questionnaire administered in Arabic was used for data collection, comprising four sections. Section 1 captured sociodemographic and contextual details, including the child's age and gender, paternal and maternal education level, displacement, socioeconomic status, the child's injury status, prenatal history (e.g., gestational hypertension), and current medication use. Section 2 assessed ADHD symptoms using the Arabic version of the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS). 33 This section included items covering the core domains of inattention (9 items, e.g., "Fails to give close attention to details"), hyperactivity-impulsivity (9 items, e.g., "Leaves seat in situations when remaining seated is expected"), and co-morbid symptoms of oppositional/conduct disorder (e.g., "Argues with adults") and anxiety/depression. Section 3 evaluated PTSD symptoms using an Arabic of the Child PTSD Symptom Scale for DSM-V (CPSS-V SR). 34 This scale assesses the 20 symptoms of PTSD outlined in the DSM-5, grouped into clusters of re-experiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. The scale was preceded by a checklist of potentially traumatic events to contextualize the child's exposure The traumatic event checklist included standardized operationally defined exposure categories. Severe events or insults were defined as direct personal exposure to acute, life threatening incidents or severe verbal or physical abuse. Witnessing a family member being insulted was defined as an individual observing a parent, sibling, or other immediate relative being subjected to humiliation, harassment, interrogation, or physical degradation. Loss of loved one due to violence was defined as bereavement of an immediate family member or close friend attributable to conflict-related violence. Frightening medical procedures were defined as exposure to painful or invasive medical interventions conducted under traumatic conditions, such as emergency surgery without adequate anesthesia, wound debridement, or treatment in overcrowded or resourced limited facilities. Experienced bullying or other frightening events referred to non-combat related threats or peer victimization that induced substantial fear, including harassment or intimidations, within shelters or displacement settings. These definitions were provided to interviewers to ensure consistent interpretation and standardized data collection across study sites. Section 4 assessed the child's functional performance in academic and social domains. Parents rated their child's performance in areas such as general academic achievement, reading, writing, and mathematics, as well as the quality of their relationships with parents and peers. Content validity for the custom-developed sections was ensured through a review process during the initial study proposal phase. Pilot study A pilot study was conducted prior to the main data collection phase to assess the clarity, validity, and reliability of the Arabic-language questionnaire. Sixty children, 30 from the injured group and 30 from the non-injured group, participated in the pilot study. Based on feedback from the interviewers and parents, minor revisions were made to improve item clarity and comprehension, particularly for questions related to socioeconomic status and maternal mental health. Responses from the pilot group were excluded from the final analysis to avoid bias. The pilot study confirmed that the interviewer-administered format was effective and that the questionnaire was well-understood by the target population. Reliability analysis for the main scales demonstrated good internal consistency, with Cronbach’s alpha values of 0.88 for the VADPRS and 0.91 for the CPSS-V SR, confirming that the instruments were reliable for use in this population. Item scoring For the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Child PTSD Symptom Scale (CPSS-V SR), items were rated on a 4-point frequency scale, with responses scored from 0 (Never) to 3 (Always/All the time). Total scores for each scale and its subscales were calculated by summing the scores of the relevant items. Higher scores indicate greater symptom severity. For the academic and social performance section, items were rated on a 5-point scale from 1 (Severe difficulty) to 5 (Excellent), with higher scores indicating better functioning. Ethics approval This study was approved by the Human Resources Department at the Palestinian Ministry of Health, which serves as the primary ethics review body for health-related research in the region. Administrative approvals were also secured from the District Directors of schools in the Gaza Strip. The first part of the interview included a detailed informed consent process. Parents or legal guardians were informed of the study's objectives, the voluntary nature of participation, and assurances of confidentiality. They were also informed that their decision to decline or withdraw from the study at any point would not result in any negative consequences. Written consent was obtained from all participants' legal guardians. No identifiable personal information was collected in the final dataset, ensuring that all responses remained anonymous. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Statistical analysis All statistical analyses were performed using R, a language and environment for statistical computing (Version 4.3.1). A p-value of less than 0.05 was considered statistically significant for all inferential tests. Descriptive statistics were first calculated to summarize the sample's sociodemographic characteristics and the primary clinical outcomes. Frequencies and percentages were used for categorical variables (e.g., gender, parental education level), while measures of central tendency and dispersion, including means, standard deviations (SD), medians, and interquartile ranges (IQR), were used for continuous variables (e.g., age, symptom scale scores). The choice between parametric and non-parametric tests was guided by the distribution of the data. The Shapiro-Wilk test was used to assess the normality of continuous variables. For normally distributed data, independent t-tests were used to compare means between two independent groups (e.g., gender differences in ADHD scores), and one-way analysis of variance (ANOVA) was used for comparisons across more than two groups (e.g., effect of paternal education on ADHD scores). For data that were not normally distributed, the non-parametric equivalents were employed: the Wilcoxon rank-sum (Mann-Whitney U) test was used for two-group comparisons (e.g., effect of injury status on PTSD scores), and the Kruskal-Wallis test was used for comparisons across more than two groups (e.g., effect of socioeconomic status on PTSD scores). When a significant result was found with ANOVA or Kruskal-Wallis tests, post-hoc tests with Bonferroni correction were conducted to identify which specific groups differed. The relationship between continuous variables was assessed using correlation analysis. Pearson's correlation coefficient (r) was used for linear relationships between normally distributed variables, while Spearman's rank correlation coefficient (ρ) was used for non-normally distributed variables or to assess monotonic relationships (e.g., correlation between ADHD and PTSD total scores). Results Data was collected on 603 children and adolescents, of whom 52.1% were male and 47.9% were female, with a median age of 9 years (IQR 7–11; range 1–17 years). Just over one-third were currently receiving medication (35.5%), whereas most were not (59.7%) and a small proportion were described as “probably” taking medication (4.8%). Nearly half of the sample had a history of injury requiring medical attention (45.4%). Prenatal and parental characteristics showed that 8.3% of participants were born preterm and 11.4% were exposed to gestational hypertension. Paternal smoking was common, occurring in approximately one-third of families, while maternal smoking during pregnancy was extremely rare (n = 2). Socioeconomic status was largely self-reported as fair (44.4%) or poor (24.2%) with smaller proportions reporting very good or excellent SES. The majority of parents had obtained at least secondary education. 82.4% had experienced severe events or insults, 78.4% had witnessed a family member being insulted, 63.1% had lost a loved one due to violence, 60.8% had undergone frightening medical procedures, and approximately 45% had experienced bullying or other frightening events. The median Vanderbilt ADHD total score was 77 (IQR 62–91; range 17–145), while the median CPSS PTSD symptom score was 23 (IQR 12–31; range 0–51). The 15-item PTSD exposure score had a median of 27 (IQR 23–28; range 18–30). Detailed sample characteristics are presented below ( Table 1 ). Table 1. Distribution of sociodemographic and clinical characteristics of the study participants (n=603). Characteristic Category n / Value % Gender Male 314 52.07 Female 289 47.93 Age (years) Mean ± SD 8.89 ± 2.59 Median (IQR) 9 (7–11) Range 1–17 Paternal education University 299 49.6 Secondary 198 32.8 Elementary 63 10.4 No formal education 43 7.1 Maternal education University 351 58.2 Secondary 197 32.7 Elementary 43 7.1 No formal education 12 2.0 Socioeconomic status Excellent 40 6.6 Very good 149 24.7 Fair 268 44.4 Poor 146 24.2 Maternal mental health Excellent 66 10.9 Very good 197 32.7 Fair 263 43.6 Poor 77 12.8 Living in area of high-intensity armed conflict Yes 536 88.89 No 67 11.11 Injury status Injured 274 45.44 Not injured 329 54.56 Gestational hypertension Present 69 11.44 Absent 534 88.56 Maternal smoking Yes 2 0.33 No 601 99.67 Paternal smoking Yes 205 34.00 No 398 66.00 Receiving medication Yes 214 35.49 No 360 59.70 Vanderbilt ADHD score Mean ± SD 76.85 ± 22.00 Median (IQR) 77 (62–91) Range 17–145 CPSS PTSD score Mean ± SD 22.29 ± 13.00 Median (IQR) 23 (12–31) Range 0–51 Note: ADHD = Attention-Deficit/Hyperactivity Disorder; CPSS = Child PTSD Symptom Scale; PTSD = Post-Traumatic Stress Disorder; SD = Standard Deviation; IQR = Interquartile Range. ADHD Symptom Severity An analysis of demographic variables revealed several significant associations with ADHD symptom severity ( Table 2 ). A significant difference was found between genders, with males (M = 80.45, SD = 21.04) exhibiting higher Vanderbilt ADHD scores than females (M = 72.94, SD = 19.18; t = 4.58, p <0.001). A