# Factors associated with an increased risk of anxiety among adolescents during the COVID-19 lockdown in the French Grand Est area

Stéphanie Bourion-Bédès, Elodie Jeanbert, Ahmet Diakhate, Hélène Rousseau, Martine Batt, Marcel Kode, Anja Todorović, Cédric Baumann

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## ► To cite this version:

Stéphanie Bourion-Bédès, Elodie Jeanbert, Ahmet Diakhate, Hélène Rousseau, Martine Batt, et al. Factors associated with an increased risk of anxiety among adolescents during the COVID-19 lockdown in the French Grand Est area. Journal of Psychiatric Research, 2024, 176, pp.40-46. 10.1016/j.jpsychires.2024.05.049. hal-04765459

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# Factors associated with an increased risk of anxiety among adolescents during the COVID-19 lockdown in the French Grand Est area

Stéphanie Bourion-Bédès<sup>a, b, *</sup>, Elodie Jeanbert<sup>c</sup>, Ahmet Diakhate<sup>b</sup>, Hélène Rousseau<sup>c</sup>, Martine Batt<sup>d</sup>, Marcel Kode<sup>d</sup>, Anja Todorović<sup>e</sup>, Cédric Baumann<sup>c, e</sup>

## ABSTRACT

The COVID-19 pandemic has impacted adolescent mental health worldwide. The current study aims to assess the feelings of French adolescents and the factors related to anxiety among these adolescents during the first lockdown due to COVID-19. A sample of 284 French adolescents from the Grand Est region aged 12–18 years completed an online survey evaluating their pandemic-related anxiety symptoms, behaviors, and feelings regarding the contingent strategies of lockdown that were taken and their living and learning conditions, family relationships, and social support. The Generalized Anxiety Disorder Scale (GAD-6) was used to assess anxiety. Data on parents’ mental health status were also collected. A word cloud was generated to visualize respondents’ feelings according to word use frequency. Cross-sectional analysis with linear regression was performed to identify the factors associated with a higher level of anxiety in adolescents. Higher anxiety scale scores were observed among females than among males (β = 1.2; P = 0.0005), among adolescents experiencing conflicts at home (β = 0.9; P = 0.03) and difficulties in isolation (β = 1.1; P = 0.02) than among those who did not report any difficulty, and among those working less than 2 h a day (β = 1.1; P = 0.003) than among those working more. Anxiety scale scores were lower in adolescents with higher family social support (β = −0.66; P < 0.001) and those with parents with no anxiety (β = −2.28; P < 0.001), lower anxiety (β = −1.38; P = 0.018), and higher mental health-related quality of life (β = −0.04; P = 0.03). These findings suggest a need to support interventions targeting parents’ anxiety, develop strategies to increase family support, and establish consistent work schedules for children.

## 1. Introduction

The COVID-19 pandemic has impacted the lives of individuals worldwide, including through physical and mental health (Holmes et al., 2020). The early weeks of the pandemic saw rapid changes in daily routines due to public health measures to prevent and reduce the spread of the virus in an exceptional way. An emerging body of literature reveals that the pandemic led to a 27.6% increase in cases of major depressive disorders and a 25.6% increase in cases of anxiety disorders globally (COVID-19 Mental Disorders Collaborators, 2021) and that certain populations, such as children and adolescents, have been more vulnerable to worsening mental health during and after a pandemic (Hawes et al., 2022; Kauhanen et al., 2023). As schools have been closed and most activities for children and adolescents that typically occur in group settings and outside the home have been canceled, children and adolescents have limited social interaction with peers, teachers, and extended family (Lee, 2020). This can be particularly challenging for

adolescents who are going through a stage of development characterized by rises in parental conflict, mental health difficulties, and a developmental need associated with social connection and acceptance from peers (Stewart et al., 2022). Depression and generalized anxiety are two of the most common mental health concerns in youth, and a previous narrative review supported the notion that the COVID-19 pandemic has become a major source of anxiety in children (Walsh et al., 2021). A recent systematic review and meta-analysis of 23 studies mostly conducted in China reported that 25.5% of children and adolescents experienced anxiety during the COVID-19 pandemic (Ma et al., 2021). Disruptions in daily routines, uncertainty, and concerns for the well-being of family and loved ones during the COVID-19 pandemic were likely associated with increases in generalized anxiety in youth (Racine et al., 2021). Moreover, higher rates of mental health problems were reported for parents during the COVID-19 pandemic than in adults without caregiving responsibilities (Fegert et al., 2020). From one day to the next, families were required to adjust to new circumstances as well

<footnote><sup>a</sup> Université Paris-Saclay, UVSQ, INSERM, Centre for Research in Epidemiology and Population Health (CESP), Team "DevPsy", 94807, Villejuif, France</footnote>

<footnote><sup>b</sup> Centre Hospitalier de Versailles, Service Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, 78 157, Le Chesnay, France</footnote>

<footnote><sup>c</sup> Methodology, Data Management and Statistics Unit, University Hospital of Nancy, 54000, Nancy, France</footnote>

<footnote><sup>d</sup> InterPsy, GRC Team, University of Lorraine, 54000, Nancy, France</footnote>

<footnote><sup>e</sup> UMR 1319 INSPIIRE, University of Lorraine, 54000, Nancy, France</footnote>

<footnote>* Corresponding author. Service universitaire de psychiatrie de l'enfant et de l'adolescent, Centre Hospitalier de Versailles, France.</footnote>

