
==== Front
BMC Psychol
BMC Psychol
BMC Psychology
2050-7283
BioMed Central London

39232816
1945
10.1186/s40359-024-01945-w
Research
Psychological strains after the crisis: evaluating separation anxiety among Iranian children and adolescents in the post-COVID-19 era
Vossoughi Mehrdad 1
Kharazi Mani 2
Mani Arash 3
Safari Farima 2
Habibi Pardis 2
Zarei Leila 2
Sarikhani Yaser 4
Heydari Seyed Taghi heydari.st@gmail.com

2
Lankarani Kamran B. 2
1 https://ror.org/03w04rv71 grid.411746.1 0000 0004 4911 7066 Mental Health Research Center, Psychosocial Health Research Institute (PHRI), Iran University of Medical Sciences, Tehran, Iran
2 https://ror.org/01n3s4692 grid.412571.4 0000 0000 8819 4698 Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
3 https://ror.org/01n3s4692 grid.412571.4 0000 0000 8819 4698 Research Center of Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
4 https://ror.org/01yxvpn13 grid.444764.1 0000 0004 0612 0898 Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
4 9 2024
4 9 2024
2024
12 47116 4 2024
12 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Objectives

The objective of this study was to specifically investigate Separation Anxiety Disorder (SAD), as one of the noteworthy disorders within the spectrum of anxiety disorders, among children and adolescents, after overcoming the crises caused by the Coronavirus Disease 2019 (COVID-19) pandemic. Efforts were also made to identify socio-demographic factors that could be associated with changes in SAD level and also to assess the effect of different constituting dimensions of SAD on the severity of this disorder.

Methods

In this cross-sectional study, face-to-face interviews were conducted with the parents of 317 (7-13-year-old) Iranian students, who were selected through a multi-stage random sampling method in the city of Shiraz. During the interviews, socio-demographic data were collected, and subsequently, SAD symptoms and dimensions were assessed using the Separation Anxiety Assessment Scale (Parent Version) (SAAS-P) questionnaire. Later, employing the Partition Around Medoids (PAM) statistical method, the participants were categorized into two groups with low and high levels of SAD. Also, to understand the interaction between the different dimensions of SAD, the network analysis method was employed. Finally, univariate analysis and logistic regression were utilized, with a significance level of 0.05, to determine potential associating factors with the level of SAD.

Results

The sample included 128 girls and 189 boys with a mean age of 9.63 ± 2.63 and 9.63 ± 1.95 years respectively. Based on the PAM method, 51.1% of the participants presented a high level of SAD. According to network analysis, it was demonstrated that the “fear of abandonment” dimension plays a central role in high levels of SAD. Based on logistic regression, female gender, age ≥ 10 years, parents’ unacademic educational background, mother’s employment, and child’s history of physical/mental problems were significantly associated with the high level of SAD.

Conclusions

A considerable number of the participants in this study presented a high level of SAD with the “fear of abandonment” being a key influential dimension of elevated levels of this disorder. Maternal employment, female gender, child’s history of health issues, and low parental education were identified as important contributors to the high SAD level. Considering these factors allows for more effective diagnostic and therapeutic interventions. However, the need for further studies remains crucial.

Keywords

Adolescents
Children
Separation anxiety disorder
http://dx.doi.org/10.13039/501100013041 Vice-Chancellor for Research, Shiraz University of Medical Sciences SG-00-17 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcIntroduction

Anxiety disorders, which impact 10 to 30% of children and adolescents, are the most common mental disorders among youth [1–4]. A number of anxiety disorders, such as Generalized Anxiety Disorder (GAD), social anxiety disorder, panic disorder, and Separation Anxiety Disorder (SAD), are more frequently observed in this population and due to their comorbidity and common clinical manifestations, are included in a spectrum of differential diagnoses [1, 5]. Previous studies have proposed a biopsychosocial theory to explain the pathogenesis of such anxiety disorders [1, 6, 7]. Offspring of parents with anxiety disorders are more likely to develop these disorders themselves, as previous research showed the influence of genetic factors by estimating at least 30% heritability [1, 8–11]. In addition, female gender, some temperamental characteristics such as shyness, cognitive factors such as overestimating stimuli and threats, being under overprotective, abusive, or neglectful parenting, and also external stressors such as loss of family members, child’s health condition, or changes in the child’s environment can be associated with higher levels of anxiety [1, 6, 12–18].

SAD, with a prevalence between 0.7% and 15.7% in different studies, is one of the common and even, according to some resources, the most common anxiety disorder among children and adolescents [19–29]. Separation anxiety, as a natural part of childhood development with survival value, usually manifests before the age of one, shaping children’s awareness of separation from their mother or caregiver [1, 5]. However, this feature diminishes around the age of two and a half, allowing the child to feel at ease even when separated from their parents [1]. When the anxiety of separation or even anticipation of separation from the primary attachment figure is excessive, unrealistic, and beyond developmental expectations, the diagnosis of SAD should be considered [1, 6, 19, 30]. In addition, other common symptoms of this disorder include excessive worry about parents getting harmed upon separation, being lost or kidnapped, getting out or being alone at home, nightmares, and even somatic symptoms such as headache, stomachache, and nausea and vomiting [1, 19, 30]. According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), these symptoms should persist for at least four weeks and be accompanied by a significant disruption in the child’s routine functioning [30].

From February 2020, when the World Health Organization (WHO) announced the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, until May 2023, when WHO declared its end as a public health emergency of international concern, notable social and psychological burdens have been imposed on various societies, including Iran [31–35]. Over this timeframe, numerous studies demonstrated the impact of this pandemic on the significant rise of anxiety disorder symptoms among children and adolescents [6, 36–43]. Moreover, conditions such as quarantines, school closures, distance learning, and possibly experiencing death from COVID-19 among family members, all could serve as external stressors and potentially increase the likelihood of SAD in this population [38, 41, 44–49].

However, even as we move beyond the challenges of the pandemic and witness a relative return to the pre-pandemic conditions, the necessity of monitoring the mental health of children and adolescents persists. Considering the mentioned background and the fact that previous studies have mostly examined the spectrum of anxiety disorders as a whole rather than individually, the objective of this study was to specifically investigate SAD, as one of the noteworthy disorders within this spectrum, in this particular group. Furthermore, efforts were made to not only identify socio-demographic factors that could potentially be associated with the changes in SAD level but also to assess the effect of different constituting dimensions of SAD on the severity of this disorder.

Methods

Ethical considerations

The Research Ethics Committee of Shiraz University of Medical Sciences (SUMS) approved the procedure and the informed consent forms of this study with the approval code of IR.SUMS.REC.1400.610. Written informed consent was obtained from each participant before starting the interview, and all principles of confidentiality, anonymity, and voluntary involvement, following the Declaration of Helsinki, were maintained.

Study design and data collection

In this cross-sectional study, a total of 317 parents of elementary school students from the city of Shiraz, one of Iran’s major cities, were selected through a multi-stage sampling from June to July 2023. From each four educational districts in Shiraz, two primary schools (a girls’ school and a boys’ school) were chosen randomly from the list of primary schools (clusters). Then 40 students from each school were randomly selected by a simple random sampling method using a random number table. Data were gathered through an in-person interview with a trained interviewer in schools with the mother or father of the students. After explaining the study objectives and obtaining consent, a structured questionnaire was completed during these face-to-face interviews. Parents who were under 18 years old or whose children were not in the age range of 7 to 13 years were excluded from the study.