weak negative correlation was observed between age and ADHD scores (r = -0.03, p=0.41), indicating no meaningful relationship. Parental education was strongly associated with ADHD symptoms. A one-way ANOVA revealed a significant effect of paternal educational level (F(3, 599) = 6.78, p < 0.001). Post-hoc tests indicated that children of fathers with a university education had significantly lower ADHD scores compared to children whose fathers had secondary, elementary, or no formal education. Similarly, maternal educational level showed a highly significant effect (F(3, 599) = 9.69, p < 0.001). The strongest association found in this study was between maternal mental health and child PTSD symptoms (χ²(3) = 68.49, p < 0.001). PTSD symptom severity in children increased progressively and substantially with poorer maternal mental health. Children of mothers with "fair" or "poor" mental health had significantly higher PTSD scores than children of mothers with "excellent" or "very good" mental health. The relationship between living in an area of high-intensity armed conflict (e.g., areas under direct evacuation orders, red zones, or active large-scale armed hostilities) and ADHD symptoms was examined. Children living in areas of high-intensity armed conflict had slightly higher mean ADHD scores (M = 77.44, SD = 20.03) than those living elsewhere in Gaza (M = 72.07, SD = 23.53); however, this difference did not reach statistical significance (t = 1.79, p = 0.078). Table 2. Vanderbilt ADHD Symptom Severity by Demographic and Environmental Factors Variable Category / Group n Mean ± SD Test p-value Summary Interpretation Gender Male 314 80.45 ± 21.04 t = 4.58 <0.001 Higher ADHD scores in males Female 289 72.94 ± 19.18 Age Continuous 603 — ρ = −0.03 0.41 No association with ADHD severity Paternal education University 299 75.5 ± 21.5 F = 6.78 <0.001 Lower ADHD scores with higher paternal education Secondary 198 79.5 ± 22.0 Elementary 63 81.0 ± 21.0 No education 43 84.0 ± 23.0 Maternal education University 351 73.5 ± 21.0 F = 9.69 <0.001 Inverse gradient between maternal education and ADHD severity Secondary 197 80.0 ± 22.5 Elementary 43 82.5 ± 21.5 No education 12 95.0 ± 20.0 High-intensity armed conflict Yes 536 77.44 ± 20.03 t = 1.79 0.078 Non-significant trend toward higher scores No 67 72.07 ± 23.53 Abbreviations: ADHD = Attention-Deficit/Hyperactivity Disorder; SD = Standard Deviation. ANOVA post-hoc comparisons performed using Tukey’s HSD test. Statistical significance set at p < 0.05. PTSD Symptom Severity Analyses of PTSD symptoms, as measured by the CPSS scale, identified several key demographic, clinical, and environmental factors associated with symptom severity ( Table 3 ). A statistically significant but small difference in PTSD scores was found between genders, with males (M = 23.34, SD = 12.91) reporting slightly higher symptom severity than females (M = 21.14, SD = 13.05; t = 2.08, p = 0.038). In contrast to ADHD symptoms, age was not significantly correlated with PTSD symptom severity (ρ = -0.06, p = 0.13), and no significant differences were found across age groups. Injury status was strongly associated with PTSD. A Wilcoxon rank-sum test revealed that injured participants reported substantially higher PTSD scores (Mdn = 30.0) compared to non-injured participants (Mdn = 17.0; W = 70,532, p < 0.001). No significant association was found between PTSD symptoms and a history of gestational hypertension or parental smoking. Socioeconomic status (SES) was significantly associated with PTSD severity (χ²(3) = 33.40, p < 0.001). Post-hoc comparisons showed that participants from "fair" and "poor" socioeconomic backgrounds had significantly higher PTSD scores than those from "excellent" or "very good" backgrounds, indicating that lower SES is a risk factor for higher PTSD symptoms . Table 3. Factors Associated with PTSD Symptom Severity (CPSS Scores) Variable Comparison / Groups Test Used Test Statistic p-value Summary Interpretation Gender Male vs Female Independent t-test t = 2.08 0.038 Slightly higher PTSD symptom severity in males Age Continuous Spearman correlation ρ = −0.06 0.13 No significant association with PTSD severity Injury status Injured vs Not injured Wilcoxon rank-sum test W = 70,532 <0.001 Significantly higher PTSD severity among injured children Gestational hypertension Present vs Absent Wilcoxon rank-sum test W = 19,613 0.382 No significant association with PTSD severity Parental smoking Smoking vs Non-smoking Wilcoxon rank-sum test W = 19,613 0.382 No significant association with PTSD severity Socioeconomic status Excellent to Poor Kruskal–Wallis test χ²(3) = 33.40 <0.001 Higher PTSD severity with lower socioeconomic status Maternal mental health Excellent to Poor Kruskal–Wallis test χ²(3) = 68.49 <0.001 Strong gradient showing higher PTSD severity with poorer maternal mental health Abbreviations: CPSS = Child PTSD Symptom Scale; PTSD = Post-Traumatic Stress Disorder. Statistical significance defined as p < 0.05. Relationship between ADHD and PTSD Symptoms The correlation between ADHD and PTSD symptom severity was assessed using two different PTSD measures ( Table 4 ). Using the CPSS scale, a Spearman's rank correlation revealed a moderate, statistically significant positive correlation between Vanderbilt ADHD scores and CPSS PTSD scores (ρ = 0.54, p < 0.001). This indicates that higher ADHD symptom severity is associated with more severe PTSD symptomatology (Figure 1). In contrast, the analysis using a custom PTSD questionnaire found a weak, significant negative correlation (ρ = -0.28, p < 0.001), which is attributable to the opposite scoring direction of that particular instrument. Table 4. Correlation Between ADHD and PTSD Symptom Severity Measures Variables Compared PTSD Measure Correlation Coefficient (ρ) p-value Interpretation Vanderbilt ADHD score CPSS PTSD score 0.54 <0.001 Moderate positive correlation indicating higher PTSD severity with increasing ADHD symptoms Vanderbilt ADHD score Custom PTSD questionnaire -0.28 <0.001 Weak negative correlation due to inverse scoring direction of the questionnaire Abbreviations: ADHD = Attention-Deficit/Hyperactivity Disorder; PTSD = Post-Traumatic Stress Disorder; CPSS = Child PTSD Symptom Scale. Spearman’s rank correlation coefficient (ρ) was used. Statistical significance was set at p < 0.05. Figure 1. Relationship between PTSD symptoms (CPSS score) and ADHD symptom burden (Vanderbilt ADHD total score.) Discussion This study describes a cohort of 603 children and adolescents diagnosed with ADHD with a median age of 9 years in the Gaza strip during the ongoing Israeli military assault. Data was collected between April 2025-October 2025. ADHD assessments were conducted across multiple governorates, including Khan Yunis, Deir El-Balah, Gaza City, and North Gaza, within schools, hospitals, outpatient medical clinics, and temporary displacement shelters. Three findings in particular merit emphasis. All of the children assessed within this cohort had been exposed to armed conflict, with 45.4% of children having a prior history of injury—this was strongly associated with PTSD. This is consistent with other literature documenting that bodily injury is a significant risk factor for PTSD in comparison to uninjured counterparts, with the risk of PTSD in injured children ranging from 13-45% in civilian populations. 35,36 Childhood adversity and environmental stressor likely contribute to the development of PTSD and pre-existing psychiatric conditions (Figure 2). 37 Figure 2. Conceptual model of how war-related physical injury may elevate child PTSD symptom severity, with maternal mental health potentially buffering or amplifying this association. Physical injury is not only an acute traumatic exposure but can also function as a chronic stressor that may manifest as PTSD over time. Injury severity and post-injury stressors play a central role in the development of delayed PTSD. In Gaza where the necessary environment for a stable recovery, safety, and rehabilitation is repeatedly disrupted, and where injury-related stress remains largely unresolved, there remains the likelihood of persistent PTSD symptom burden. 38 A statistically significant difference but small difference was reported between genders in our study, with males reporting slightly higher symptom severity than females likely due to differing social roles with younger males often having a higher exposure to certain forms of violence due to greater outdoor exposure. 39 The elevated exposure of males to traumatic events has also been observed in other conflict settings such as Uganda, Syria, Sri Lanka, and Rwanda. 40 One important finding in our study was the inverse relationship between maternal mental health and child PTSD symptoms. Poor maternal mental health was linked to higher PTSD scores in children likely due to negative parenting behaviors such as abuse, parental stress and household instability due to bereavement shapes long-term psychological outcomes in children impacting emotional regulation. 41–43 A study conducted in Gaza in 2008 further corroborates our findings as it similarly reported war trauma and parents’ emotional responses being associated with children’s anxiety and PTSD-related symptoms. 44 With all of our participants experiencing significant traumatic events, their PTSD risk is likely amplified as a direct relationship has been previously documented with traumatic exposure and PTSD. 45 Previous studies in Gaza (based on past Israeli military invasions of the besieged enclave) have also reported an elevated prevalence of PTSD among children, some estimating that 9.8% of children having complete symptoms of PTSD and 39.3% having partial symptoms. 45 Over half of Gaza’s children likely have PTSD, in part due to the loss of family members and continued exposure to traumatic events, the likes of which have not been experienced to this scale in prior armed hostilities in and around the Gaza strip. 31,46 Socioeconomic status (SES) was also significantly associated with PTSD severity in our study, with 68.6% of our participants likely being at risk for PTSD due to their economic status being ranked as either poor or fair. SES can manifest it in Gaza today through food insecurity, residence in a tent, frequent displacement, rather than solely income loss. Low SES has a bidirectional relationship with PTSD severity, likely due to the fact SES increases the chance for traumatic exposure and food insecurity, with internal displacement presenting itself as a traumatic stressor. People who are displaced more than once might also be more at risk for developing PTSD since they are more likely to encounter repeated episodes of war-related trauma and violence. 