<footnote>E-mail addresses: stephanie.bourion-bedes@uvsq.fr (S. Bourion-Bédès), e.jeanbert@chru-nancy.fr (E. Jeanbert), ahdiakhate@ght78sud.fr (A. Diakhate), h. rousseau@chru-nancy.fr (H. Rousseau), martine.batt@univ-lorraine.fr (M. Batt), marcel.kode@univ-lorraine.fr (M. Kode), c.baumann@chru-nancy.fr (C. Baumann).</footnote>
as studying and working from home, take on new roles as schooling
demands evolved, and deal with new or exacerbated hardships (e.g.,
household, job loss, reduced income, illness, social isolation, and
restricted mobility) (Hawes et al., 2022), thus potentially stressing all
family members (Stracke et al., 2023).

The identification of risk factors associated with a higher level of anxiety in adolescents particularly in anxiety-provoking situations such as the COVID-19 pandemic is needed (Parsons, 2020; Tang et al., 2020), as understanding adolescents' health is crucial and sets the stages for later outcomes (Singh et al., 2020; Mohler-Kuo et al., 2021); this information might guide public health and policy makers on strategies and interventions to improve mental health among children and adolescents during pandemics. On the one hand, previous studies have shown that girls, older children, children living in an urban region, and children with a friend/relative infected by COVID-19 appear to be most prone to mental health problems (Zhou et al., 2020; Duan et al., 2020). On the other hand, protective factors such as social support have been shown to prevent anxiety symptoms in adolescents (Qi et al., 2020). Nevertheless, research on the associations between parents' and children's psychological states during the lockdown is sparse. A recent study highlighted the significant association between parents' and children's anxiety. However, the children were not interviewed directly; instead, their anxiety levels were measured using a parent/teacher questionnaire about symptoms they had witnessed in the children (Saddik et al., 2021). A limitation of this hetero-evaluation is that anxious parents might be more likely to report or recognize anxiety in their children.

Thus, to better understand the needs of adolescents in anxiety-
provoking situations and to develop preventive interventions, this
study aimed to a) assess the feelings and behaviors of French adolescents
aged 12–18 years old under lockdown regarding the contingent strate-
gies of lockdown that were taken and b) identify factors related to a
higher level of anxiety in adolescents, including sociodemographic
factors, living and learning conditions, family relationships, social sup-
port, and parental health status characteristics. Because certain factors
are modifiable, examining their role could aid in the implementation of
strategies to decrease anxiety.

## 2. Methods

2.1. *Design and participants*

This present cross-sectional study was assessed based on the data
obtained from the observational Feelings and Psychological Impact of
the COVID-19 Epidemic Among Children, Adolescents, and Their Par-
ents in the Grand Est Area (PIMS2-CoV19). Data collection was con-
ducted from May 26th to July 6th, 2020. From a complete list of middle
and high schools, schools were randomly selected using proportionate
stratification for the baseline identification and recruitment of partici-
pants. Eligible participants were adolescents aged 12–18 years currently
living in the Grand Est area and studying in one of the selected schools.
The survey was disseminated through school institutional mailing lists.
Information about the study and the online survey were accessible with
an internet connection. Parents and children were asked to complete a
20-min online survey on anxiety, health-related quality of life, and
COVID-19-related experiences after providing agreement to participate.
Questions about demographics, living conditions, and parents' anxiety
and stress were completed by one parent. Among the 1509 school-
children aged 12–18 years who accessed the online survey, 308 agreed
to participate. Complete data were obtained for 284 children from 230
distinct households. In total, 284 children and 230 parents were
included. All procedures were approved by the Institutional Review
Board (Comité National Informatique et Liberté-registration 2220408)
and were conducted in full compliance with the national regulations and
the principles of the Declaration of Helsinki.

## 2.2. Measures

There were two parts of the online survey: one part for the parent and another part for the child. A code allowed each respondent to access to the appropriate part. Sociodemographic data as well as living and learning conditions were completed by the parents. Age and gender were re-entered by the children at the beginning of the completion of their questionnaire. Information on feelings and behaviors was completed by the children. Parents and children completed the self-questionnaires in their respective parts.

2.2.1. *Sociodemographic data, living and learning conditions, feelings and behaviors*

Data on children's age, sex, and education level were obtained. Among learning and living conditions, time spent on homework, home location, type of residence, access to a private outside space, frequency of physical activity, presence of noise and conflict in the household, and means used to mitigate anxiety were obtained. Two open questions assessed adolescents' feelings about the lockdown: “When you think of lockdown, what 3 words or expressions come directly to mind?” and “Could you rank these words or expressions from most to least representative?” Information on the presence of a relative in the household who was infected with COVID-19 was also collected from the parent.