Questionnaire

A two-section questionnaire was designed for this study. The first section was aimed at gathering socio-demographic data and exploring some aspects of the relationship between the parents and the child. These data included parents’ age, educational background, employment status, psychiatric disorders history, and substance abuse history, as well as the family’s monthly income, monthly medical expenditure, number of children, and the quality of the parent-child relationship. In addition, data were collected regarding the child’s gender, age, and physical and mental health status, educational status, experiencing the death of relatives due to COVID-19, and experiencing calamitous events in the past year.

The second section was the Separation Anxiety Assessment Scale (Parent Version) (SAAS-P). This 34-item questionnaire, which various studies have supported its reliability, validity, and clinical applicability, encompasses four main dimensions of SAD, including fear of being alone, fear of abandonment, fear of physical illness, and worry about calamitous events, and two other research subscales including frequency of calamitous events, and safety signals index [50–52]. A 2016 study conducted by Talaienejad et al. [53] analyzed the psychometric properties of the SAAS-P questionnaire and suggested it as a promising measure to evaluate SAD in the Iranian population of children and adolescents. The obtained Cronbach’s alpha coefficient for the total score of this questionnaire was 0.86, and for the main subscales of fear of being alone, fear of abandonment, fear of physical illness, and worry about calamitous events were 0.74, 0.73, 0.68, and 0.62 respectively [53]. In addition, a 2018 study also conducted by Talaienejad et al. [54], explained the method of calculating the total and each subscale’s score from this questionnaire, however, no cut-off point was suggested to determine the severity level of each of them. Therefore, to assess the extent of separation anxiety symptoms among the participants, and determine the importance of each of the 6 dimensions of SAD evaluated by the SAAS-P questionnaire; specific statistical methods, explained below, were employed.

Statistical analysis

Data were summarized using frequency (percentage), and mean ± Standard Deviation (SD) for qualitative and quantitative variables, respectively.

The Partition Around Medoids (PAM) method was used to classify the questionnaire’s score into distinct clusters. The clustering technique is based on minimizing the dissimilarities between the individuals within a cluster. This method is more robust in the presence of outliers than the traditional k-means clustering. The best number of clusters was determined using internal clustering validity indices and stability measures. The number of clusters (k) with the maximum value of internal clustering validity (here Silhouette and Calinski-Harabsz) and minimum values of stability measures (here APN: Average Proportion of Non-Overlap, and ADM: Average Distance Between Means) is optimal. The indices recommended that considering two clusters (k = 2), namely low level and high level, classifies SAD best. Mean dimensions were compared between the two clusters using an independent-sample t-test and Cohen’s d, reported as effect size.

Univariate and adjusted Odds Ratios (OR) and 95% Confidence Intervals (CI) were used to assess the relationship between independent variables and the two clusters of SAD symptoms (namely low and high levels). The adjusted ORs were computed using a logistic regression model and backward selection method to select influential independent variables.

Network analysis based on the Gaussian graphical model was employed to better understand the interaction between the 6 dimensions (nodes) of the SAAS-P questionnaire. The methods report strength, betweenness, and closeness centrality measures to assess the role of each node in the relationship graph. The edges were estimated by the G-Lasso method.

Package “cluster” [55] and “qgraph” [56] were used to implement PAM and network analysis, respectively, in R software version 4.3.2 [57]. Throughout this study, the type I error rate (α) was set to 0.05.

Results

Of the 317 children recruited in the study, 128 were girls and 189 were boys. The children aged 7 to 13 with a mean of 9.63 ± 2.14 years. Mothers constituted the majority of respondents (76.3%). The mean age of mothers and fathers was 34.81 ± 5.88 and 39.49 ± 6.42 years, respectively.

The PAM method revealed that considering two clusters (namely low and high) can adequately categorize the SAAS-P questionnaire score of the participants. Based on this classification, 162 (51.1%) children had a high level of separation anxiety. The mean total score and the 6 dimensions of the questionnaire in the two clusters of SAD levels are presented in Table 1. The results indicated that the mean total and all 6 dimensions’ scores in the cluster with the low level of SAD were significantly lower than the other cluster (all P < 0.001). Moreover, all Cohen’s d effect sizes indicated that the mean differences were noticeably large (> 0.8). Among the 6 dimensions, the greatest differences belonged to the “fear of being alone”, “fear of abandonment”, “frequency of calamitous events”, and “fear of physical illness” dimensions.

Table 1 Mean total and 6 dimensions’ score of the SAAS-P questionnaire categorized into two clusters, estimated by the PAM method

	SAD category		
Low level	High level	P value*	Cohen’s d	
Fear of being alone	7.04 ± 1.97	12.68 ± 2.57	< 0.001	2.46	
Fear of abandonment	5.66 ± 1.20	11.36 ± 3.08	< 0.001	2.42	
Fear of physical illness	6.17 ± 1.27	10.97 ± 2.65	< 0.001	2.30	
Worry about calamitous events	7.48 ± 2.01	11.93 ± 2.61	< 0.001	1.90	
Frequency of calamitous events	22.57 ± 2.75	29.57 ± 3.14	< 0.001	2.37	
Safety signals index	6.84 ± 1.79	3.48 ± 1.75	< 0.001	1.82	
Total score	55.75 ± 6.90	87.90 ± 9.35	< 0.001	3.90	
The values in the table are mean ± Standard Deviation (SD)

*Independent-sample t-test

The network analysis results for the 6 dimensions of the SAAS-P questionnaire for children in the categories of low and high levels of SAD are presented in Figs. 1 and 2. Table 2 also presents the values of centrality measures used in Fig. 2. It was illustrated that the network of children with a high level of SAD had a simpler and more centered network, with more zero edges between dimensions (nodes). The “worry about calamitous events” dimension has no edge in the high-risk network. In this network, the “fear of abandonment” dimension is the most central and important, with the highest strength and attained all possible betweenness scores. Interestingly, the “fear of being alone” and “frequency of calamitous events” dimensions are connected indirectly to the “fear of physical illness” and “safety signals index” dimensions via the “fear of abandonment” dimension, and there is no direct edge between them. One can conclude that any change in the “fear of abandonment” dimension is accompanied by a direct change in other dimensions. Therefore, this dimension can be considered as a predominant variable for early identification and any possible intervention to reduce separation anxiety. In contrast, the network of the children in the category of the low level of SAD was more dispersed. The most central dimension was the “frequency of calamitous events” followed by the “fear of physical illness”. Although the network of the category with the low level of SAD included more dimensions with non-zero edges, the relationships were not as strong as those obtained in the network of the category with the high level of SAD.