47,48 In addition to this, PTSD is correlated to food insecurity, perhaps partly even due to its adverse impact on cognitive function impairing decision making capabilities and reducing searching and benefiting from aid pathways (however minimal they may be). 49–51 The ongoing armed conflict has prompted children to often retrieve aid for their families, due to disability, injury, incapacity, or death of parental figures who may otherwise participate in such tasks. A broader conceptual synthesis linking war exposure, PTSD symptom severity, and ADHD symptom burden is shown below ( Figure 3 ) . Figure 3. Conceptual synthesis of pathways linking war exposure to PTSD symptom severity and ADHD symptom burden in war-exposed children This study's findings align somewhat with studies from other conflict zones. An analysis from the Syrian Civil War investigating PTSD in children documents internal displacement, exposure to violence, and loss of family members as significant risk factors for PTSD. 52 Similar associations between structural deprivation and poor mental health outcomes have also been documented in a systematic review from sub-Saharan Africa, which identified food insecurity as a key contributor to PTSD in children and adolescents. 53 These factors are also present in the Gaza strip but often have occurred in greater magnitude with over 90% of the population having been internally displaced at some point, the entire population exposed to some level of armed conflict, at least 77% suffering from food insecurity at certain points, and over 80% from loss or injury of family members due to the ethnic cleansing carried out by the Israeli military. 54–58 These chronic stressors likely exert a cascading effect on maternal mental health as shown in our study. A study conducted on over 50,000 refugee children in Denmark showcased that paternal PTSD is associated with increased risk of psychiatric disorders in offspring, including PTSD. 59 This is particularly relevant in Gaza given the number of studies that have pointed to high rates of anxiety, depression, stress, and trauma among Palestinian adults. 4,60–62 Aside from deprivation of the essential components of life that weave into the social determinants of health, prior history of injury has also been noted to be a risk factor for PTSD, as one study in Northwest Ethiopia has displayed. 63 This aligns with our study with children and adolescents being disproportionately affected from the war in Gaza with the region hosting the largest number of child amputees globally. 64,65 Collectively these patterns accentuate the humanitarian crisis in the Gaza Strip with near universal exposure to displacement, food insecurity and war related trauma likely amplifying the risk of PTSD beyond that observed in other conflict settings. Several limitations of this study should be noted. Firstly, since our study utilizes a cross sectional design, we can not necessarily infer a causative analysis. ADHD symptoms, PTSD symptoms, and injury history may have bidirectional correlations which were not entirely analyzed. In addition to this, we utilized convenience sampling, which may introduce a sort of selection bias and may not be representative of all children in Gaza (though this is mitigated in large part due to the extreme circumstances well documented). Furthermore, injury and trauma severity was reported largely by the caregiver, introducing the possibility of misclassification. Fourth, ADHD and PTSD was measured using self-report as described by caregivers rather than necessarily a clinical diagnosis. This is important since trauma related symptoms such as deficient sleep, pain, and router factors can exacerbate ADHD symptoms. Environmental stressors such as food insecurity, household loss, and displacement were not fully examined, and so therefore confounding is possible. Declarations Ethics approval and consent to participate The study was approved by the Human Resources Department at the Palestinian Ministry of Health, the primary ethics review body for health research in the Gaza Strip. Administrative approvals were obtained from District School Directors. Written informed consent was secured from parents or legal guardians, and assent from participating children when feasible. Participation was voluntary, with the right to decline or withdraw at any time. No personal identifiers were collected, and all data were anonymized prior to analysis. The study adhered to the principles of the Declaration of Helsinki. Consent for publication Not applicable. No identifiable individual data are included. Availability of data and materials The dataset is not publicly available due to the sensitive nature of data collected from minors in a conflict setting and the risk of deductive disclosure. De-identified data may be available from the corresponding author upon reasonable request, subject to ethics approval and a data-use agreement. Competing interests The authors declare no competing interests. Funding No specific funding was received for this study. Author Contributions: Abdalrahman Ajjur: conceptualization, data curation, writing - review & editing Younis Elijla: conceptualization, data curation, writing - review & editing Aya Abu Samak: conceptualization, data curation, writing - review & editing Shayan Ali: conceptualization, writing - original draft, writing - review & editing Afnan Alsadoni: conceptualization, data curation, writing - review & editing Nedaa Altelbani: conceptualization, data curation, writing - review & editing Shahd Ahmed: conceptualization, data curation, writing - review & editing Eman Ayyad: conceptualization, data curation, writing - review & editing Hadeel Alawar: conceptualization, data curation, writing - review & editing Israa Mezyed: conceptualization, data curation, writing - review & editing Hamzah Alattar: conceptualization, data curation, writing - review & editing Mohammed Abudiab: conceptualization, data curation, writing - review & editing Sohaib Al-Zaharna: conceptualization, data curation, writing - review & editing Bilal Irfan: conceptualization, supervision, writing - review & editing Acknowledgements: We would like to thank Dr. Moayed Jouda for his support. 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East Mediterr Health J 2025; 31 : 89–96. Madoro D, Kerebih H, Habtamu Y, et al. Post-Traumatic Stress Disorder and Associated Factors Among Internally Displaced People in South Ethiopia: A Cross-Sectional Study. NDT 2020; Volume 16 : 2317–26. Ali M, Mutavi T, Mburu JM, Mathai M. Prevalence of Posttraumatic Stress Disorder and Depression Among Internally Displaced Persons in Mogadishu-Somalia. NDT 2023; Volume 19 : 469–78. Brewster GS, Peterson L, Roker R, Ellis ML, Edwards JD. Depressive Symptoms, Cognition, and Everyday Function Among Community-Residing Older Adults. J Aging Health 2017; 29 : 367–88. Sumner JA, Hagan K, Grodstein F, Roberts AL, Harel B, Koenen KC. Posttraumatic stress disorder symptoms and cognitive function in a large cohort of middle-aged women: S umner et al . Depress Anxiety 2017; 34 : 356–66. Hage Boutros P, Hachem S, Bou Serhal R, Yazbeck N, Azzam F, Atallah B. 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Famine confirmed for first time in Gaza. https://www.who.int/news/item/22-08-2025-famine-confirmed-for-first-time-in-gaza (accessed Oct 9, 2025). ‘Tragedy foretold and stain on our collective humanity’: Special Rapporteur warns of mass ethnic cleansing in the West Bank. United Nations Human Rights Office of the High Commissioner. 2025; published online March 18. https://www.ohchr.org/en/press-releases/2025/03/tragedy-foretold-and-stain-our-collective-humanity-special-rapporteur-warns (accessed Feb 5, 2026). Amnesty International concludes Israel is committing genocide against Palestinians in Gaza. Amnesty International. 2024; published online Dec 5. https://www.amnesty.org/en/latest/news/2024/12/amnesty-international-concludes-israel-is-committing-genocide-against-palestinians-in-gaza/ (accessed May 23, 2025). UNRWA Situation Report #184 on the Humanitarian Crisis in the Gaza Strip and the West Bank, including East Jerusalem. United Nations | The Question of Palestine. 2025; published online Aug 15. https://www-un-org.proxy.lib.umich.edu/unispal/document/unrwa-sitrep-184-15aug25/ (accessed Feb 5, 2026). Back Nielsen M, Carlsson J, Køster Rimvall M, Petersen JH, Norredam M. Risk of childhood psychiatric disorders in children of refugee parents with post-traumatic stress disorder: a nationwide, register-based, cohort study. The Lancet Public Health 2019; 4 : e353–9. Aldabbour B, Helles YR, Abu Warda NM, et al. Trauma, environmental insecurity, and coping strategies as determinants of sleep disturbances among adults in Gaza during wartime. Egypt J Neurol Psychiatry Neurosurg 2026; 62 : 4. Aldabbour B, El-Jamal M, Abuabada A, et al. The Psychological Toll of War and Forced Displacement in Gaza: A Study on Anxiety, PTSD, and Depression. Chronic Stress (Thousand Oaks) 2025; 9 : 24705470251334943. Aldabbour B, Abuabada A, Lahlouh A, et al. Psychological impacts of the Gaza war on Palestinian young adults: a cross-sectional study of depression, anxiety, stress, and PTSD symptoms. BMC Psychology 2024; 12 : 696. Simie D, Azale T, Gashaw F, Wondie M, Gebeyehu DA, Mekuriaw BY. Post-traumatic stress disorder symptoms among youths in war-affected areas of Northeast Ethiopia. BMC Psychiatry 2025; 25 : 871. Daniele L. Infanticide in the Name of Proportionality: Gaza as a World Order Problem. Georgetown Journal of International Affairs. 