2.2.2. *Adolescents’ anxiety and social support*

Anxiety was measured by the GAD-6 derived from the original Generalized Anxiety Disorder-7 items scale (GAD-7) (Spitzer et al., 2006), as the GAD-6 scale presents better psychometric properties in this French adolescent population than the original GAD-7 (Todorović et al., 2023). With this self-administered rating scale, adolescents were asked to what extent each of the items described them in the past 2 weeks. The GAD-6 consists of six items with a 3-point Likert-type scale of “not at all”, “several days”, and “nearly every day”, scored as 0, 1, and 2, respectively. Thus, GAD-6 scores range from 0 to 12, with higher scores representing higher anxiety symptom levels. In our study, the GAD-6 scale showed good internal consistency (α = 0.85). The Multidimensional Scale of Perceived Social Support (MSPSS) is a self-assessment questionnaire exploring social support from three sources: family (extended or nuclear unit of people related by birth or affinity), friends (people who share mutual affection but not related by blood) and significant others (people considered important, influential or intimately close) (Zimet et al., 1988). The MSPSS was applied since it was previously used among adolescents (Ling et al., 2015). It comprises a total of 12 items, with 4 items for each subscale. Each item is rated on a 7-point Likert scale ranging from 1 (“very strongly disagree”) to 7 (“very strongly agree”). The scores for the 4 items in each subscale were added to obtain the subscale scores, with higher scores indicating higher perceived social support.

2.2.3. *Parents’ health status and social support*

The Perceived Stress Scale-10 (PSS-10) was used to assess parents'
stress. This 10-item form is derived from the original 14-item version
developed to measure "the degree situations in one's life appraised as
stressful" (Cohen et al., 1983). Each item reflecting the frequency of an
indicator of stress over the past month is scored on a 5-point Likert-type
scale ranging from 0 "never" to 4 "very often". Thus, PSS-10 scores range
from 0 to 40, with higher scores reflecting greater perceived stress. A
score of 0–13 is considered "low stress", 14–26 is considered "moderate
stress", and 26–40 is considered "high stress" (AlAteeq et al., 2020). The
French version of the measure has previously demonstrated good in-
ternal consistency (Lesage et al., 2012). Parent anxiety was screened
with the French GAD-7, which has previously been confirmed to have
good internal consistency and external validity (Micoulaud-Franchi
et al., 2016). A score of 5–9 is considered "mild anxiety", 10–14 is
considered "moderate anxiety" and 15–21 is considered "severe anxiety"
(Spitzer et al., 2006). Health-related quality of life was assessed by the
validated French version of the Medical Outcomes Study Short-Form 12-item Health Survey (SF-12) (Gandek et al., 1998). A physical health component summary (PCS) and a mental health component summary (MCS) were calculated from all 12 items. Higher scores indicated better self-reported health status. Social support was measured the same MSPSS scale used for the child.

## 2.3. Statistical analyses

Data are represented as the mean ± standard deviation (SD) or median as appropriate for continuous variables and as the number and the percentage for categorical variables.

Bivariable linear regressions were performed to select candidate variables for the multivariable model. The variable to be explained was the continuous GAD-6 score. The explanatory variables were socio-demographic factors, living and learning conditions, family relationships, social support and parental health status. The results are expressed as the mean when the explanatory variable was categorical and as Pearson's correlation coefficient when it was continuous. Only variables with a test p-value <0.2 were eligible for the multivariable linear regression model. A forward selection procedure was applied to retain significant independent factors. The absence of collinearity between the variables used in the model was also verified. The significance threshold was set at 5%. Positive and significant β coefficients reflected the effects of factors on the level of anxiety. Analyses were performed using SAS 9.4 (SAS Inst., Cary, NC, USA).

The answers to the two open questions assessing the adolescents' feelings about COVID-19 were clustered into themes. Themes were ranked according to their frequency of occurrence (high to low). Word cloud generation, a method used to visualize textual data, is increasingly used in clinical research as a quick and practical method to provide a synopsis of the main themes in textual data. A word cloud created by nuagesdemots.fr displays the most frequently used words in descending order by size. Larger-sized words depict a higher frequency of the word.

# 3. Results

## 3.1. Characteristics of the adolescent and parent samples

A total of 284 adolescents from 230 distinct households participated. The characteristics of the sample of children are summarized in Table 1. Over half of the sample identified as female (55.3%), and the participants' mean age was 14.9 years old (SD = 2.1). A total of 65.2% lived with both parents during the lockdown. More than half lived (59.2%) in rural areas, and 21.6% reported never leaving home. Furthermore, 6.5% reported having no access to outdoor areas. The participants were mostly from middle school (60.2%).

Seventy-one of the sample (25.4%) reported spending less than 2 h per day on homework during the lockdown. Of the 284 participants, 31.7% reported conflicts with family members in their house and where they spent the lockdown, and 14.8% found it difficult to isolate themselves in the dwelling. In addition, 14.5% had someone in their household infected with COVID-19.

Regarding the coronavirus outbreak, it was found that 46.6% of the parents who participated presented a moderate to high level of stress, with a PSS-10 score higher than 13. The rate of parents' mild anxiety was 30%, and the rates of moderate and severe anxiety were 13.5% and 3.5%, respectively. Over a quarter of the parents (29.7%) reported a work interruption due to the lockdown, and 36.9% reported being a full-time worker telecommuting from home. Less than half of them (48.3%) reported spending 2 h or more per day on child schoolwork during the lockdown. Almost half of the parents (43.5%) indicated taking on daily specific COVID-19 prevention behaviors at home, such as disinfecting door handles and changing and washing clothes worn outdoors to avoid contamination. The characteristics of the parents' sample are summarized in Table 2.