Fig. 1 Network (relationship graph) for the 6 dimensions (nodes) of the SAAS-P questionnaire by risk clusters resulting from the PAM method (low- and high-level groups). FA: Fear of abandonment; FBA: Fear of being alone; FCE: Frequency of calamitous events; FPhI: Fear of physical illness; SSI: Safety signals index; WCE: Worry about calamitous events

Fig. 2 Standardized values of centrality measures for the 6 dimensions (nodes) of the SAAS-P questionnaire by risk clusters resulted from the PAM method (low- and high-level of SAD). Participants in the low-level group are represented by the blue line, and the high-level group by the red line. FA: Fear of abandonment; FBA: Fear of being alone; FCE: Frequency of calamitous events; FPhI: Fear of physical illness; SSI: Safety signals index; WCE: Worry about calamitous events

Table 2 Centrality measures of the network analysis for each of the 6 dimensions of the SAAS-P questionnaire for children with low- and high-level of SAD (the standardized centrality measure, z-score values, reported)

	SAD category	
Low level	High level	
Strength	Betweenness	closeness	Strength	Betweenness	closeness	
Fear of being alone	0.21	0.00	0.55	− 0.25	-0.41	-0.53	
Fear of abandonment	-0.85	-0.79	-0.93	1.76	2.04	1.62	
Fear of physical illness	0.45	0.79	0.92	0.29	-0.41	0.30	
Worry about calamitous events	-0.33	-0.79	-0.65	-1.28	-0.41	-	
Frequency of calamitous events	1.64	1.58	1.18	-0.31	-0.41	-0.63	
Safety signals index	-1.11	-0.79	-1.07	-0.20	-0.41	-0.77	

Table 3 shows univariate analysis and logistic regression results for examining the association between parents’ and children’s demographic features and the child’s level of SAD. Univariate analysis showed that the child’s gender, child’s age, respondent to the questionnaire, mother’s age, parents’ educational background, mother’s employment status, relatives’ death due to COVID-19, parent’s substance abuse history, monthly medical expenditure, child’s health status, the quality of parent-child relationship and child’s past year’s history of calamitous events were significantly associated with the high level of SAD.

Table 3 Association between parents’ and child’s demographic features with the child’s level of SAD based on logistic regression

	SAD	OR (95% CI) *	P value	OR (95% CI) **	P value	
Low level	High level	
Child’s gender	Girl	52 (40.6)	76 (59.4)	1.75 (1.11–2.75)	0.015	2.79 (1.37–5.65)	0.005	
Boy	103 (54.5)	86 (45.5)	1	-	1	-	
Child’s age	< 10	126 (70.4)	53 (29.6)	1	-	1	-	
≥ 10	29 (21.0)	109 (79.0)	8.94 (5.31–15.03)	< 0.001	3.56 (1.63–7.76)	0.001	
Respondent to the questionnaire	Mother	128 (52.9)	114 (47.1)	1	-	1	-	
Father	27 (36.0)	48 (64.0)	2.00 (1.17–3.41)	0.011	0.48 (0.21–1.10)	0.083	
Mother’s age	Less than 30	12 (20.7)	46 (79.3)	6.13 (2.76–13.76)	< 0.001	-	-	
30–39	103 (53.1)	91 (46.9)	1.41 (0.80–2.51)	0.237	-	-	
More than 40	40 (61.5)	25 (38.5)	1	-	-	-	
Mother’s educational background	Under diploma	31 (43.7)	40 (56.3)	4.21 (2.10–8.44)	< 0.001	4.95 (1.56–15.72)	0.007	
Diploma	62 (37.6)	103 (62.4)	5.42 (2.97–9.91)	< 0.001	3.23 (1.30–8.05)	0.012	
University	62 (76.5)	19 (23.5)	1	-	1	-	
Father’s educational background	Under diploma	34 (56.7)	26 (43.3)	1.69 (0.86–3.31)	0.128	4.13 (1.27–13.44)	0.018	
Diploma	57 (34.8)	107 (65.2)	4.14 (2.40–7.14)	< 0.001	4.07 (1.65–10.03)	0.002	
University	64 (68.8)	29 (31.2)	1	-	1	-	
Mother’s employment status	Full-time/ retired	23 (39.0)	36 (61.0)	2.74 (1.51–4.99)	0.001	2.57 (1.08–6.11)	0.033	
Part-time	4 (7.0)	53 (93.0)	23.23 (8.08–66.80)	< 0.001	28.56 (6.80-119.90)	< 0.001	
Housewife	128 (63.7)	73 (36.3)	1	-	1	-	
Father’s employment status	Full-time/ retired	55 (45.8)	65 (54.2)	0.95 (0.35–2.56)	0.912	1.25 (0.29–5.45)	0.764	
Part-time	92 (51.4)	87 (48.6)	0.76 (0.29-2.00)	0.575	0.56 (0.14–2.29)	0.422	
Unemployed	8 (44.4)	10 (55.6)	1	-	1	-	
Income status	< expenses	88 (47.6)	97 (52.4)	1	-	-	-	
≥expenses	67 (50.8)	65 (49.2)	0.88 (0.56–1.38)	0.577	-	-	
Relatives’ death due to COVID-19	No	129 (59.2)	115 (47.1)	1	-	-	-	
Yes	25 (34.7)	47 (65.3)	2.11 (1.22–3.64)	0.007	-	-	
Parents’ psychiatric disorder history	No	145 (49.7)	147 (50.3)	1	-	-	-	
Yes	10 (40.0)	15 (60.0)	1.48 (0.64–3.40)	0.354	-	-	
Parent’s substance abuse history	No	151 (50.7)	147 (49.3)	1	-	-	-	
Yes	4 (21.1)	15 (78.9)	3.85 (1.25–11.88)	0.012	-	-	
Monthly medical expenditure	≤ 10% of monthly income	120 (56.3)	93 (43.7)	1	-	-	-	
> 10% of monthly income	35 (33.7)	69 (66.3)	2.54 (1.56–4.15)	< 0.001	-	-	
Number of children in the family	1	24 (38.7)	38 (61.3)	1.46 (0.73–2.90)	0.282	2.84 (0.99–8.12)	0.052	
2	96 (52.7)	86 (47.3)	0.83 (0.48–1.42)	0.488	1.10 (0.48–2.50)	0.828	
≥ 3	35 (47.9)	38 (52.1)	1	-	1	-	
Child’s health status	Healthy	147 (52.7)	132 (47.3)	1	-	1	-	
Physical/mental problem	8 (21.1)	30 (78.9)	4.18 (1.85–9.43)	< 0.001	5.00 (1.50-16.72)	0.009	
Child’s educational status	Very good	75 (68.2)	35 (31.8)	0.50 (0.21–1.18)	0.115	0.87 (0.22–3.40)	0.837	
Good	48 (39.0)	75 (61.0)	1.68 (0.73–3.89)	0.223	3.40 (0.90-12.78)	0.071	
Relatively good	18 (31.6)	39 (68.4)	2.33 (0.91–5.97)	0.077	2.22 (0.52–9.51)	0.281	
Weak	14 (51.9)	13 (41.8)	1	-	1	-	
Quality of parent-child relationship	Very good	103 (69.6)	45 (30.4)	1	-	1	-	
Good	38 (33.6)	75 (66.4)	4.52 (2.67–7.63)	< 0.001	1.90 (0.86–4.23)	0.115	
Relatively good	9 (20.5)	35 (79.5)	8.90 (3.95–20.05)	< 0.001	3.85 (0.95–11.32)	0.060	
Weak	5 (41.7)	7 (58.3)	3.20 (0.97–10.64)	0.059	2.22 (0.52–9.51)	0.281	
Child’s past year’s history of calamitous events	No	141 (51.5)	133 (48.5)	1	-	-	-	
Yes	14 (32.6)	29 (67.4)	2.20 (1.11–4.34)	0.021	-	-	
* Univariate analysis odds ratios and 95% confidence interval

** Adjusted odds ratio and 95% confidence interval resulted from the logistic regression method

The odds ratios with bold style were statistically significant

Based on logistic regression results, being a girl (OR = 2.79, %95CI:1.37–5.65), age equal or over 10 years (OR = 3.56, %95CI:1.63–7.76), mother’s unacademic educational background (under diploma: OR = 4.95, %95CI:1.56–15.72, diploma: OR = 3.23, %95CI: 1.30–8.05), father’s unacademic educational background (under diploma: OR = 4.13, %95CI:1.27–13.44, diploma: OR = 4.07, %95CI: 1.65–10.03), mother’s employment status (full-time: OR = 2.57, %95CI: 1.08–6.11, part-time: OR = 28.56, %95CI: 6.80-119.90), and child having a physical/mental problem (OR = 5.0, %95CI: 1.50-16.72), were positively associated with the high level of SAD.