2025; published online Sept 26. https://gjia.georgetown.edu/2025/09/26/infanticide-in-the-name-of-proportionality-gaza-as-a-world-order-problem/ (accessed Feb 5, 2026). Irfan B, Habal M. Challenging the Narrative: Are Children “Collateral” in War? Journal of Craniofacial Surgery 2026; 37 : 393–4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 02 Apr, 2026 Editor invited by journal 05 Mar, 2026 Editor assigned by journal 04 Mar, 2026 Submission checks completed at journal 04 Mar, 2026 First submitted to journal 22 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8941410","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617768824,"identity":"614e571b-0dd6-4785-8172-63aaf9a6c191","order_by":0,"name":"Abdalrahman Ajjur","email":"","orcid":"","institution":"Al-Azhar University – Gaza","correspondingAuthor":false,"prefix":"","firstName":"Abdalrahman","middleName":"","lastName":"Ajjur","suffix":""},{"id":617768825,"identity":"81dcc9e6-f906-4ce5-a993-84446e222554","order_by":1,"name":"Younis 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20:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8941410/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8941410/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106534051,"identity":"073e213d-cff2-49e9-9f4b-24cbfcaf964f","added_by":"auto","created_at":"2026-04-09 15:01:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":108329,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelationship between PTSD symptoms (CPSS score) and ADHD symptom burden (Vanderbilt ADHD total score.)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8941410/v1/f3bc6880c09bf79a8941cfc4.png"},{"id":106534052,"identity":"5961a169-453e-4016-85c1-b64e05290f50","added_by":"auto","created_at":"2026-04-09 15:01:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":275893,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual model of how war-related physical injury may elevate child PTSD symptom severity, with maternal mental health potentially buffering or amplifying this association.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8941410/v1/4de8294cf040ffa14ebf5955.png"},{"id":106534053,"identity":"e6668ef8-ee51-4df5-9547-4dfc6e94414c","added_by":"auto","created_at":"2026-04-09 15:01:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":449364,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual synthesis of pathways linking war exposure to PTSD symptom severity and ADHD symptom burden in war-exposed children\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8941410/v1/63f7c238f58c7981a0b0728d.png"},{"id":106724800,"identity":"7da20c39-0430-4d62-bb48-c383466efb7a","added_by":"auto","created_at":"2026-04-12 18:29:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2168988,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8941410/v1/821f35a3-c4b0-4b15-9f92-9c121d16a5aa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Post-Traumatic Stress and ADHD Symptoms Among Children in the Gaza Strip Since 2023: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe mental well-being of children is influenced by a number of factors, including socio-economic status, family environment, and education.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Such influences may however dramatically change in contexts of war and armed conflict. Armed conflict can disrupt the social, economic, and environmental conditions necessary to healthy well-being, and often weakens or even reverses the protective effects of factors that typically support children's mental health.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Children living in conflict zones are often exposed to prolonged stressors and repeated traumatic events that can affect their physical and psychological state and health. The escalation of armed hostilities in the Gaza strip since October 2023 that has lasted well over two years has resulted in extensive destruction of civilian infrastructure, including schools, shelters, tents, and homes, and has led to widespread forced displacement, loss of life, and left children particularly vulnerable to a wide range of mental health disorders.\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Among the most common disorders observed among children in conflict-zones are post-traumatic stress disorder (PTSD) and attention-deficit/hyperactivity disorder (ADHD).\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePTSD is a psychiatric disorder that can arise after direct or indirect exposure to traumatic events.\u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Symptoms can include intrusive memories, flashbacks, nightmares, avoidance behaviors, hyperarousal, and emotional numbing, which can impact developmental stages, cognition, and daily life.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e ADHD on the other hand is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity, which often has reported to result in academic underachievement, interpersonal difficulties, and increased vulnerability to further psychological stressors.\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Children exposed to prolonged conflict may experience PTSD and ADHD symptoms either independently or concurrently, thus making diagnosis and treatment more challenging.\u003c/p\u003e \u003cp\u003eThe mechanisms through which war can contribute to PTSD and ADHD in children are multifactorial. Direct exposure to life-threatening events, witnessing death or injury of family members, destruction of homes, and forced displacement can overwhelm a child\u0026rsquo;s coping capacities, thus triggering chronic stress responses.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Prolonged exposure to such stress can disrupt neurodevelopment, impair executive functioning, and sensitize the brain to hyperarousal, increasing vulnerability to both PTSD and ADHD.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Additionally, chronic stressors that often arise as a consequence of armed conflict, such as poverty, interrupted schooling, and lack of social support, could worsen psychological vulnerability and may affect the severity and expression of symptoms.\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e If left unaddressed, PTSD can lead to chronic anxiety, depression, impaired social relationships, academic difficulties, and increased risk of substance abuse or behavioral problems in adolescence and adulthood. Untreated ADHD may persist, leading to continued academic underachievement, interpersonal difficulties, and higher vulnerability to additional stressors. The coexistence of PTSD and ADHD is particularly concerning, as several studies have reported an increased risk of developing PTSD in individuals already diagnosed with ADHD, which can sometimes complicate clinical presentation and treatment planning.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch from occupied Palestine, including the Gaza Strip and West Bank, have shown a high rate of PTSD among children exposed to conditions of military occupation and armed conflict, ranging from 6% to 70% depending on exposure severity and timing.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Despite growing research into children's mental health in areas of armed, few studies have directly investigated whether war-related physical injuries contribute to higher rates or increased severity of PTSD and ADHD in children. Many existing studies focus either on the general population of children or on those with physical injuries, without necessarily comparing the two groups. This leaves a significant gap in understanding how physical trauma interacts with potential disability and psychological stressors amid conditions of armed conflict. Recognition and investigation of such differences is important for developing targeted interventions, informing mental health policy, and appropriately allocating resources to support the most at-risk children.\u003c/p\u003e \u003cp\u003eGiven the lengthy duration and scale of casualties during the Israeli military assault on Gaza, and the extensive exposure of children to both direct physical injuries and indirect trauma, this study aims to compare the prevalence and severity of PTSD and ADHD between physically injured and non-injured children. It also seeks to examine how injury severity, trauma exposure, and sociodemographic factors may impact mental health outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sample size\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted in the Gaza strip between April and October 2025 to assess the mental health impact of the Israeli military invasion on children. The primary objective of our study was to assess the prevalence and severity of post-traumatic stress disorder (PTSD) and attention-deficit/hyperactivity disorder (ADHD) symptoms in physically injured versus non-injured children exposed to war related trauma. To determine a statistically robust sample size, the Raosoft online sample size calculator was applied as a reference. Assuming a 95% confidence level, a 5% margin of error, and a 50% response distribution for a large population, the calculated minimum required sample size was 385 participants. The study's initial target, as outlined in the proposal, was set higher at approximately 500 children to ensure adequate statistical power for comparing injured and non-injured groups. A convenience sampling method was utilized due to severe practical constraints and risks to personal safety within Gaza, which made random sampling methodologies infeasible. A total of 603 children were successfully recruited and completed the questionnaires, significantly exceeding both the calculated minimum and the initial target. All 603 responses were deemed complete and were included in the final analysis. The findings are therefore representative of the sampled population, though generalizability may be limited due to the non-probability sampling approach.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population and sampling technique\u003c/h3\u003e\n\u003cp\u003eA convenience sampling approach was employed to recruit participants from accessible locations, including schools, hospitals, medical clinics, and temporary shelters across four governorates of the Gaza strip (Khan Yunis, Deir El-Balah, Gaza, and North Gaza). Rafah was not included due to most of its population having been displaced or ethnically cleansed by the time of this study. This method was chosen due to the urgent and unstable nature of population groups amid repeated displacement events, and the limitations on access to comprehensive population rosters that prevented the implementation of systematic random sampling. The study intentionally included two primary subgroups: children who had sustained physical injuries due to the recent armed hostilities and those who had not. This purposive aspect of the sampling was critical to achieving the study's primary objective of comparing mental health outcomes between these two groups. While convenience sampling can introduce selection bias, this approach was one of the only viable methods to gather timely data in such an acute humanitarian emergency.