<table><caption>**Table 1**
Sociodemographic, living and learning conditions of the sample of children (N = 284).</caption><thead><tr><th rowspan="2"></th><th colspan="2">Full sample (N = 284)</th></tr><tr><th>N</th><th>%/Mean (SD)</th></tr></thead><tbody><tr><td>Age</td><td>284</td><td>14.9 (2.1)</td></tr><tr><td>Sex</td><td></td><td></td></tr><tr><td>Male</td><td>127</td><td>44.7</td></tr><tr><td>Female</td><td>157</td><td>55.3</td></tr><tr><td>Family structure (missing = 2)</td><td></td><td></td></tr><tr><td>Both parents</td><td>184</td><td>65.2</td></tr><tr><td>Single parent, separated parents with partner</td><td>98</td><td>34.8</td></tr><tr><td>Number of children or adolescents living at home</td><td></td><td></td></tr><tr><td>1</td><td>46</td><td>16.4</td></tr><tr><td>2</td><td>153</td><td>54.5</td></tr><tr><td>3 or +</td><td>82</td><td>29.1</td></tr><tr><td>Educational level</td><td></td><td></td></tr><tr><td>Middle school</td><td>171</td><td>60.2</td></tr><tr><td>High school</td><td>113</td><td>39.8</td></tr><tr><td>Home location</td><td></td><td></td></tr><tr><td>Urban</td><td>115</td><td>40.8</td></tr><tr><td>Rural</td><td>167</td><td>59.2</td></tr><tr><td>Access to a private outside area</td><td></td><td></td></tr><tr><td>No access</td><td>15</td><td>5.3</td></tr><tr><td>Exclusive use</td><td>261</td><td>91.9</td></tr><tr><td>Collective use</td><td>8</td><td>2.8</td></tr><tr><td>Frequency of physical activity</td><td></td><td></td></tr><tr><td>Extremely</td><td>35</td><td>12.3</td></tr><tr><td>A lot</td><td>70</td><td>24.7</td></tr><tr><td>Moderately</td><td>96</td><td>33.8</td></tr><tr><td>A little</td><td>53</td><td>18.6</td></tr><tr><td>Never practicing</td><td>30</td><td>10.6</td></tr><tr><td>Time spent on homework (missing = 4)</td><td></td><td></td></tr><tr><td>&lt;2 h a day</td><td>71</td><td>25.4</td></tr><tr><td>≥2 h a day</td><td>209</td><td>74.6</td></tr><tr><td>Difficulty isolating at home</td><td></td><td></td></tr><tr><td>No</td><td>242</td><td>85.2</td></tr><tr><td>Yes</td><td>42</td><td>14.8</td></tr><tr><td>Tensions and conflicts at home</td><td></td><td></td></tr><tr><td>No</td><td>194</td><td>68.3</td></tr><tr><td>Yes</td><td>90</td><td>31.7</td></tr><tr><td>Noise within the residence</td><td></td><td></td></tr><tr><td>No</td><td>258</td><td>90.8</td></tr><tr><td>Yes</td><td>26</td><td>9.2</td></tr><tr><td>Noise outside the residence</td><td></td><td></td></tr><tr><td>No</td><td>254</td><td>89.4</td></tr><tr><td>Yes</td><td>30</td><td>10.6</td></tr><tr><td>Someone in the household infected with COVID-19</td><td></td><td></td></tr><tr><td>No</td><td>243</td><td>85.5</td></tr><tr><td>Confirmed cases, hospitalized cases</td><td>41</td><td>14.5</td></tr></tbody></table>

Abbreviations: SD, standard deviation.

## 3.2. Children's behaviors, perceptions of lockdown, anxiety and social support scores

As shown in Table 3, media entertainment was largely successfully used by adolescents rather than physical exercise and reading as a means to relieve their distress and address their concerns regarding the negative conditions they were experiencing. Fig. 1 illustrates adolescents' perceptions of lockdown based on the frequency of the occurrence of each word. The most frequently recurring words beyond 3 citations are shown next to the word cloud. The phrase "exit ban" is appeared most often. The words "home", "boredom", "homework" and "COVID-19" followed "exit ban" in terms of their relative frequency. In addition, the words "anxiety", "loneliness", "screens" and "stress" stand out.

The results of the GAD-6 and MSPSS are presented in Table 4. The mean GAD-6 score was 3.4 (SD = 3.2), the median score was 3.0, and the interquartile range was 1–5. The mean MSPSS total score was 5.6 (SD = 1.3). The mean scores for support from family, friends, and significant others were 5.7 (SD = 1.4), 5.5 (SD = 1.6), and 5.7 (SD = 1.3), respectively.
<table><caption>**Table 2**