Discussion

In this study, 51.1% of the participants presented high levels of separation anxiety symptoms. Although this number cannot necessarily be interpreted as the prevalence of SAD among the 7-13-year-old children investigated in this study, it still suggests that a relatively large number of children in this age group may suffer from this type of anxiety [3, 21, 23, 24, 27]. Previous studies have shown that the COVID-19 pandemic led to a significant rise in anxiety disorders among youth. Even though the current study was conducted shortly after the pandemic subsided, these high levels of separation anxiety symptoms may still be influenced by the profound challenges that emerged during that period [36, 38, 42, 47, 58–60].

The SAAS-P questionnaire was employed in this study for the evaluation of SAD. This questionnaire not only allows for an overall evaluation of the SAD but also enables the investigation of its six distinct dimensions. The results of the analyses indicated that in the category of participants with a high level of SAD, the “fear of abandonment” dimension plays a key role. This dimension, which indirectly connects the dimensions of the “fear of being alone” and “frequency of calamitous events” to the “fear of physical illness” and “safety signals index”, can serve as a central point for diagnostic and therapeutic interventions. This result is congruent with the findings of the 2005 study conducted by Hajinlian et al. [52], which demonstrated the “fear of abandonment” as the most predictive dimension (83%) of SAD. On the other hand, network analysis revealed that the dimension of “worry about calamitous events” had no connection with the other five dimensions. Nevertheless, similar to the other five dimensions, this dimension exhibited a P-value < 0.001 and a Cohen’s d effect size > 0.8, indicating its significant role. Therefore, it can be stated that this dimension remains an independent factor that can generally influence the level of SAD symptoms and should not be overlooked.

Additionally, the results of the analyses of this study revealed that multiple socio-demographic factors are associated with the high level of SAD. Among them, factors such as the father being the respondent to the questionnaire, mother’s age less than 30, child’s relatives’ death due to COVID-19, parent’s substance abuse history, monthly medical expenditure more than 10% of monthly income, good quality of parent-child relationship, and child’s past year’s history of calamitous events were found to be statistically significant in univariate analysis, however, in logistic regression, they were omitted from the statistical model or their association with SAD levels were no longer significant. This absence of association based on logistic regression, particularly regarding factors like the death of relatives, parents’ substance abuse, high medical expenses in the family, and the occurrence of calamitous events for the child, which can each act as external stressors or disrupt the family’s safe environment, seems to be somehow incongruent with previous studies [1, 6, 12, 23, 27]. This omission of certain factors from the statistical model or the lack of significant associations after logistic regression seems to be due to differences in the choice of statistical models in different studies and also the presence of multicollinearity. For example, factors such as high medical expenses and substance abuse may be correlated, thus reducing their individual statistical significance after the logistic regression. Moreover, previous studies have indicated the genetic predisposition of anxiety disorders and the association between parental psychiatric problems and increased SAD symptoms among children [11–13, 58]. However, in this study, despite estimating an odds ratio of 1.48, this relationship did not reach statistical significance.

Among the factors that had a significant association with the high level of SAD based on the logistic regression, the most prominent one was the part-time employment status of the mother. While full-time maternal employment also showed a significant relationship with SAD symptoms, part-time employment with an odds ratio of 28.56, indicated that it could be a highly noteworthy risk factor for this condition among children. The employment status of mothers, who are considered the main caregivers for the children in Iranian society, affects the main cause of this disorder, which is separation from the major attachment figure [1, 19] In addition, it has been observed that there is a possibility that the worry about potential harm to the mother following separation may result in severe distress and even nightmares in children [1, 30]. The higher impact of part-time employment compared to full-time may stem from the variation in the mother’s working hours and reduced predictability of the duration spent alongside the mother for the child.

Based on logistic regression results, this study also indicated that girls and children with a history of physical or mental health issues significantly presented more SAD symptoms, which is congruent with the findings of various previous studies [3, 17, 23, 27, 47]. Regarding age, this study demonstrated that older children had significantly more SAD symptoms. However, the findings of previous studies on this matter were diverse, with some suggesting an increase in symptoms and others indicating a decrease in symptoms with advancing age [3, 12, 47, 58]. Meanwhile, some other studies indicated changes in the nature and types of SAD symptoms with age variations [19, 61, 62]. Another finding of the present study indicated a significant increase in SAD symptoms in the group whose parents had lower educational levels. Prior studies suggested that when parents have a better understanding of the nature of anxiety and choose more effective coping strategies, such as avoiding overprotection or excessive restriction, SAD can be better controlled and this fact can explain the finding of this study regarding parents’ educational level [19, 63–65].

SAD, as a noteworthy anxiety disorder with comorbidity with many other disorders in this spectrum, has the potential to persist even into adulthood and be a risk factor for other psychiatric diseases, therefore, it demands adequate attention both in research and clinical settings [1, 19, 66, 67]. Given that effective therapeutic approaches such as parent-focused interventions, psychotherapy, and pharmacotherapy have been suggested for the management of this disorder, early diagnosis, and intervention, especially in children with risk factors can prevent many potential future subsequences [1, 63, 68].

Strengths and limitations

To enhance precision, the entire data-gathering process was conducted through in-person interviews. Moreover, in this study, efforts were made to examine the symptoms and dimensions of SAD distinctly compared to previous studies, utilizing specific statistical methods. On the other hand, however, the time-consuming and cost-intensive nature of conducting face-to-face interviews restricted the sample size of this study. Also, considering the need to provide special conditions for interviewing children, the possibility of conducting interviews with them alongside their parents did not take place. Additionally, the conducted study was cross-sectional, therefore, it inherently had limitations, such as the inability to examine the psychological characteristics of the study population over a specific timeframe.

Conclusion

This study revealed that a considerable number of the investigated children and adolescents presented a high level of SAD. The “fear of abandonment” emerged as a key dimension influencing elevated levels of this disorder in this population. Additionally, maternal part-time employment, female gender, child’s history of physical or mental health issues, and low parental education levels were among the most important contributors that can predispose children to this disorder. By considering these influential dimensions and potential risk factors, this disorder can be diagnosed more effectively and therapeutic interventions can be targeted toward the correct aspects. However, the necessity for further studies to clarify the diverse elements of this disorder remains crucial.

Acknowledgements

Not applicable.

Author contributions

M.V. contributed to the data curation, writing and editing of the original draft, data analysis, and preparing Figs. 1 and 2, and Tables 1, 2 and 3. M.K. contributed to the data curation, writing and editing of the original draft, and interpreting the results. A.M. contributed to the study design, writing, and editing of the original draft, and interpreting the results. F.S., P.H., L.Z., and Y.S., contributed to the data curation, and writing and editing of the original draft. S.H. contributed to the study design, data analysis, project administration, editing of the draft, and supervision. K.B. contributed to the study design, project administration, and supervision. All authors reviewed the manuscript.

