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Abstract

Challenges faced by adult-child caregivers can intensify during calamitous events, potentially resulting in adjustment disorder symptoms. This study examined the contribution of demographic characteristics (age and gender), self-reported number of war-related stressful events, intolerance of uncertainty, and caregiver burden to explaining adjustment symptoms among adult-child caregivers who resided in Israel during the initial months of the Israel-Gaza war. A total of 402 Israeli adult-child caregivers participated in the study. We performed a three-step multiple hierarchical regression analysis. All independent variables included in the regression model had a significant contribution to explaining the variance in the dependent variable. Being female, younger, experiencing a higher number of war-related stressful events, higher reported intolerance of uncertainty, and greater reported caregiver burden were related to higher levels of adjustment disorder symptoms. The findings underscore the complex relationship between caregiving demands, wartime stressors, caregiver characteristics, and adjustment disorder symptoms among adult-child caregivers residing in Israel. Amidst 21st-century uncertainties, the challenges associated with caring for an older parent may intensify, along with their potential negative consequences. These findings lay the groundwork for developing policies and services tailored to provide adapted support to family caregivers during such challenging times.

Keywords

Adjustment disorder symptoms adult-child caregivers caregiver burden intolerance of uncertainty wartime

Introduction

Population ageing has increased older adults’ dependency, placing growing demands on family members who serve as unpaid primary caregivers (e.g., Kingston et al., 2017). Adult-child caregivers experience distinct stressors, such as role reversal and competing work and family demands; however, research often groups them with other family caregivers, obscuring their heightened mental health risks (e.g., Luichies et al., 2021; Schulz et al., 2020).

Caregiving challenges intensify during crises, as safety threats, uncertainty, and disrupted resources undermine caregivers’ well-being (e.g., Allen et al., 2022; Boucher et al., 2022). War poses particular risks for older adults, who experience heightened physical, functional, and psychological vulnerability and barriers to essential resources (e.g., Armocida et al., 2022; Carpiniello, 2023). In Israel, war exposure among older adults has been associated with increased anxiety, psychological distress, cognitive and functional decline, and poorer subjective health, especially among those displaced from their homes (e.g., Faran et al., 2024; Palgi et al., 2015). These challenges may, in turn, intensify the caregiving burden and distress among family caregivers, yet empirical research on caregivers’ emotional responses to war remains limited (Dolberg et al., 2025; Ne’eman-Haviv et al., 2025).

On October 7, 2023, Hamas-led militants launched a large-scale attack on Israel, followed by prolonged armed conflict, mass evacuations, and widespread mobilization (Taub Center, 2024). The war has been linked to marked increases in psychological distress, depression, anxiety, and PTSD symptoms among Israeli civilians (Levi-Belz et al., 2024). While PTSD reflects more long-term responses, adjustment disorder captures more immediate maladaptive reactions during ongoing crises, including preoccupation, distress, and impaired functioning (Maercker et al., 2013; WHO, 2018).

The present study examines how age, gender, exposure to war-related stressors, intolerance of uncertainty, and caregiving burden contributed to adjustment disorder symptoms among Israeli adult-child caregivers during the initial months of the war.

Intolerance of uncertainty

War undermines predictability and stability, intensifying stress by limiting individuals’ ability to anticipate future outcomes (Nickerson et al., 2023; Rahimi et al., 2021). Uncertainty is inherent to caregiving for older adults and is exacerbated during wartime when caregivers’ capacity to ensure safety and meet basic needs is compromised (Boucher et al., 2022; Schulz et al., 2020). Intolerance of uncertainty—a dispositional difficulty with tolerating ambiguity (Carleton, 2016)—has been linked to anxiety, depression, adjustment difficulties, and psychological distress, primarily in pandemic-related research (e.g., Del Valle et al., 2020; Kestler-Peleg et al., 2023). Evidence from military conflict settings, though limited, suggests similar associations with poorer mental health and reduced well-being (e.g., Nickerson et al., 2023; Zerach & Levi-Belz, 2019).

Caregiver burden

Caregiver burden reflects the emotional, physical, financial, and time-related strain associated with caring for older adults with chronic illness or impairment (Liu et al., 2020). Elevated burden has been consistently linked to psychological distress and reduced quality of life (Jika et al., 2021; Ringer et al., 2017). Crisis contexts, including disasters and pandemics, intensify the caregiving burden through disrupted care systems, reduced professional support, and heightened safety concerns (Boucher et al., 2022; Pickering et al., 2021). Recent evidence from Israel indicates that war-related stress further increases the caregiving burden among adult-child caregivers (Dolberg et al., 2025; Ne’eman-Haviv et al., 2025).