Characteristics of the parents of the sample of children.</caption><thead><tr><th rowspan="2"></th><th colspan="2">Full sample (N = 230)</th></tr><tr><th>N</th><th>%/Mean (SD)</th></tr></thead><tbody><tr><td><strong>Occupational status during the lockdown (missing=8)</strong></td><td></td><td></td></tr><tr><td>Work interruption</td><td>66</td><td>29.7</td></tr><tr><td>Full-time worker telecommuting from home</td><td>82</td><td>36.9</td></tr><tr><td>Full-time worker at work</td><td>49</td><td>22.1</td></tr><tr><td>Worker working most of the time at work, remaining time at home</td><td>13</td><td>5.9</td></tr><tr><td>Worker working most time at home, remaining time at work</td><td>12</td><td>5.4</td></tr><tr><td><strong>COVID-19 prevention behaviors at home</strong></td><td></td><td></td></tr><tr><td>No</td><td>130</td><td>56.5</td></tr><tr><td>Yes</td><td>100</td><td>43.5</td></tr><tr><td><strong>Time spent on child school work (missing=2)</strong></td><td></td><td></td></tr><tr><td>&lt;2 h a day</td><td>118</td><td>51.7</td></tr><tr><td>2–4 h a day</td><td>72</td><td>31.6</td></tr><tr><td>&gt;4 h a day</td><td>38</td><td>16.7</td></tr><tr><td><strong>PSS-10- total score</strong></td><td></td><td></td></tr><tr><td>Low stress (0–13)</td><td>123</td><td>53.5</td></tr><tr><td>Moderate stress (14–26)</td><td>94</td><td>40.9</td></tr><tr><td>High perceived stress (27–40)</td><td>13</td><td>5.7</td></tr><tr><td><strong>GAD-7- total score</strong></td><td></td><td></td></tr><tr><td>Normal (0–4)</td><td>122</td><td>53.0</td></tr><tr><td>Mild anxiety (5–9)</td><td>69</td><td>30.0</td></tr><tr><td>Moderate anxiety (10–14)</td><td>31</td><td>13.5</td></tr><tr><td>Severe anxiety (15–21)</td><td>8</td><td>3.5</td></tr><tr><td>SF-12 PCS score</td><td>230</td><td>51.7 (7.8)</td></tr><tr><td>SF-12 MCS score</td><td>230</td><td>44.9 (11.6)</td></tr><tr><td>MSPSS-total score</td><td>230</td><td>5.5 (1.2)</td></tr><tr><td><strong>MSPSS-subscales</strong></td><td></td><td></td></tr><tr><td>Family</td><td>230</td><td>5.5 (1.3)</td></tr><tr><td>Friend</td><td>230</td><td>5.3 (1.5)</td></tr><tr><td>Significant other</td><td>230</td><td>5.7 (1.3)</td></tr></tbody></table>

Abbreviations: SD, standard deviation; PSS-10, 10-item Perceived Stress Scale; GAD-7,7-item Generalized Anxiety Disorder; SF-12, Short Form SF-12; MSPSS, Multidimensional Scale of Perceived Social Support.

<table><caption>**Table 3**

Means used by children to mitigate anxiety during the COVID-19 lockdown.</caption><thead><tr><th>Option</th><th>Not used</th><th>Ineffective 1</th><th>2</th><th>3</th><th>4</th><th>Very effective 5</th></tr></thead><tbody><tr><td>Media entertainment, %</td><td>0.7</td><td>2.8</td><td>5.0</td><td>11.0</td><td>28.8</td><td>51.6</td></tr><tr><td>Reading entertainment, %</td><td>24.6</td><td>7.5</td><td>14.3</td><td>16.4</td><td>17.9</td><td>19.3</td></tr><tr><td>Physical exercise, %</td><td>15.0</td><td>3.9</td><td>11.4</td><td>20.0</td><td>27.9</td><td>21.8</td></tr><tr><td>Snacking between meals, %</td><td>25.0</td><td>11.8</td><td>13.2</td><td>16.1</td><td>17.5</td><td>16.4</td></tr></tbody></table>

### 3.3. Factors associated with a higher level of anxiety during the first lockdown

Table 5 shows the results of bivariate and multivariable analyses. The proportion of variance explained (i.e., R2) was 0.38. Among adolescents' sociodemographics, female gender was associated with a higher level of anxiety (β = 1.2; P = 0.0005). Among living conditions, experiencing conflicts at home (β = 0.9; P = 0.03) and difficulties in isolation (β = 1.1; P = 0.02) were associated with a higher level of anxiety. In terms of learning conditions, working less than 2 h a day (β = 1.1; P = 0.003) was linked to higher anxiety than working more. In terms of social support, both the family and significant other dimensions were associated with the level of anxiety. The GAD-6 score was lower for adolescents with higher family social support (β = -0.66; P < 0.001). Finally, a lower level of parental anxiety was associated with a lower level of adolescent anxiety (β from -1.38; P = 0.018 to -2.28; P < 0.001) (Table 5). Similarly, regarding parental health-related quality of life, the higher the score was, the lower the anxiety score of the adolescent (β = -0.04; P = 0.03).

## 4. Discussion

The present study reports the results of a survey carried out during a critical and particularly anxiety-provoking period when the population was under lockdown, which is of public health significance for an adolescent population at an increased risk of mental health problems (Magson et al., 2021). "Anxiety", "stress" and "loneliness" were the expressions of emotional status that were most reflected in the word cloud. This is aligned with numerous publications showing that students were highly vulnerable to mental health issues during the COVID-19 pandemic and that mental health problems increased during the pandemic (Magson et al., 2021; Jojoa et al., 2022). Among sociodemographic factors, our results suggest that female adolescents were more vulnerable to high levels of anxiety than male adolescents, which is consistent with the findings of previous studies (Zhou et al., 2020; McElroy et al., 2020; Chen et al., 2021). Regarding age, divergent results have been published, with some previous studies reporting that age was positively associated with anxiety among adolescents (Zhou et al., 2020) and others reporting no association (Chen et al., 2020). No association was found with anxiety regarding age in our study. In terms of learning conditions, adolescents faced considerable uncertainties in terms of their educational prospects and academic examination at this time of lockdown. As previously reported, various facets of online learning with reduced opportunities for interaction and imbalance in the distribution of learning resources may promote psychological distress in adolescents (Kim et al., 2022). The results of the present study also highlighted a link between low daily study time (less than 2 h per day) and a higher level of anxiety. These new findings will provide guidance to teachers, political leaders, and parents regarding timely and effective intervention to provide help for school training as appropriate for adolescents in such a context. Although previous research during the lockdown among Chinese youth has shown that children and adolescents who spent less than 0.5 h exercising had increased odds of self-reported psychological distress than those who spent more than 1 h exercising (Qin et al., 2021), our results did not find any association between anxiety and the frequency of physical exercise. However, the results of our multivariable analysis suggest a trend in favor of physical exercise, but a lack of power certainly explains the lack of significant results.