Funding

This study was financially supported by the Vice Chancellor of Research at Shiraz University of Medical Sciences (grant ID: SG-00-17), however, the funding body did not play any role in the designing of the study, collecting, analyzing, and interpreting the data, and writing the manuscript.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The Research Ethics Committee of Shiraz University of Medical Sciences (SUMS) approved the procedure and the informed consent forms of this study with the approval code of IR.SUMS.REC.1400.610. Written informed consent was obtained from each participant before starting the interview, and all principles of confidentiality, anonymity, and voluntary involvement, following the Declaration of Helsinki, were maintained.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

GAD Generalized Anxiety Disorder

SAD Separation Anxiety Disorder

DSM-5 Diagnostic and Statistical Manual of Mental Disorders, fifth edition

WHO World Health Organization

COVID-19 Coronavirus Disease 2019

SAAS-P Separation Anxiety Assessment Scale (Parent Version)

PAM Partition Around Medoids

ADM Average Distance Between Means

OR Odds Ratios

CI Confidence Interval

SD Standard Deviation

SUMS Shiraz University of Medical Sciences

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Boland RJ, Verduin ML, Ruiz P, Shah A, Kaplan HI, Sadock BJ. Kaplan & Sadock’s synopsis of psychiatry. Philadelphia: Wolters Kluwer Philadelphia; 2022. https://emergency.lwwhealthlibrary.com/book.aspx?bookid=3071
2. Kessler RC Avenevoli S Costello EJ Georgiades K Green JG Gruber MJ Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication adolescent supplement Arch Gen Psychiatry 2012 69 4 372 80 10.1001/archgenpsychiatry.2011.160 22147808
Kessler RC, Avenevoli S, Costello EJ, Georgiades K, Green JG, Gruber MJ, et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication adolescent supplement. Arch Gen Psychiatry. 2012;69(4):372–80.22147808 10.1001/archgenpsychiatry.2011.160
3. Merikangas KR He JP Burstein M Swanson SA Avenevoli S Cui L Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey replication–adolescent supplement (NCS-A) J Am Acad Child Adolesc Psychiatry 2010 49 10 980 9 10.1016/j.jaac.2010.05.017 20855043
Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey replication–adolescent supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980–9.20855043 10.1016/j.jaac.2010.05.017
4. Wagner G Zeiler M Waldherr K Philipp J Truttmann S Dür W Mental health problems in Austrian adolescents: a nationwide, two-stage epidemiological study applying DSM-5 criteria Eur Child Adolesc Psychiatry 2017 26 12 1483 99 10.1007/s00787-017-0999-6 28540609
Wagner G, Zeiler M, Waldherr K, Philipp J, Truttmann S, Dür W, et al. Mental health problems in Austrian adolescents: a nationwide, two-stage epidemiological study applying DSM-5 criteria. Eur Child Adolesc Psychiatry. 2017;26(12):1483–99.28540609 10.1007/s00787-017-0999-6
5. Bennett S, Walkup JT. Anxiety disorders in children and adolescents: Assessment and diagnosis. In: TW P, editorAccessed on January 26,. UpToDate. UpToDate, Waltham, MA, (2024): Wolters Kluwer.
6. Bennett S, Walkup JT. Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course. In: TW P, editorAccessed on January 26,. UpToDate. UpToDate, Waltham, MA, (2024): Wolters Kluwer.
7. Essau CA Petermann F Anxiety disorders in children and adolescents: Epidemiology 2013 risk factors and treatment Routledge
Essau CA, Petermann F. Anxiety disorders in children and adolescents: Epidemiology. risk factors and treatment: Routledge; 2013.
8. Havinga PJ Boschloo L Bloemen AJ Nauta MH de Vries SO Penninx BW Doomed for disorder? High incidence of Mood and anxiety disorders in offspring of depressed and anxious patients: a prospective cohort study J Clin Psychiatry 2017 78 1 e8 17 10.4088/JCP.15m09936 27898206
Havinga PJ, Boschloo L, Bloemen AJ, Nauta MH, de Vries SO, Penninx BW, et al. Doomed for disorder? High incidence of Mood and anxiety disorders in offspring of depressed and anxious patients: a prospective cohort study. J Clin Psychiatry. 2017;78(1):e8–17.27898206 10.4088/JCP.15m09936
9. Trzaskowski M Eley TC Davis OS Doherty SJ Hanscombe KB Meaburn EL First genome-wide association study on anxiety-related behaviours in childhood PLoS ONE 2013 8 4 e58676 10.1371/journal.pone.0058676 23565138
Trzaskowski M, Eley TC, Davis OS, Doherty SJ, Hanscombe KB, Meaburn EL, et al. First genome-wide association study on anxiety-related behaviours in childhood. PLoS ONE. 2013;8(4):e58676.23565138 10.1371/journal.pone.0058676
10. Schiele MA Costa B Abelli M Martini C Baldwin DS Domschke K Oxytocin receptor gene variation, behavioural inhibition, and adult separation anxiety: role in complicated grief World J Biol Psychiatry 2018 19 6 471 9 10.1080/15622975.2018.1430374 29353531
Schiele MA, Costa B, Abelli M, Martini C, Baldwin DS, Domschke K, et al. Oxytocin receptor gene variation, behavioural inhibition, and adult separation anxiety: role in complicated grief. World J Biol Psychiatry. 2018;19(6):471–9.29353531 10.1080/15622975.2018.1430374
11. Johnson JG Cohen P Kasen S Brook JS Parental concordance and offspring risk for anxiety, conduct, depressive, and substance use disorders Psychopathology 2008 41 2 124 8 10.1159/000112028 18059114
Johnson JG, Cohen P, Kasen S, Brook JS. Parental concordance and offspring risk for anxiety, conduct, depressive, and substance use disorders. Psychopathology. 2008;41(2):124–8.18059114 10.1159/000112028
12. Blanco C Rubio J Wall M Wang S Jiu CJ Kendler KS Risk factors for anxiety disorders: common and specific effects in a national sample Depress Anxiety 2014 31 9 756 64 10.1002/da.22247 24577934
Blanco C, Rubio J, Wall M, Wang S, Jiu CJ, Kendler KS. Risk factors for anxiety disorders: common and specific effects in a national sample. Depress Anxiety. 2014;31(9):756–64.24577934 10.1002/da.22247
13. Narmandakh A Roest AM de Jonge P Oldehinkel AJ Psychosocial and biological risk factors of anxiety disorders in adolescents: a TRAILS report Eur Child Adolesc Psychiatry 2021 30 12 1969 82 10.1007/s00787-020-01669-3 33113027
Narmandakh A, Roest AM, de Jonge P, Oldehinkel AJ. Psychosocial and biological risk factors of anxiety disorders in adolescents: a TRAILS report. Eur Child Adolesc Psychiatry. 2021;30(12):1969–82.33113027 10.1007/s00787-020-01669-3
