Background <p>School violence significantly impacts young people’s mental health, but there’s limited research from low- and middle-income contexts. Therefore, guided by an ecological framework, this study aimed to examine psychological distress and multiple forms of violence, along with factors at different levels of social ecology, and to demonstrate a cumulative (dose–response) association between distress and these factors in Kosovo.</p> Methods <p>Using cross-sectional data from a nationally representative sample of 12,040 students in grades 6–9 from 100 public schools across 13 municipalities, this study measured psychological distress using the Kessler Psychological Distress Scale (K10) and school victimization, alongside family dynamics, school climate, and risk factors. Multivariable linear regression models with cluster-robust standard errors at the school level were estimated, and a cumulative exposure index (0–12) was used to test for a dose–response association.</p> Results <p>Findings from the study showed that students with higher psychological distress levels often encountered school risk factors and various forms of peer victimization, particularly socio-emotional issues and cyberbullying. In contrast, satisfaction with family life and good relationships with teachers helped reduce distress. The overall model revealed that 31% of the variation in student distress can be explained by the factors studied, which is quite significant. Each type of violence that a student experienced was associated with a notable increase of 1.25 points in their K10 distress score.</p> Conclusions <p>Findings show multiple school-related indicators, including school risk factors and teacher/staff relationships, were independently associated with psychological distress in the adjusted model. These findings have implications for the development of school-based strategies that actively involve teachers and school management in improving school climate, school safety, and parental involvement.</p>