Regarding living conditions, in contrast with previous research (Selçuk et al., 2021), our results did not show a significant relationship between living in an urban area and the level of anxiety, even though the contamination was higher in urban areas due to the impact of population density and restrictions greater to live in urban areas than in rural areas. In contrast with Zhou (Zhou et al., 2020), we did not find that awareness of COVID-19 prevention measures such as wearing a mask and practicing hand hygiene were protective factors against anxiety symptoms. Previous findings have suggested that the level of prevention and control measures for COVID-19 might have had protective psychological effects in the early stages of the epidemic. Thus, as expected, adolescents who experienced familial conflicts and difficulties isolating at home were more anxious than those who did not experience this. In line with this, this study showed that adolescents with lower family social support levels reported higher levels of anxiety. These results are crucial, as the home is one of the first places in which mental health issues often surface. Thus, due to the challenge of staying at home with the entire family in a developmental period when adolescents need to connect with peers and seek greater autonomy from their parents (Magson et al., 2020), it appears imperative that family support be strongly implemented at home. Surprisingly, friends' social support was not associated with the level of anxiety, but significant others' social support was. Certain hypotheses should be mentioned. Compared to family and friends, significant others in a person's life play expansive
<table><caption>Most recurring words in frequency analysis</caption><thead><tr><td>Words</td><td>Citations</td></tr></thead><tbody><tr><td>Exit ban</td><td>88</td></tr><tr><td>Home</td><td>65</td></tr><tr><td>Homework</td><td>61</td></tr><tr><td>Boredom</td><td>58</td></tr><tr><td>COVID-19</td><td>38</td></tr><tr><td>Loss of social connection</td><td>37</td></tr><tr><td>Screens</td><td>35</td></tr><tr><td>Stress</td><td>27</td></tr><tr><td>Anxiety</td><td>25</td></tr><tr><td>Family</td><td>25</td></tr><tr><td>Loneliness</td><td>22</td></tr><tr><td>Loss of freedom</td><td>20</td></tr><tr><td>Sleeping</td><td>19</td></tr><tr><td>Teleworking</td><td>11</td></tr><tr><td>Depression</td><td>10</td></tr><tr><td>Barrier gestures</td><td>10</td></tr><tr><td>Eating</td><td>10</td></tr><tr><td>Lack</td><td>9</td></tr><tr><td>Board games</td><td>8</td></tr><tr><td>Inactivity</td><td>7</td></tr><tr><td>Long</td><td>7</td></tr><tr><td>Hard</td><td>4</td></tr><tr><td>Repetitive</td><td>3</td></tr><tr><td>Death</td><td>3</td></tr><tr><td>Misunderstanding</td><td>3</td></tr><tr><td>Uncertainty</td><td>3</td></tr><tr><td>Others</td><td>21</td></tr><tr><td>Missing</td><td>60</td></tr></tbody></table>

<figure><img src="image_4.png" /><figcaption>**Table 4**
Anxiety and social support scores of the sample of children.</figcaption></figure>

<table><thead><tr><th rowspan="2"></th><th colspan="2">Full sample (N = 284)</th></tr><tr><th>N</th><th>%/Mean (SD)</th></tr></thead><tbody><tr><td>GAD-6- total score</td><td>284</td><td>3.4 (3.2)</td></tr><tr><td>MSPSS-total score</td><td>284</td><td>5.6 (1.3)</td></tr><tr><td>MSPSS-subscales</td><td></td><td></td></tr><tr><td>Family</td><td>284</td><td>5.7 (1.4)</td></tr><tr><td>Friend</td><td>284</td><td>5.5 (1.6)</td></tr><tr><td>Significant other</td><td>284</td><td>5.7 (1.3)</td></tr></tbody></table>

Abbreviations: SD, standard deviation; GAD-6,6-item Generalized Anxiety Disorder; MSPSS, Multidimensional Scale of Perceived Social Support.

and virtually guaranteed emotional, informational, and instrumental roles through the provision of empathy, a sense of relationship stability, financial support, and nonjudgmental counsel, among others (Thoits, 2020). Due to the lockdown and the possibility of new forms of relationships online, the quality or quantity of perceived social support from others could have been more insecure. Moreover, although the MSPSS is widely used, in the literature, there are some discrepancies about its factorial properties (Teh et al., 2019), including in the adolescent population (Chou, 2000).

As expected, our study confirmed the association between the level of parents' perceived health and the level of children's anxiety. As previous findings have already demonstrated that children of anxious parents are twice as likely to have anxiety problems than children of nonanxious parents (Lawrence et al., 2019), our results also suggest that research into interventions targeting parental anxiety should be considered to improve outcomes among children. Interestingly, our results highlighted that the level of anxiety among children is even more impacted for those with parents experiencing moderate to severe anxiety than those with mild anxiety. These results highlight not only the need for innovative programs to manage anxiety and treat widespread

mental health problems among parents but also to consider interventions for parents experiencing moderate to severe anxiety. In the context of the COVID-19 lockdown, these findings support the development of eHealth interventions as a first option, given their feasibility, acceptability, and lower resource use (MacKinnon et al., 2022). Since the pandemic, the number of studies on eHealth programs for parents has increased, but the effects of different types of interventions, including video conferencing, apps, and website-based programs, including or not including some clinician contact, need to be evaluated.