14. Dadds MR A brief parent-focused intervention reduces anxiety disorders in socially inhibited children Evid Based Ment Health 2011 14 2 49 10.1136/ebmh1154 21502155
Dadds MR. A brief parent-focused intervention reduces anxiety disorders in socially inhibited children. Evid Based Ment Health. 2011;14(2):49.21502155 10.1136/ebmh1154
15. Asselmann E Wittchen HU Lieb R Beesdo-Baum K The role of the mother-child relationship for anxiety disorders and depression: results from a prospective-longitudinal study in adolescents and their mothers Eur Child Adolesc Psychiatry 2015 24 4 451 61 10.1007/s00787-014-0596-x 25201054
Asselmann E, Wittchen HU, Lieb R, Beesdo-Baum K. The role of the mother-child relationship for anxiety disorders and depression: results from a prospective-longitudinal study in adolescents and their mothers. Eur Child Adolesc Psychiatry. 2015;24(4):451–61.25201054 10.1007/s00787-014-0596-x
16. Bruce LC Heimberg RG Goldin PR Gross JJ CHILDHOOD MALTREATMENT AND RESPONSE TO COGNITIVE BEHAVIORAL THERAPY AMONG INDIVIDUALS WITH SOCIAL ANXIETY DISORDER Depress Anxiety 2013 30 7 662 9 10.1002/da.22112 23554134
Bruce LC, Heimberg RG, Goldin PR, Gross JJ, CHILDHOOD MALTREATMENT, AND RESPONSE TO COGNITIVE BEHAVIORAL THERAPY AMONG INDIVIDUALS WITH SOCIAL ANXIETY DISORDER. Depress Anxiety. 2013;30(7):662–9.23554134 10.1002/da.22112
17. Naldan ME Karayagmurlu A Ahıskalıoglu EO Cevizci MN Aydin P Kara D Is surgery a risk factor for separation anxiety in children? Pediatr Surg Int 2018 34 7 763 7 10.1007/s00383-018-4273-x 29728760
Naldan ME, Karayagmurlu A, Ahıskalıoglu EO, Cevizci MN, Aydin P, Kara D. Is surgery a risk factor for separation anxiety in children? Pediatr Surg Int. 2018;34(7):763–7.29728760 10.1007/s00383-018-4273-x
18. Battaglia M Touchette É Garon-Carrier G Dionne G Côté SM Vitaro F Distinct trajectories of separation anxiety in the preschool years: persistence at school entry and early-life associated factors J Child Psychol Psychiatry 2016 57 1 39 46 10.1111/jcpp.12424 25912177
Battaglia M, Touchette É, Garon-Carrier G, Dionne G, Côté SM, Vitaro F, et al. Distinct trajectories of separation anxiety in the preschool years: persistence at school entry and early-life associated factors. J Child Psychol Psychiatry. 2016;57(1):39–46.25912177 10.1111/jcpp.12424
19. McKay D, Storch E. Handbook of Child and Adolescent Anxiety Disorders2011.
20. Mohammadi MR Badrfam R Khaleghi A Hooshyari Z Ahmadi N Zandifar A Prevalence, comorbidity and predictor of separation anxiety disorder in children and adolescents Psychiatr Q 2020 91 4 1415 29 10.1007/s11126-020-09778-7 32418141
Mohammadi MR, Badrfam R, Khaleghi A, Hooshyari Z, Ahmadi N, Zandifar A. Prevalence, comorbidity and predictor of separation anxiety disorder in children and adolescents. Psychiatr Q. 2020;91(4):1415–29.32418141 10.1007/s11126-020-09778-7
21. Shear K Jin R Ruscio AM Walters EE Kessler RC Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication Am J Psychiatry 2006 163 6 1074 83 10.1176/ajp.2006.163.6.1074 16741209
Shear K, Jin R, Ruscio AM, Walters EE, Kessler RC. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(6):1074–83.16741209 10.1176/ajp.2006.163.6.1074
22. Bowen RC Offord DR Boyle MH The prevalence of overanxious disorder and separation anxiety disorder: results from the Ontario Child Health Study J Am Acad Child Adolesc Psychiatry 1990 29 5 753 8 10.1097/00004583-199009000-00013 2228929
Bowen RC, Offord DR, Boyle MH. The prevalence of overanxious disorder and separation anxiety disorder: results from the Ontario Child Health Study. J Am Acad Child Adolesc Psychiatry. 1990;29(5):753–8.2228929 10.1097/00004583-199009000-00013
23. Silove D Alonso J Bromet E Gruber M Sampson N Scott K Pediatric-Onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey Am J Psychiatry 2015 172 7 647 56 10.1176/appi.ajp.2015.14091185 26046337
Silove D, Alonso J, Bromet E, Gruber M, Sampson N, Scott K, et al. Pediatric-Onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. Am J Psychiatry. 2015;172(7):647–56.26046337 10.1176/appi.ajp.2015.14091185
24. Franz L Angold A Copeland W Costello EJ Towe-Goodman N Egger H Preschool anxiety disorders in pediatric primary care: prevalence and comorbidity J Am Acad Child Adolesc Psychiatry 2013 52 12 1294 e3031 10.1016/j.jaac.2013.09.008 24290462
Franz L, Angold A, Copeland W, Costello EJ, Towe-Goodman N, Egger H. Preschool anxiety disorders in pediatric primary care: prevalence and comorbidity. J Am Acad Child Adolesc Psychiatry. 2013;52(12):1294–e3031.24290462 10.1016/j.jaac.2013.09.008
25. Jalali M Pourahmadi E P-132 - prevalence of anxiety disorders among 10–14 years old children in Gorgan Eur Psychiatry 2012 27 S1 1 10.1016/S0924-9338(12)74299-2 22153731
Jalali M, Pourahmadi E. P-132 - prevalence of anxiety disorders among 10–14 years old children in Gorgan. Eur Psychiatry. 2012;27(S1):1.22153731 10.1016/S0924-9338(12)74299-2
26. Cartwright-Hatton S McNicol K Doubleday E Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children Clin Psychol Rev 2006 26 7 817 33 10.1016/j.cpr.2005.12.002 16517038
Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children. Clin Psychol Rev. 2006;26(7):817–33.16517038 10.1016/j.cpr.2005.12.002
27. Nassi A Mehrabizade Honarmand M Shehni Yailagh M Bassaknejad S Talebpour A The epidemiology of separation anxiety disorder in Isfahan Primary School Male Students Iran J Epidemiol 2012 8 3 47 57
Nassi A, Mehrabizade Honarmand M, Shehni Yailagh M, Bassaknejad S, Talebpour A. The epidemiology of separation anxiety disorder in Isfahan Primary School Male Students. Iran J Epidemiol. 2012;8(3):47–57.
28. Amiri S Mohammadi MR Ahmadi N Khaleghi A Nourouzi S Asl Rahimi V Prevalence of Psychiatric disorders among children and adolescents in the East Azerbaijan Province, Tabriz, Iran in 2017 Iran J Psychiatry Behav Sci 2019 13 4 e88594
Amiri S, Mohammadi MR, Ahmadi N, Khaleghi A, Nourouzi S, Asl Rahimi V, et al. Prevalence of Psychiatric disorders among children and adolescents in the East Azerbaijan Province, Tabriz, Iran in 2017. Iran J Psychiatry Behav Sci. 2019;13(4):e88594.
29. Zarafshan H Mohammadi MR Salmanian M Prevalence of anxiety disorders among children and adolescents in Iran: a systematic review Iran J Psychiatry 2015 10 1 1 7 26005473
Zarafshan H, Mohammadi MR, Salmanian M. Prevalence of anxiety disorders among children and adolescents in Iran: a systematic review. Iran J Psychiatry. 2015;10(1):1–7.26005473