\u003c/p\u003e\n\u003ch3\u003eRecruitment and data collection\u003c/h3\u003e\n\u003cp\u003eThis study targeted children and adolescents aged 1 to 17 years residing in the Gaza strip who had been exposed to conflict-related traumatic events. Informed consent was obtained from parents and/or legal guardians, and assent from included children whenever possible. Exclusion criteria included the presence of pre-existing health conditions or disabilities that were unrelated to the current war and could confound the assessment of ADHD or PTSD symptoms, such as intellectual disabilities, autism spectrum disorder (ASD), epilepsy, or severe neurological impairments.\u003c/p\u003e \u003cp\u003eData collection was conducted using a structured, interviewer-administered questionnaire. The survey was administered in Arabic by a trained team of seven medical students from the Islamic University of Gaza (IUG) and Al-Azhar University in Gaza. The use of trained interviewers helped ensure consistency and clarity, particularly given the sensitive nature of the topics and the wide age range of the child participants. At the beginning of each interview, the research team provided a detailed informed consent statement to the parent or guardian, explaining the purpose of the study, the confidentiality of responses, and the voluntary nature of participation. Only after written consent was obtained did the interview proceed. No personal identifiers were collected in the final dataset, and all responses were anonymized for analysis.\u003c/p\u003e\n\u003ch3\u003eStudy tool\u003c/h3\u003e\n\u003cp\u003eA structured, multi-part questionnaire administered in Arabic was used for data collection, comprising four sections. Section 1 captured sociodemographic and contextual details, including the child's age and gender, paternal and maternal education level, displacement, socioeconomic status, the child's injury status, prenatal history (e.g., gestational hypertension), and current medication use.\u003c/p\u003e \u003cp\u003eSection 2 assessed ADHD symptoms using the Arabic version of the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS).\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e This section included items covering the core domains of inattention (9 items, e.g., \"Fails to give close attention to details\"), hyperactivity-impulsivity (9 items, e.g., \"Leaves seat in situations when remaining seated is expected\"), and co-morbid symptoms of oppositional/conduct disorder (e.g., \"Argues with adults\") and anxiety/depression.\u003c/p\u003e \u003cp\u003eSection 3 evaluated PTSD symptoms using an Arabic of the Child PTSD Symptom Scale for DSM-V (CPSS-V SR).\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e This scale assesses the 20 symptoms of PTSD outlined in the DSM-5, grouped into clusters of re-experiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. The scale was preceded by a checklist of potentially traumatic events to contextualize the child's exposure\u003c/p\u003e \u003cp\u003eThe traumatic event checklist included standardized operationally defined exposure categories. Severe events or insults were defined as direct personal exposure to acute, life threatening incidents or severe verbal or physical abuse. Witnessing a family member being insulted was defined as an individual observing a parent, sibling, or other immediate relative being subjected to humiliation, harassment, interrogation, or physical degradation. Loss of loved one due to violence was defined as bereavement of an immediate family member or close friend attributable to conflict-related violence. Frightening medical procedures were defined as exposure to painful or invasive medical interventions conducted under traumatic conditions, such as emergency surgery without adequate anesthesia, wound debridement, or treatment in overcrowded or resourced limited facilities. Experienced bullying or other frightening events referred to non-combat related threats or peer victimization that induced substantial fear, including harassment or intimidations, within shelters or displacement settings. These definitions were provided to interviewers to ensure consistent interpretation and standardized data collection across study sites.\u003c/p\u003e \u003cp\u003eSection 4 assessed the child's functional performance in academic and social domains. Parents rated their child's performance in areas such as general academic achievement, reading, writing, and mathematics, as well as the quality of their relationships with parents and peers. Content validity for the custom-developed sections was ensured through a review process during the initial study proposal phase.\u003c/p\u003e\n\u003ch3\u003ePilot study\u003c/h3\u003e\n\u003cp\u003eA pilot study was conducted prior to the main data collection phase to assess the clarity, validity, and reliability of the Arabic-language questionnaire. Sixty children, 30 from the injured group and 30 from the non-injured group, participated in the pilot study. Based on feedback from the interviewers and parents, minor revisions were made to improve item clarity and comprehension, particularly for questions related to socioeconomic status and maternal mental health. Responses from the pilot group were excluded from the final analysis to avoid bias. The pilot study confirmed that the interviewer-administered format was effective and that the questionnaire was well-understood by the target population. Reliability analysis for the main scales demonstrated good internal consistency, with Cronbach\u0026rsquo;s alpha values of 0.88 for the VADPRS and 0.91 for the CPSS-V SR, confirming that the instruments were reliable for use in this population.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eItem scoring\u003c/h2\u003e \u003cp\u003eFor the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Child PTSD Symptom Scale (CPSS-V SR), items were rated on a 4-point frequency scale, with responses scored from 0 (Never) to 3 (Always/All the time). Total scores for each scale and its subscales were calculated by summing the scores of the relevant items. Higher scores indicate greater symptom severity. For the academic and social performance section, items were rated on a 5-point scale from 1 (Severe difficulty) to 5 (Excellent), with higher scores indicating better functioning.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics approval\u003c/h3\u003e\n\u003cp\u003eThis study was approved by the Human Resources Department at the Palestinian Ministry of Health, which serves as the primary ethics review body for health-related research in the region. Administrative approvals were also secured from the District Directors of schools in the Gaza Strip. The first part of the interview included a detailed informed consent process. Parents or legal guardians were informed of the study's objectives, the voluntary nature of participation, and assurances of confidentiality. They were also informed that their decision to decline or withdraw from the study at any point would not result in any negative consequences. Written consent was obtained from all participants' legal guardians. No identifiable personal information was collected in the final dataset, ensuring that all responses remained anonymous. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using R, a language and environment for statistical computing (Version 4.3.1). A p-value of less than 0.05 was considered statistically significant for all inferential tests. Descriptive statistics were first calculated to summarize the sample's sociodemographic characteristics and the primary clinical outcomes. Frequencies and percentages were used for categorical variables (e.g., gender, parental education level), while measures of central tendency and dispersion, including means, standard deviations (SD), medians, and interquartile ranges (IQR), were used for continuous variables (e.g., age, symptom scale scores). The choice between parametric and non-parametric tests was guided by the distribution of the data. The Shapiro-Wilk test was used to assess the normality of continuous variables. For normally distributed data, independent t-tests were used to compare means between two independent groups (e.g., gender differences in ADHD scores), and one-way analysis of variance (ANOVA) was used for comparisons across more than two groups (e.g., effect of paternal education on ADHD scores). For data that were not normally distributed, the non-parametric equivalents were employed: the Wilcoxon rank-sum (Mann-Whitney U) test was used for two-group comparisons (e.g., effect of injury status on PTSD scores), and the Kruskal-Wallis test was used for comparisons across more than two groups (e.g., effect of socioeconomic status on PTSD scores). When a significant result was found with ANOVA or Kruskal-Wallis tests, post-hoc tests with Bonferroni correction were conducted to identify which specific groups differed. The relationship between continuous variables was assessed using correlation analysis. Pearson's correlation coefficient (r) was used for linear relationships between normally distributed variables, while Spearman's rank correlation coefficient (ρ) was used for non-normally distributed variables or to assess monotonic relationships (e.g., correlation between ADHD and PTSD total scores).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eData was collected on 603 children and adolescents, of whom 52.1% were male and 47.9% were female, with a median age of 9 years (IQR 7\u0026ndash;11; range 1\u0026ndash;17 years). Just over one-third were currently receiving medication (35.5%), whereas most were not (59.7%) and a small proportion were described as \u0026ldquo;probably\u0026rdquo; taking medication (4.8%). Nearly half of the sample had a history of injury requiring medical attention (45.4%). Prenatal and parental characteristics showed that 8.3% of participants were born preterm and 11.4% were exposed to gestational hypertension. Paternal smoking was common, occurring in approximately one-third of families, while maternal smoking during pregnancy was extremely rare (n = 2).