There are some limitations to the present study, and the results should be interpreted in light of several limitations. First, the study focused on adolescents in specific areas of France who volunteered to participate in an online survey, which may have impacted sample representativeness. Second, the research used only self-report measures that were completed using electronic support, which may have excluded potential participants without the internet. Third, this was a cross-sectional study, which limits the ability to make statements about causal relationships. Finally, despite the large number of determinants included in the analyses, the multivariate models explained 38% of the variance; thus, a larger sample could have provided greater statistical power and the inclusion of all potential factors not accounted for by our study. Despite these limitations, this study provides invaluable information on the anxiety of children aged 12–18 years, particularly in anxiety-provoking situations, such as the lockdown during the COVID-19 pandemic. Our results draw attention to interesting findings about routines related to schoolwork and family social support to mitigate the adverse effects of school closures and social restrictions. These results provide novel information that identifies high-risk groups of adolescents and shows that adolescents' level of anxiety is related not only to their parents' state of anxiety but also to parents' severity level of anxiety. These findings support homework recommendations, psychological interventions and family assistance to prevent negative psychological problems for future infectious disease disasters.
<table><caption>**Table 5**
Factors associated with children's anxiety during the COVID-19 lockdown.</caption><thead><tr><th rowspan="3"></th><th colspan="4">GAD-6 score N = 271</th></tr><tr><th colspan="2">Bivariable analysis</th><th colspan="2">Multivariable analysis*<br>R<sup>2</sup> = 0.38</th></tr><tr><th>Moy/r</th><th>P value</th><th>β (SD)</th><th>P value</th></tr></thead><tbody><tr><td><strong>Patient characteristics</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Age (years)</td><td>0.10</td><td>0.286</td><td></td><td></td></tr><tr><td>Gender</td><td></td><td>0.003</td><td></td><td>0.0005</td></tr><tr><td>Male</td><td>2.73</td><td></td><td>0.000</td><td></td></tr><tr><td>Female</td><td>4.02</td><td></td><td>1.19</td><td></td></tr><tr><td>Educational level</td><td></td><td>0.22</td><td></td><td></td></tr><tr><td>Middle school</td><td>3.25</td><td></td><td></td><td></td></tr><tr><td>High school</td><td>3.74</td><td></td><td></td><td></td></tr><tr><td><strong>Living and learning conditions</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Home location</td><td></td><td>0.21</td><td></td><td></td></tr><tr><td>Urban</td><td>3.76</td><td></td><td></td><td></td></tr><tr><td>Rural</td><td>3.27</td><td></td><td></td><td></td></tr><tr><td>Type of residence</td><td></td><td>0.19</td><td></td><td>0.11</td></tr><tr><td>House</td><td>3.33</td><td></td><td>0.00</td><td></td></tr><tr><td>Apartment</td><td>4.00</td><td></td><td>0.73</td><td></td></tr><tr><td>Access to a private outside</td><td></td><td>0.44</td><td></td><td></td></tr><tr><td>No access</td><td>4.47</td><td></td><td></td><td></td></tr><tr><td>Exclusive use</td><td>3.38</td><td></td><td></td><td></td></tr><tr><td>Collective use</td><td>3.63</td><td></td><td></td><td></td></tr><tr><td>Frequency of physical activity</td><td></td><td>0.01</td><td></td><td>0.06</td></tr><tr><td>Extremely</td><td>2.22</td><td></td><td>0.00</td><td></td></tr><tr><td>A lot</td><td>2.41</td><td></td><td>-0.08</td><td>0.94</td></tr><tr><td>Moderately</td><td>3.58</td><td></td><td>0.62</td><td>0.53</td></tr><tr><td>A little</td><td>4.08</td><td></td><td>1.24</td><td>0.22</td></tr><tr><td>Never practicing</td><td>4.26</td><td></td><td>1.08</td><td>0.32</td></tr><tr><td>Time spent on homework</td><td></td><td>0.07</td><td></td><td>0.003</td></tr><tr><td>&lt;2 h a day</td><td>4.18</td><td></td><td>1.14</td><td></td></tr><tr><td>&gt;2 h a day</td><td>3.17</td><td></td><td>0.00</td><td></td></tr><tr><td>Difficulty isolating at home</td><td></td><td>0.001</td><td></td><td>0.02</td></tr><tr><td>No</td><td>3.18</td><td></td><td>0.00</td><td></td></tr><tr><td>Yes</td><td>4.95</td><td></td><td>1.11</td><td></td></tr><tr><td>Tensions and conflicts at home</td><td></td><td>&lt;0.0001</td><td></td><td>0.03</td></tr><tr><td>No</td><td>2.77</td><td></td><td>0.00</td><td></td></tr><tr><td>Yes</td><td>4.90</td><td></td><td>0.87</td><td></td></tr><tr><td>Noise within the residence</td><td></td><td>0.15</td><td></td><td></td></tr><tr><td>No</td><td>3.36</td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>4.31</td><td></td><td></td><td></td></tr><tr><td>Someone infected with COVID-19</td><td></td><td>0.99</td><td></td><td></td></tr><tr><td>In the household</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>3.44</td><td></td><td></td><td></td></tr><tr><td>Confirmed, hospitalized cases</td><td>3.44</td><td></td><td></td><td></td></tr></tbody></table>