The current study

Based on prior research, the study tested the following hypotheses: women and younger adult-child caregivers would report higher adjustment disorder symptoms than men and older caregivers (H1–H2); greater exposure to war-related stressors would be associated with higher symptom levels (H3); and higher intolerance of uncertainty and caregiving burden would each be associated with elevated adjustment disorder symptoms (H4–H5).

Methods

Participants

The study focused on Israeli adult-child caregivers aged 40 and older who provided care to their aging parents before and during the Hamas–Israel war following the October 7 terror attack. The sample included 402 Hebrew-speaking participants (45.8% cisgender men, 54.2% cisgender women), with a mean age of 51.36 years (SD = 9.03; range = 40–74). The mean age of care recipients was 79.08 years (SD = 8.64; range = 60–100). Most participants had a higher education (58.2%), were married or in a committed relationship (75.1%), and were employed (72.4%). Participants resided across Israel, with 34.8% living in the south, 26.4% in the north, and 38.8% in central regions.

Procedure

Following ethics approval, data were collected between early November and early December 2023 using a structured Hebrew-language online questionnaire distributed via social media platforms and a survey company. The study targeted adult-child caregivers residing in Israel, with screening questions used to ensure eligibility and the wartime context highlighted in the study invitation.

Participants provided informed consent electronically after receiving information about the study’s aims, procedures, and confidentiality protection measures. Due to online recruitment, a response rate could not be calculated. Missing data were handled using listwise deletion (Kang, 2013), which was unlikely to bias results given the sample size.

Measurements

Demographic variables included age and gender (0 = cisgender men, 1 = cisgender women, 2 = other).

Exposure to war-related stressful events was assessed by six yes/no items capturing personal or family exposure to evacuation, military recruitment, victimization, kidnapping, or displacement; a cumulative score reflected the number of events experienced.

Intolerance of uncertainty was measured using the 12-item Intolerance of Uncertainty Scale–Short Form (IUS-12; Carleton et al., 2007), rated on a 5-point scale (α = .88).

Caregiver burden was assessed with the short screening version of the Zarit Burden Interview (Bédard et al., 2001), rated on a 0–4 scale (α = .88).

Adjustment disorder symptoms were measured using the ADNM-4 (Ben-Ezra et al., 2018), adapted to reference the ongoing war; items were rated from 1 (never) to 4 (often), with higher summed scores indicating greater symptom severity (α = .84).

Background variables included education, relationship status, employment, region of residence, and parents’ age (see Table 1).

Table 1.

Means, standard deviations, and Pearson correlations of research variables (n = 402).

Variables	n (%)	M (SD)	Range	1	2	3	4	5
1. Gender	Male: 184 (45.8)		_	_
1. Gender	Female: 218 (54.2)		_	_
2. Age		51.36 (9.03)	40–74	.129**
3. War-related stressful events		.65 (.92)	0–5	−.009	−.064
4. Intolerance of uncertainty		2.89 (.67)	1.17–4.67	−.036	−.054	.015
5. Caregiver burden		12.65 (7.78)	0–36	.122*	.057	.058	.197***
6. Adjustment disorder symptoms		11.01 (3.08)	4–16	.364***	−.082	.109*	.338***	.276***

*p < .05; **p < .01;p < .001.

Data analysis

A three-step hierarchical multiple regression analysis was conducted using IBM SPSS Statistics (Version 29) to examine factors associated with adjustment disorder symptoms among adult-child caregivers. Gender and age were entered in the first step, war-related stressful events in the second step, and psychological factors (intolerance of uncertainty and caregiving burden) in the third step. The sample size was adequate for the number of predictors (Tabachnick & Fidell, 2001) and no multicollinearity was detected (maximum VIF = 1.06). Pearson correlations among the reserach variables are presented in Table 1.

Results

Hierarchical regression analysis (see Table 2) revealed that all independent variables included in the regression model contributed significantly to explaining the variance in the dependent variable, namely, 29.2% of the variance was explained in the final model. All the research hypotheses were confirmed. Specifically, it was observed that women (H₁1) and younger adults (H₂1) reported higher levels of adjustment disorder symptoms than did men and older adults. Consistent with H₁3, respondents who encountered a higher number of war-related stressful events reported higher levels of adjustment disorder symptoms compared to those exposed to fewer events. Similarly, and in line with H₁4, respondents who reported higher levels of intolerance of uncertainty exhibited higher levels of adjustment disorder symptoms than did those with lower intolerance of uncertainty. Finally, consistent with H₁5, respondents who reported greater levels of caregiver burden showed higher levels of adjustment disorder symptoms compared to respondents reporting lower levels of caregiver burden.

Table 2.

Summary of hierarchical regression analysis for variables predicting adjustment disorder symptoms among the adult-child caregivers.