\u003c/p\u003e\n\u003cp\u003eSocioeconomic status was largely self-reported as fair (44.4%) or poor (24.2%) with smaller proportions reporting very good or excellent SES. The majority of parents had obtained at least secondary education. 82.4% had experienced severe events or insults, 78.4% had witnessed a family member being insulted, 63.1% had lost a loved one due to violence, 60.8% had undergone frightening medical procedures, and approximately 45% had experienced bullying or other frightening events. The median Vanderbilt ADHD total score was 77 (IQR 62\u0026ndash;91; range 17\u0026ndash;145), while the median CPSS PTSD symptom score was 23 (IQR 12\u0026ndash;31; range 0\u0026ndash;51). The 15-item PTSD exposure score had a median of 27 (IQR 23\u0026ndash;28; range 18\u0026ndash;30). Detailed sample characteristics are presented below (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Distribution of sociodemographic and clinical characteristics of the study participants (n=603).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"420\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en / Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e52.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e47.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8.89 \u0026plusmn; 2.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e9 (7\u0026ndash;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u0026ndash;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePaternal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMaternal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e351\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e58.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSocioeconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eFair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMaternal mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eFair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eLiving in area of high-intensity armed conflict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e88.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInjury status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eInjured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e45.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNot injured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e329\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e54.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eGestational hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e11.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e88.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMaternal smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e601\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e99.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePaternal smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e34.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e66.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eReceiving medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e35.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e59.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eVanderbilt ADHD score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e76.85 \u0026plusmn; 22.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e77 (62\u0026ndash;91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e17\u0026ndash;145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCPSS PTSD score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e22.29 \u0026plusmn; 13.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e23 (12\u0026ndash;31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0\u0026ndash;51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: ADHD = Attention-Deficit/Hyperactivity Disorder; CPSS = Child PTSD Symptom Scale; PTSD = Post-Traumatic Stress Disorder; SD = Standard Deviation; IQR = Interquartile Range.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eADHD Symptom Severity\u003c/h2\u003e\n\u003cp\u003eAn analysis of demographic variables revealed several significant associations with ADHD symptom severity (\u003cstrong\u003eTable 2\u003c/strong\u003e). A significant difference was found between genders, with males (M = 80.45, SD = 21.04) exhibiting higher Vanderbilt ADHD scores than females (M = 72.94, SD = 19.18; t = 4.58, p \u0026lt;0.001). A weak negative correlation was observed between age and ADHD scores (r = -0.03, p=0.41), indicating no meaningful relationship.\u003c/p\u003e\n\u003cp\u003eParental education was strongly associated with ADHD symptoms. A one-way ANOVA revealed a significant effect of paternal educational level (F(3, 599) = 6.78, p \u0026lt; 0.001). Post-hoc tests indicated that children of fathers with a university education had significantly lower ADHD scores compared to children whose fathers had secondary, elementary, or no formal education. Similarly, maternal educational level showed a highly significant effect (F(3, 599) = 9.69, p \u0026lt; 0.001). The strongest association found in this study was between maternal mental health and child PTSD symptoms (\u0026chi;\u0026sup2;(3) = 68.49, p \u0026lt; 0.001). PTSD symptom severity in children increased progressively and substantially with poorer maternal mental health. Children of mothers with \u0026quot;fair\u0026quot; or \u0026quot;poor\u0026quot; mental health had significantly higher PTSD scores than children of mothers with \u0026quot;excellent\u0026quot; or \u0026quot;very good\u0026quot; mental health.\u003c/p\u003e\n\u003cp\u003eThe relationship between living in an area of high-intensity armed conflict (e.g., areas under direct evacuation orders, red zones, or active large-scale armed hostilities) and ADHD symptoms was examined. Children living in areas of high-intensity armed conflict had slightly higher mean ADHD scores (M = 77.44, SD = 20.03) than those living elsewhere in Gaza (M = 72.07, SD = 23.53); however, this difference did not reach statistical significance (t = 1.79, p = 0.078).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Vanderbilt ADHD Symptom Severity by Demographic and Environmental Factors\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory / Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSummary Interpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e80.45 \u0026plusmn; 21.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003et = 4.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eHigher ADHD scores in males\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e72.94 \u0026plusmn; 19.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e603\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026rho; = \u0026minus;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eNo association with ADHD severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003ePaternal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e75.5 \u0026plusmn; 21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eF = 6.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eLower ADHD scores with higher paternal education\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e79.5 \u0026plusmn; 22.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e81.0 \u0026plusmn; 21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e84.0 \u0026plusmn; 23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMaternal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e351\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e73.5 \u0026plusmn; 21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eF = 9.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eInverse gradient between maternal education and ADHD severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e80.0 \u0026plusmn; 22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e82.5 \u0026plusmn; 21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e95.0 \u0026plusmn; 20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eHigh-intensity armed conflict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e77.44 \u0026plusmn; 20.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003et = 1.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eNon-significant trend toward higher scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e72.07 \u0026plusmn; 23.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: ADHD = Attention-Deficit/Hyperactivity Disorder; SD = Standard Deviation. ANOVA post-hoc comparisons performed using Tukey\u0026rsquo;s HSD test. Statistical significance set at p \u0026lt; 0.05.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003ePTSD Symptom Severity\u003c/h2\u003e\n\u003cp\u003eAnalyses of PTSD symptoms, as measured by the CPSS scale, identified several key demographic, clinical, and environmental factors associated with symptom severity (\u003cstrong\u003eTable 3\u003c/strong\u003e). A statistically significant but small difference in PTSD scores was found between genders, with males (M = 23.34, SD = 12.91) reporting slightly higher symptom severity than females (M = 21.14, SD = 13.05; t = 2.08, p = 0.038). In contrast to ADHD symptoms, age was not significantly correlated with PTSD symptom severity (\u0026rho; = -0.06, p = 0.13), and no significant differences were found across age groups.\u003c/p\u003e\n\u003cp\u003eInjury status was strongly associated with PTSD. A Wilcoxon rank-sum test revealed that injured participants reported substantially higher PTSD scores (Mdn = 30.0) compared to non-injured participants (Mdn = 17.0; W = 70,532, p \u0026lt; 0.001). No significant association was found between PTSD symptoms and a history of gestational hypertension or parental smoking.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSocioeconomic status (SES) was significantly associated with PTSD severity (\u0026chi;\u0026sup2;(3) = 33.40, p \u0026lt; 0.001). Post-hoc comparisons showed that participants from \u0026quot;fair\u0026quot; and \u0026quot;poor\u0026quot; socioeconomic backgrounds had significantly higher PTSD scores than those from \u0026quot;excellent\u0026quot; or \u0026quot;very good\u0026quot; backgrounds, indicating that lower SES is a risk factor for higher PTSD symptoms .