<table><thead><tr><th rowspan="3"></th><th colspan="4">GAD-6 score N = 271</th></tr><tr><th colspan="2">Bivariable analysis</th><th colspan="2">Multivariable analysis* R<sup>2</sup> 0.38</th></tr><tr><th>Moy/r</th><th>P value</th><th>β (SD)</th><th>P value</th></tr></thead><tbody><tr><td>COVID-19 prevention behaviors</td><td></td><td>0.83</td><td></td><td></td></tr><tr><td>No</td><td>3.33</td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>3.46</td><td></td><td></td><td></td></tr><tr><td>MSPSS-subscales</td><td></td><td></td><td></td><td></td></tr><tr><td>Family</td><td>-0.61</td><td>&lt;0.0001</td><td>-0.66</td><td>&lt;0.001</td></tr><tr><td>Friend</td><td>-0.28</td><td>0.02</td><td></td><td></td></tr><tr><td>Significant other</td><td>-0.20</td><td>0.16</td><td>0.52</td><td>0.008</td></tr><tr><td><strong>Parents' characteristics</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Family structure</td><td></td><td>0.04</td><td></td><td></td></tr><tr><td>Both parents</td><td>3.10</td><td></td><td></td><td></td></tr><tr><td>Separated parents with partner</td><td>4.28</td><td></td><td></td><td></td></tr><tr><td>Single parent</td><td>3.99</td><td></td><td></td><td></td></tr><tr><td>Time spent on child school work</td><td></td><td>0.64</td><td></td><td></td></tr><tr><td>&lt;2 h a day</td><td>3.42</td><td></td><td></td><td></td></tr><tr><td>&ge;2 h a day</td><td>3.27</td><td></td><td></td><td></td></tr><tr><td>PSS-10- total score</td><td></td><td>&lt;0.001</td><td></td><td></td></tr><tr><td>Low stress (0-13)</td><td>2.42</td><td></td><td></td><td></td></tr><tr><td>Moderate to severe stress (14-26)</td><td>4.59</td><td></td><td></td><td></td></tr><tr><td>GAD-7- total score</td><td></td><td>&lt;0.001</td><td></td><td>0.002</td></tr><tr><td>Normal (0-4)</td><td>2.42</td><td></td><td>-2.28</td><td>&lt;0.001</td></tr><tr><td>Mild anxiety (5-9)</td><td>3.93</td><td></td><td>-1.38</td><td>0.018</td></tr><tr><td>Moderate to severe anxiety (10-21)</td><td>5.76</td><td></td><td>0.00</td><td></td></tr><tr><td>SF-12 PCS score</td><td>-0.02</td><td>0.42</td><td></td><td></td></tr><tr><td>SF-12 MCS score</td><td>-0.10</td><td>&lt;0.0001</td><td>-0.04</td><td>0.03</td></tr></tbody></table>

Abbreviations: SD, standard deviation; PSS-10, 10-item Perceived Stress Scale; GAD-7,7-item Generalized Anxiety Disorder; SF-12, Short Form SF-12; MSPSS, Multidimensional Scale of Perceived Social Support.

## 5. Conclusion

This study showed that different individual and environmental factors inherent to the children, their parents and the anxiety-provoking situation experienced (lockdown during the COVID-19 pandemic) were associated with moderate to high anxiety in children. Based on these findings, it appears necessary for schools and families to pay attention to the mental health of school-aged adolescents and adopt several measures to create a positive environment to increase family support and establish schedules to work for consistency. Given the importance and influence of parents during the child's development and to reduce the impact on children's mental health, it also appears important to develop interventions to mediate family conflicts and psychological assistance for families for future infectious disease disasters. eHealth interventions in the context of lockdown offer a promising and accessible option to promote well-being and mental health among parents and children. The content of such programs and their implementation should be monitored and adjusted, targeting a wide range of interventions that could be administered with or without clinician contact to parents alone or with their children, including parenting skills, child behavior, and parental mental health.

## Data availability

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

## Ethical considerations

Informed consent was obtained from all individual participants included in the study. All procedures were approved by the institutional review board (Comité National Informatique et Liberté-registration 2220408) and were conducted in full compliance with the national regulations and the principles of the Declaration of Helsinki.

## Funding statement

This research received no external funding.

## CRediT authorship contribution statement

Stéphanie Bourion-Bédès: Writing – original draft, Conceptualization. Elodie Jeanbert: Writing – review & editing, Formal analysis. Ahmet Diakhate: Validation, Formal analysis. Hélène Rousseau: Formal analysis, Data curation. Martine Batt: Conceptualization. Marcel Kode: Formal analysis. Anja Todorović: Writing – review & editing. Cédric Baumann: Conceptualization, Methodology, Writing – original draft, Writing – review & editing.

## Declaration of competing interest

The authors declare that they have no conflicts of interest to disclose.

## Acknowledgments

We would like to thank the study participants, without whom this publication could not have been possible. We also thank the Centre Hospitalier de Versailles for editorial assistance. We are also grateful to Ms. Fourmanoir for her assistance.
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