30. Diagnostic and statistical manual of mental disorders DSM-5 2013 5 ed. Arlington, VA American Psychiatric Association
Diagnostic and statistical manual of mental disorders. DSM-5. 5th ed. ed. Arlington, VA :: American Psychiatric Association; 2013.
31. Huang C Wang Y Li X Ren L Zhao J Hu Y Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Lancet 2020 395 10223 497 506 10.1016/S0140-6736(20)30183-5 31986264
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.31986264 10.1016/S0140-6736(20)30183-5
32. Doosti-Irani A Haghdoost AA Najafi F Eybpoosh S Moradi G Bagheri Amiri F How can the epidemic curve of COVID-19 in Iran be interpreted? J Res Health Sci 2020 20 3 e00491 10.34172/jrhs.2020.27 33169723
Doosti-Irani A, Haghdoost AA, Najafi F, Eybpoosh S, Moradi G, Bagheri Amiri F, et al. How can the epidemic curve of COVID-19 in Iran be interpreted? J Res Health Sci. 2020;20(3):e00491.33169723 10.34172/jrhs.2020.27
33. Mowla A Ardekani A Feili A Rahimian Z Effects of COVID-19 pandemic and lockdown on mental health of Iranian people Przegl Epidemiol 2021 75 4 484 9 10.32394/pe.75.44 35543421
Mowla A, Ardekani A, Feili A, Rahimian Z. Effects of COVID-19 pandemic and lockdown on mental health of Iranian people. Przegl Epidemiol. 2021;75(4):484–9.35543421 10.32394/pe.75.44
34. Pfefferbaum B North CS Mental Health and the Covid-19 pandemic N Engl J Med 2020 383 6 510 2 10.1056/NEJMp2008017 32283003
Pfefferbaum B, North CS. Mental Health and the Covid-19 pandemic. N Engl J Med. 2020;383(6):510–2.32283003 10.1056/NEJMp2008017
35. Statement on the fifteenth meeting of the IHR. (2005) Emergency Committee on the COVID-19 pandemic World Health Organization2023 https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic
36. Racine N McArthur BA Cooke JE Eirich R Zhu J Madigan S Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a Meta-analysis JAMA Pediatr 2021 175 11 1142 50 10.1001/jamapediatrics.2021.2482 34369987
Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a Meta-analysis. JAMA Pediatr. 2021;175(11):1142–50.34369987 10.1001/jamapediatrics.2021.2482
37. Smirni P, Lavanco G, Smirni D. Anxiety in older adolescents at the time of COVID-19. J Clin Med. 2020;9(10).
38. Meherali S, Punjani N, Louie-Poon S, Abdul Rahim K, Das JK, Salam RA et al. Mental Health of children and adolescents amidst COVID-19 and Past Pandemics: a Rapid systematic review. Int J Environ Res Public Health. 2021;18(7).
39. Jones EAK, Mitra AK, Bhuiyan AR. Impact of COVID-19 on Mental Health in adolescents: a systematic review. Int J Environ Res Public Health. 2021;18(5).
40. Panchal U Salazar de Pablo G Franco M Moreno C Parellada M Arango C The impact of COVID-19 lockdown on child and adolescent mental health: systematic review Eur Child Adolesc Psychiatry 2023 32 7 1151 77 10.1007/s00787-021-01856-w 34406494
Panchal U, Salazar de Pablo G, Franco M, Moreno C, Parellada M, Arango C, et al. The impact of COVID-19 lockdown on child and adolescent mental health: systematic review. Eur Child Adolesc Psychiatry. 2023;32(7):1151–77.34406494 10.1007/s00787-021-01856-w
41. Saulle R De Sario M Bena A Capra P Culasso M Davoli M School closures and mental health, wellbeing and health behaviours among children and adolescents during the second COVID-19 wave: a systematic review of the literature Epidemiol Prev 2022 46 5–6 333 52 36384255
Saulle R, De Sario M, Bena A, Capra P, Culasso M, Davoli M, et al. School closures and mental health, wellbeing and health behaviours among children and adolescents during the second COVID-19 wave: a systematic review of the literature. Epidemiol Prev. 2022;46(5–6):333–52.36384255
42. Nearchou F Flinn C Niland R Subramaniam SS Hennessy E Exploring the impact of COVID-19 on Mental Health outcomes in Children and adolescents: a systematic review Int J Environ Res Public Health 2020 17 22 10.3390/ijerph17228479
Nearchou F, Flinn C, Niland R, Subramaniam SS, Hennessy E. Exploring the impact of COVID-19 on Mental Health outcomes in Children and adolescents: a systematic review. Int J Environ Res Public Health. 2020;17:22.10.3390/ijerph17228479
43. Tang S Xiang M Cheung T Xiang YT Mental health and its correlates among children and adolescents during COVID-19 school closure: the importance of parent-child discussion J Affect Disord 2021 279 353 60 10.1016/j.jad.2020.10.016 33099049
Tang S, Xiang M, Cheung T, Xiang YT. Mental health and its correlates among children and adolescents during COVID-19 school closure: the importance of parent-child discussion. J Affect Disord. 2021;279:353–60.33099049 10.1016/j.jad.2020.10.016
44. Magson NR Freeman JYA Rapee RM Richardson CE Oar EL Fardouly J Risk and Protective Factors for Prospective Changes in Adolescent Mental Health during the COVID-19 pandemic J Youth Adolesc 2021 50 1 44 57 10.1007/s10964-020-01332-9 33108542
Magson NR, Freeman JYA, Rapee RM, Richardson CE, Oar EL, Fardouly J. Risk and Protective Factors for Prospective Changes in Adolescent Mental Health during the COVID-19 pandemic. J Youth Adolesc. 2021;50(1):44–57.33108542 10.1007/s10964-020-01332-9
45. Terin H Açıkel SB Yılmaz MM Şenel S The effects of anxiety about their parents getting COVID-19 infection on children’s mental health Eur J Pediatr 2023 182 1 165 71 10.1007/s00431-022-04660-z 36264340
Terin H, Açıkel SB, Yılmaz MM, Şenel S. The effects of anxiety about their parents getting COVID-19 infection on children’s mental health. Eur J Pediatr. 2023;182(1):165–71.36264340 10.1007/s00431-022-04660-z
46. Kolcakoglu K Yucel G Anxiety and harmful oral habits in preschool children during the 2020 first-wave COVID–19 lockdown in Turkey Dent Med Probl 2021 58 4 433 9 10.17219/dmp/142284 34931763
Kolcakoglu K, Yucel G. Anxiety and harmful oral habits in preschool children during the 2020 first-wave COVID–19 lockdown in Turkey. Dent Med Probl. 2021;58(4):433–9.34931763 10.17219/dmp/142284
47. Di Riso D, Bertini S, Spaggiari S, Olivieri F, Zaffani S, Comerlati L et al. Short-term effects of COVID-19 lockdown in Italian children and adolescents with type 1 diabetes Mellitus: the role of separation anxiety. Int J Environ Res Public Health. 2021;18(11).
48. Sinnathamby A, Ng SH, Zain A, Lu L, Yong C, Thong X et al. Anxiety in hospitalised families: lessons from the early phase of the COVID-19 pandemic. Singap Med J. 2023.