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Factors Associated with PTSD Symptom Severity (CPSS Scores)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparison / Groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest Used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest Statistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSummary Interpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eMale vs Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eIndependent t-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003et = 2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eSlightly higher PTSD symptom severity in males\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eSpearman correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026rho; = \u0026minus;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eNo significant association with PTSD severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eInjury status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eInjured vs Not injured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eWilcoxon rank-sum test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eW = 70,532\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eSignificantly higher PTSD severity among injured children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eGestational hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ePresent vs Absent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eWilcoxon rank-sum test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eW = 19,613\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eNo significant association with PTSD severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eParental smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eSmoking vs Non-smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eWilcoxon rank-sum test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eW = 19,613\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eNo significant association with PTSD severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSocioeconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eExcellent to Poor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eKruskal\u0026ndash;Wallis test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;(3) = 33.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eHigher PTSD severity with lower socioeconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMaternal mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eExcellent to Poor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eKruskal\u0026ndash;Wallis test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;(3) = 68.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 182px;\"\u003e\n \u003cp\u003eStrong gradient showing higher PTSD severity with poorer maternal mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: CPSS = Child PTSD Symptom Scale; PTSD = Post-Traumatic Stress Disorder. Statistical significance defined as p \u0026lt; 0.05.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eRelationship between ADHD and PTSD Symptoms\u003c/h2\u003e\n\u003cp\u003eThe correlation between ADHD and PTSD symptom severity was assessed using two different PTSD measures (\u003cstrong\u003eTable 4\u003c/strong\u003e). Using the CPSS scale, a Spearman\u0026apos;s rank correlation revealed a moderate, statistically significant positive correlation between Vanderbilt ADHD scores and CPSS PTSD scores (\u0026rho; = 0.54, p \u0026lt; 0.001). This indicates that higher ADHD symptom severity is associated with more severe PTSD symptomatology (Figure 1). In contrast, the analysis using a custom PTSD questionnaire found a weak, significant negative correlation (\u0026rho; = -0.28, p \u0026lt; 0.001), which is attributable to the opposite scoring direction of that particular instrument.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Correlation Between ADHD and PTSD Symptom Severity Measures\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eVariables Compared\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003ePTSD Measure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eCorrelation Coefficient (\u0026rho;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 241px;\"\u003e\n \u003cp\u003eInterpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eVanderbilt ADHD score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eCPSS PTSD score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 241px;\"\u003e\n \u003cp\u003eModerate positive correlation indicating higher PTSD severity with increasing ADHD symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eVanderbilt ADHD score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eCustom PTSD questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 241px;\"\u003e\n \u003cp\u003eWeak negative correlation due to inverse scoring direction of the questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: ADHD = Attention-Deficit/Hyperactivity Disorder; PTSD = Post-Traumatic Stress Disorder; CPSS = Child PTSD Symptom Scale. Spearman\u0026rsquo;s rank correlation coefficient (\u0026rho;) was used. Statistical significance was set at p \u0026lt; 0.05.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1. Relationship between PTSD symptoms (CPSS score) and ADHD symptom burden (Vanderbilt ADHD total score.)\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study describes a cohort of 603 children and adolescents diagnosed with ADHD with a median age of 9 years in the Gaza strip during the ongoing Israeli military assault. Data was collected between April 2025-October 2025. ADHD assessments were conducted across multiple governorates, including Khan Yunis, Deir El-Balah, Gaza City, and North Gaza, within schools, hospitals, outpatient medical clinics, and temporary displacement shelters. Three findings in particular merit emphasis. All of the children assessed within this cohort had been exposed to armed conflict, with 45.4% of children having a prior history of injury\u0026mdash;this was strongly associated with PTSD. This is consistent with other literature documenting that bodily injury is a significant risk factor for PTSD in comparison to uninjured counterparts, with the risk of PTSD in injured children ranging from 13-45% in civilian populations.\u003csup\u003e35,36\u003c/sup\u003e Childhood adversity and environmental stressor likely contribute to the development of PTSD and pre-existing psychiatric conditions (Figure 2).\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2. \u003c/strong\u003eConceptual model of how war-related physical injury may elevate child PTSD symptom severity, with maternal mental health potentially buffering or amplifying this association.\u003c/p\u003e\n\u003cp\u003ePhysical injury is not only an acute traumatic exposure but can also function as a chronic stressor that may manifest as PTSD over time. Injury severity and post-injury stressors play a central role in the development of delayed PTSD. In Gaza where the necessary environment for a stable recovery, safety, and rehabilitation is repeatedly disrupted, and where injury-related stress remains largely unresolved, there remains the likelihood of persistent PTSD symptom burden.\u003csup\u003e38\u003c/sup\u003e A statistically significant difference but small difference was reported between genders in our study, with males reporting slightly higher symptom severity than females likely due to differing social roles with younger males often having a higher exposure to certain forms of violence due to greater outdoor exposure.\u003csup\u003e39\u003c/sup\u003e The elevated exposure of males to traumatic events has also been observed in other conflict settings such as Uganda, Syria, Sri Lanka, and Rwanda.\u003csup\u003e40\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOne important finding in our study was the inverse relationship between maternal mental health and child PTSD symptoms. Poor maternal mental health was linked to higher PTSD scores in children likely due to negative parenting behaviors such as abuse, parental stress and household instability due to bereavement shapes long-term psychological outcomes in children impacting emotional regulation.\u003csup\u003e41\u0026ndash;43\u003c/sup\u003e A study conducted in Gaza in 2008 further corroborates our findings as it similarly reported war trauma and parents\u0026rsquo; emotional responses being associated with children\u0026rsquo;s anxiety and PTSD-related symptoms.\u003csup\u003e44\u003c/sup\u003e With all of our participants experiencing significant traumatic events, their PTSD risk is likely amplified as a direct relationship has been previously documented with traumatic exposure and PTSD.\u003csup\u003e45\u003c/sup\u003e Previous studies in Gaza (based on past Israeli military invasions of the besieged enclave) have also reported an elevated prevalence of PTSD among children, some estimating that 9.8% of children having complete symptoms of PTSD and 39.3% having partial symptoms.\u003csup\u003e45\u003c/sup\u003e Over half of Gaza\u0026rsquo;s children likely have PTSD, in part due to the loss of family members and continued exposure to traumatic events, the likes of which have not been experienced to this scale in prior armed hostilities in and around the Gaza strip.\u003csup\u003e31,46\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSocioeconomic status (SES) was also significantly associated with PTSD severity in our study, with 68.6% of our participants likely being at risk for PTSD due to their economic status being ranked as either poor or fair. SES can manifest it in Gaza today through food insecurity, residence in a tent, frequent displacement, rather than solely income loss. Low SES has a bidirectional relationship with PTSD severity, likely due to the fact SES increases the chance for traumatic exposure and food insecurity, with internal displacement presenting itself as a traumatic stressor. People who are displaced more than once might also be more at risk for developing PTSD since they are more likely to encounter repeated episodes of war-related trauma and violence.\u003csup\u003e47,48\u003c/sup\u003e In addition to this, PTSD is correlated to food insecurity, perhaps partly even due to its adverse impact on cognitive function impairing decision making capabilities and reducing searching and benefiting from aid pathways (however minimal they may be).