Research variables	B	Std. Error	Beta	T	R	Adj.R ²	ΔR²	F
Step 1					.377	.138	.142	F_(2,391) = 32.47^***
Gender	2.296	.290	.373	7.91^***
Age	−.041	.016	−.122	−2.57^*
Step 2					.392	.147	.011	F_(3,390) = 23.69^***
Gender	2.296	.289	.374	7.95^***
Age	−.039	.016	−.116	−2.46^*
War-related stressful events	.354	.155	.107	2.29^*
Step 3					.549	.292	.147	F_(5,388) = 33.43^***
Gender	2.227	.265	.362	8.39^***
Age	−.037	.015	−.109	−2.53^*
War -related stressful events	.298	.141	.090	2.11^*
Intolerance of uncertainty	1.416	.197	.312	7.18^***
Caregiver burden	.066	.017	.172	3.92^**

*p < .05, **p < .01, ***p < .001.

Note. Gender (coded as dummy): 0-male, 1-female.

Discussion

The challenges faced by adult-child caregivers may intensify during humanitarian disasters, increasing the risk of adjustment disorder symptoms (Allen et al., 2022; Peterson et al., 2023). Accordingly, this study examined how demographic characteristics, war-related stress exposure, intolerance of uncertainty, and caregiving burden were associated with adjustment disorder symptoms among Israeli adult-child caregivers during the Hamas–Israel war. The findings indicate that caregiving demands and war-related stressors jointly contributed to elevated adjustment disorder symptoms.

Greater exposure to war-related stressors was associated with more severe adjustment disorder symptoms, underscoring the war’s role as a significant psychological stressor. This finding aligns with previous research showing that humanitarian crises exacerbate the challenges of caring for older adults (e.g., Allen et al., 2022; Peterson et al., 2023).

Lower tolerance of uncertainty was associated with higher adjustment disorder symptoms among adult-child caregivers, highlighting intolerance of uncertainty as a key vulnerability during wartime. In conditions of insecurity and resource scarcity, caregivers must manage pervasive uncertainty alongside intensified caregiving demands for older parents with physical, functional, and cognitive difficulties (Armocida et al., 2022; Kar, 2022). Consistent with research on caregiving during humanitarian disasters, which documents reduced resources, inadequate preparedness, and deterioration among older adults (Boucher et al., 2022; Pickering et al., 2021), the present findings suggest that such challenges are particularly associated with heightened adjustment disorder symptoms among caregivers with low tolerance for uncertainty.

Higher caregiving burden was also associated with increased adjustment disorder symptoms. Consistent with earlier findings, crisis conditions intensify caregiving demands and burden, undermining caregivers’ mental well-being and extending established links between caregiving burden and psychological distress to the wartime context (e.g., Boucher et al., 2022; del-Pino-Casado et al., 2021).

Women and younger adult caregivers reported higher adjustment disorder symptoms than men and older caregivers, consistent with previous research (Lotzin et al., 2021; Rossi et al., 2020). This heightened vulnerability may reflect heavier and more complex caregiving responsibilities, often combined with additional family roles, whereas older caregivers may benefit from greater caregiving experience and resilience when coping with wartime uncertainty (Lee & Tang, 2015; Palgi et al., 2015).

Against the backdrop of global population ageing and the expanding role of family caregivers (Kingston et al., 2017), extensive research has examined caregiving experiences and their implications for mental health and quality of life (Longacre et al., 2017; Luichies et al., 2021). By focusing on adult-child caregivers during wartime, this study extends the emerging literature on caregiving and coping in humanitarian disaster contexts (Allen et al., 2022; Peterson et al., 2023).

Limitations

This study has several limitations, including the use of a cross-sectional, online Hebrew-language convenience sample, which limits causal inference and generalizability, particularly to caregivers from minority or lower socioeconomic groups. In addition, the absence of prewar measures and the inclusion of a limited set of caregiving-related variables restrict conclusions regarding change over time and contextual influences.

Recommendations for further research and practice

Future research should examine adjustment disorder symptoms across diverse caregiver populations using mixed methods and accounting for caregiving context, risk factors, and coping resources to inform policy and service development in disaster settings. On a practical level, caregivers with high war-related stress exposure, low tolerance for uncertainty, and high caregiving burden—particularly women and younger caregivers—should be prioritized for assessment and targeted individual and group-based interventions aimed at reducing distress and strengthening resilience during wartime.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Open research statement

As part of IARR’s encouragement of open research practices, the authors have provided the following information: This research was not pre-registered. The data used in the research are available. The data can be obtained by emailing: sagit.lev@biu.ac.il. The materials used in the research are available. The materials can be obtained by emailing: sagit.lev@biu.ac.il.

Ethical considerations

This study was approved by the Bar-Ilan Research Ethics Committee (approval no. 102307) on Month 11, 2023. All participants provided written informed consent prior to participating.

ORCID iDs

Sagit Lev

Pnina Dolberg

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