49. Alnamnakani M Alenezi S Temsah H Alothman M Murshid RE Alonazy H Psychosocial impact of Lockdown on children due to COVID-19: a cross-sectional study Clin Pract Epidemiol Ment Health 2022 18 e174501792203210 10.2174/17450179-v18-e2203210 37274846
Alnamnakani M, Alenezi S, Temsah H, Alothman M, Murshid RE, Alonazy H, et al. Psychosocial impact of Lockdown on children due to COVID-19: a cross-sectional study. Clin Pract Epidemiol Ment Health. 2022;18:e174501792203210.37274846 10.2174/17450179-v18-e2203210
50. Hahn L, Hajinlian J, Eisen AR, Winder B, Pincus DB. Measuring the dimensions of separation anxiety and early panic in children and adolescents: The Separation Anxiety Assessment Scale. 37th annual convention of the Association for Advancement of Behavior Therapy; Boston, MA2003.
51. Hajinlian J Hahn LG Eisen AR Zilli-Richardson L Reddy LA Winder B The phenomenon of separation anxiety across DSM-IV internalizing and externalizing disorders 2003 37 Boston, MA Annual Convention of the Association for the Advancement of Behavior Therapy
Hajinlian J, Hahn LG, Eisen AR, Zilli-Richardson L, Reddy LA, Winder B, et al. The phenomenon of separation anxiety across DSM-IV internalizing and externalizing disorders. 37 ed. Boston, MA: Annual Convention of the Association for the Advancement of Behavior Therapy; 2003.
52. Hajinlian J, Mesnick J, Eisen AR. Separation anxiety symptom dimensions and DSM-IV anxiety disorders: Correlates, comorbidity, and clinical utility. 39th annual convention of the Association for Behavioral and Cognitive Therapies; Washington, DC2005.
53. Talaeinejad N Ghanbari S Mazaheri M Asgari A Preliminary Properties of Separation Anxiety Assessment Scale (parent version) Dev Pscychology 2016 12 47 225 35
Talaeinejad N, Ghanbari S, Mazaheri M, Asgari A. Preliminary Properties of Separation Anxiety Assessment Scale (parent version). Dev Pscychology. 2016;12(47):225–35.
54. Talaienejad N Separation anxiety Assessment Scale (parent version): instruction and scoring (Persian Version) 2018 14 55 343 6
Talaienejad N. Separation anxiety Assessment Scale (parent version): instruction and scoring. (Persian Version). 2018;14(55):343–6.
55. Maechler M, Rousseeuw P, Struyf A, Hubert M, Hornik K, Studer M, Roudier P, Gonzalez J. Package ‘cluster’. 2013.
56. Epskamp S, Costantini G, Haslbeck J, Cramer AO, Epskamp MS, RSVGTipsDevice. S. Package ‘qgraph’. 2017.
57. R Core Team R: a Language and Environment for Statistical Computing 2023 Vienna, Austria R Foundation for Statistical Computing
R Core Team. R: a Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2023.
58. Dotto C, Montanaro M, Spaggiari S, Cecinati V, Brescia L, Insogna S et al. Early evidence of the interplay between separation anxiety symptoms and COVID-19-Related worries in a group of children diagnosed with Cancer and their mothers. Child (Basel). 2022;9(4).
59. Kathirvel N Post COVID-19 pandemic mental health challenges Asian J Psychiatr 2020 53 102430 10.1016/j.ajp.2020.102430 33264840
Kathirvel N. Post COVID-19 pandemic mental health challenges. Asian J Psychiatr. 2020;53:102430.33264840 10.1016/j.ajp.2020.102430
60. Iqbal SZ Li B Onigu-Otito E Naqvi MF Shah AA The long-term Mental Health effects of COVID-19 Psychiatric Annals 2020 50 12 522 5 10.3928/00485713-20201103-01
Iqbal SZ, Li B, Onigu-Otito E, Naqvi MF, Shah AA. The long-term Mental Health effects of COVID-19. Psychiatric Annals. 2020;50(12):522–5.10.3928/00485713-20201103-01
61. Hale WW Raaijmakers Q Muris P van Hoof A Meeus W Developmental trajectories of adolescent anxiety disorder symptoms: a 5-year prospective community study J Am Acad Child Adolesc Psychiatry 2008 47 5 556 64 10.1097/CHI.0b013e3181676583 18356762
Hale WW 3rd, Raaijmakers Q, Muris P, van Hoof A, Meeus W. Developmental trajectories of adolescent anxiety disorder symptoms: a 5-year prospective community study. J Am Acad Child Adolesc Psychiatry. 2008;47(5):556–64.18356762 10.1097/CHI.0b013e3181676583
62. Last CG Somatic complaints in anxiety disordered children J Anxiety Disord 1991 5 2 125 38 10.1016/0887-6185(91)90024-N
Last CG. Somatic complaints in anxiety disordered children. J Anxiety Disord. 1991;5(2):125–38.10.1016/0887-6185(91)90024-N
63. Rapee RM Kennedy SJ Ingram M Edwards SL Sweeney L Altering the trajectory of anxiety in at-risk young children Am J Psychiatry 2010 167 12 1518 25 10.1176/appi.ajp.2010.09111619 20810472
Rapee RM, Kennedy SJ, Ingram M, Edwards SL, Sweeney L. Altering the trajectory of anxiety in at-risk young children. Am J Psychiatry. 2010;167(12):1518–25.20810472 10.1176/appi.ajp.2010.09111619
64. Fisak B, Penna A, Mian ND, Lamoli L, Margaris A, Cruz S. The effectiveness of anxiety interventions for Young children: a Meta-Analytic Review. J Child Fam Stud. 2023:1–12.
65. Eisen AR Raleigh H Neuhoff CC The unique impact of parent training for separation anxiety disorder in children Behav Ther 2008 39 2 195 206 10.1016/j.beth.2007.07.004 18502252
Eisen AR, Raleigh H, Neuhoff CC. The unique impact of parent training for separation anxiety disorder in children. Behav Ther. 2008;39(2):195–206.18502252 10.1016/j.beth.2007.07.004
66. Lewinsohn PM Holm-Denoma JM Small JW Seeley JR Joiner TE Separation anxiety disorder in Childhood as a risk factor for Future Mental illness J Am Acad Child Adolesc Psychiatry 2008 47 5 548 55 10.1097/CHI.0b013e31816765e7 18356763
Lewinsohn PM, Holm-Denoma JM, Small JW, Seeley JR, Joiner TE. Separation anxiety disorder in Childhood as a risk factor for Future Mental illness. J Am Acad Child Adolesc Psychiatry. 2008;47(5):548–55.18356763 10.1097/CHI.0b013e31816765e7
67. Kendall PC Brady EU Verduin TL Comorbidity in childhood anxiety disorders and treatment outcome J Am Acad Child Adolesc Psychiatry 2001 40 7 787 94 10.1097/00004583-200107000-00013 11437017
Kendall PC, Brady EU, Verduin TL. Comorbidity in childhood anxiety disorders and treatment outcome. J Am Acad Child Adolesc Psychiatry. 2001;40(7):787–94.11437017 10.1097/00004583-200107000-00013
68. Compton SN Walkup JT Albano AM Piacentini JC Birmaher B Sherrill JT Child/Adolescent anxiety Multimodal Study (CAMS): rationale, design, and methods Child Adolesc Psychiatry Ment Health 2010 4 1 10.1186/1753-2000-4-1 20051130
Compton SN, Walkup JT, Albano AM, Piacentini JC, Birmaher B, Sherrill JT, et al. Child/Adolescent anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health. 2010;4:1.20051130 10.1186/1753-2000-4-1