\u003csup\u003e49\u0026ndash;51\u003c/sup\u003e The ongoing armed conflict has prompted children to often retrieve aid for their families, due to disability, injury, incapacity, or death of parental figures who may otherwise participate in such tasks. A broader conceptual synthesis linking war exposure, PTSD symptom severity, and ADHD symptom burden is shown below (\u003cstrong\u003eFigure 3\u003c/strong\u003e)\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3. \u003c/strong\u003eConceptual synthesis of pathways linking war exposure to PTSD symptom severity and ADHD symptom burden in war-exposed children\u003c/p\u003e\n\u003cp\u003eThis study\u0026apos;s findings align somewhat with studies from other conflict zones. An analysis from the Syrian Civil War investigating PTSD in children documents internal displacement, exposure to violence, and loss of family members as significant risk factors for PTSD.\u003csup\u003e52\u003c/sup\u003e Similar associations between structural deprivation and poor mental health outcomes have also been documented in a systematic review from sub-Saharan Africa, which identified food insecurity as a key contributor to PTSD in children and adolescents.\u003csup\u003e53\u003c/sup\u003e These factors are also present in the Gaza strip but often have occurred in greater magnitude with over 90% of the population having been internally displaced at some point, the entire population exposed to some level of armed conflict, at least 77% suffering from food insecurity at certain points, and over 80% from loss or injury of family members due to the ethnic cleansing carried out by the Israeli military.\u003csup\u003e54\u0026ndash;58\u003c/sup\u003e These chronic stressors likely exert a cascading effect on maternal mental health as shown in our study. A study conducted on over 50,000 refugee children in Denmark showcased that paternal PTSD is associated with increased risk of psychiatric disorders in offspring, including PTSD.\u003csup\u003e59\u003c/sup\u003e This is particularly relevant in Gaza given the number of studies that have pointed to high rates of anxiety, depression, stress, and trauma among Palestinian adults.\u003csup\u003e4,60\u0026ndash;62\u003c/sup\u003e Aside from deprivation of the essential components of life that weave into the social determinants of health, prior history of injury has also been noted to be a risk factor for PTSD, as one study in Northwest Ethiopia has displayed.\u003csup\u003e63\u003c/sup\u003e This aligns with our study with children and adolescents being disproportionately affected from the war in Gaza with the region hosting the largest number of child amputees globally.\u003csup\u003e64,65\u003c/sup\u003e Collectively these patterns accentuate the humanitarian crisis in the Gaza Strip with near universal exposure to displacement, food insecurity and war related trauma likely amplifying the risk of PTSD beyond that observed in other conflict settings.\u003c/p\u003e\n\u003cp\u003eSeveral limitations of this study should be noted. Firstly, since our study utilizes a cross sectional design, we can not necessarily infer a causative analysis. ADHD symptoms, PTSD symptoms, and injury history may have bidirectional correlations which were not entirely analyzed. In addition to this, we utilized convenience sampling, which may introduce a sort of selection bias and may not be representative of all children in Gaza (though this is mitigated in large part due to the extreme circumstances well documented). Furthermore, injury and trauma severity was reported largely by the caregiver, introducing the possibility of misclassification. Fourth, ADHD and PTSD was measured using self-report as described by caregivers rather than necessarily a clinical diagnosis. This is important since trauma related symptoms such as deficient sleep, pain, and router factors can exacerbate ADHD symptoms. Environmental stressors such as food insecurity, household loss, and displacement were not fully examined, and so therefore confounding is possible. \u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study was approved by the Human Resources Department at the Palestinian Ministry of Health, the primary ethics review body for health research in the Gaza Strip. Administrative approvals were obtained from District School Directors. Written informed consent was secured from parents or legal guardians, and assent from participating children when feasible. Participation was voluntary, with the right to decline or withdraw at any time. No personal identifiers were collected, and all data were anonymized prior to analysis. The study adhered to the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable. No identifiable individual data are included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The dataset is not publicly available due to the sensitive nature of data collected from minors in a conflict setting and the risk of deductive disclosure. De-identified data may be available from the corresponding author upon reasonable request, subject to ethics approval and a data-use agreement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No specific funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbdalrahman Ajjur:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYounis Elijla:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAya Abu Samak:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShayan Ali:\u003c/strong\u003e conceptualization, writing - original draft, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAfnan Alsadoni:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNedaa Altelbani:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShahd Ahmed:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEman Ayyad:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHadeel Alawar:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIsraa Mezyed:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHamzah Alattar:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohammed Abudiab:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSohaib Al-Zaharna:\u003c/strong\u003e conceptualization, data curation, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBilal Irfan:\u003c/strong\u003e conceptualization, supervision, writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe would like to thank Dr. Moayed Jouda for his support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGr\u0026uuml;ning Parache L, Vogel M, Meigen C, Kiess W, Poulain T. 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Challenging the Narrative: Are Children \u0026ldquo;Collateral\u0026rdquo; in War? \u003cem\u003eJournal of Craniofacial Surgery\u003c/em\u003e 2026; \u003cstrong\u003e37\u003c/strong\u003e: 393\u0026ndash;4.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8941410/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8941410/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eArmed conflict exposes children to repeated traumatic events that may substantially increase the risk of psychological disorders. In the Gaza Strip, prolonged hostilities since October 2023 have resulted in widespread displacement, physical injury, bereavement, and severe socioeconomic disruption. Post-traumatic stress disorder (PTSD) and attention-deficit/hyperactivity disorder (ADHD) are among the most commonly reported psychiatric conditions in conflict-affected children. However, few studies have directly compared mental health outcomes between physically injured and non-injured children within the same war-exposed population. This study aimed to assess the prevalence and severity of PTSD and ADHD symptoms among children in Gaza and to examine associations with injury status, socioeconomic factors, and maternal mental health.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted between April and October 2025 across four governorates in the Gaza Strip. A total of 603 children and adolescents aged 1–17 years were recruited using convenience sampling from schools, hospitals, clinics, and displacement shelters. ADHD symptoms were assessed using the Arabic version of the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS), and PTSD symptoms were measured using the Arabic Child PTSD Symptom Scale for DSM-5 (CPSS-V). Descriptive statistics, t-tests, non-parametric tests, ANOVA, and correlation analyses were performed using R (version 4.3.1). Statistical significance was defined as p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eAmong 603 participants (median age 9 years; 52.1% male), 45.4% had sustained conflict-related physical injuries. Injured children had significantly higher PTSD symptom severity compared to non-injured children (median 30 vs 17; p \u0026lt; 0.001). Lower socioeconomic status and poorer maternal mental health were strongly associated with higher PTSD severity (p \u0026lt; 0.001). ADHD symptom scores were significantly higher in males (p \u0026lt; 0.001) and were inversely associated with parental education. A moderate positive correlation was observed between ADHD and PTSD symptom severity (ρ = 0.54, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eChildren in Gaza exposed to armed conflict demonstrate substantial PTSD and ADHD symptom burden, particularly those with physical injuries, lower socioeconomic status, and maternal psychological distress. The coexistence of ADHD and PTSD symptoms highlights the need for integrated, trauma-informed mental health interventions in conflict settings. These findings underscore the urgent necessity for targeted psychological screening and support services for war-affected children.\u003c/p\u003e","manuscriptTitle":"Post-Traumatic Stress and ADHD Symptoms Among Children in the Gaza Strip Since 2023: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 15:01:35","doi":"10.21203/rs.3.rs-8941410/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-02T12:03:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-05T11:40:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T08:07:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-04T08:04:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-02-22T20:40:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05273d1a-a884-4e9c-9526-478b2237abd2","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T15:01:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 15:01:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8941410","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8941410","identity":"rs-8941410","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}