Journal of Affective Disorders 263 (2020) 450–457

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Social anxiety disorder among children and adolescents: A nationwide T

survey of prevalence, socio-demographic characteristics, risk factors and co-
morbidities
Mohammad Reza Mohammadia, , Mona Salehia, , Ali Khaleghia, Zahra Hooshyaria,
⁎ ⁎

Seyed Ali Mostafavia, Nastaran Ahmadib, Seyed Kaveh Hojjatc, Parvin Safavid, Man Amanate,
⁎⁎

a
Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
b
Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
c
Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
d
Clinical Research Development Unit, Hajar Hospital, Shahrekord University of Medical Sciences, Shahrekord, Iran
e
Faculty of Medicine, Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran

ABSTRACT

Background: Social anxiety disorder is a frequent psychiatric disorder. We aimed to estimate the life-time prevalence, socio-demographic characteristics, risk factors
and co-morbidities of this condition among children and adolescents.
Methods: This was a cross sectional national survey conducted in Iranian individuals aged 6 to 18 years. Face-to-face household interviews were performed by trained
clinical psychologists. The Farsi version of the kiddie schedule for affective disorders and schizophrenia for school-age children/present and lifetime version (K-SADS-
PL) was administered to estimate the SAD prevalence. Parental personality traits and their psychopathologies were also obtained using Millon clinical multiaxial
inventory, third edition (MCMI-III) to find the possible risk factors.
Results: From 29,878 participants, 585 individuals were diagnosed with SAD and weighted lifetime prevalence of 1.8% was observed. The odds of this condition was
significantly higher among older adolescents (odds ratio (OR):1.47; 95% confidence interval(CI): 1.11-1.95) and individuals with paternal history of psychiatric
hospitalization (OR: 2.96; 95%CI: 1.29-6.79). Higher means of persistent depression disorder (OR: 1.009; 95%CI: 1.000-1.018) and melancholic personality trait (OR:
1.007; 95%CI: 1.001-1.014) in mothers as well as schizophrenia spectrum (OR: 1.014; 95%CI: 1.001-1.027) and anxiety (OR: 1.010; 95%CI: 1.010-1.021) in fathers
were statistically associated with higher odds of SAD in their children. Other anxiety disorders and behavioral disorders were the most prevalent co-morbidities.
Limitations: The cross-sectional analysis does not enable analyses of possible causal associations. Lacking control group and follow-up periods were other major
limitations that should be resolved in future studies.
Conclusion: Clinicians and researchers need to continue studying this condition at all levels and in all developmental periods.

1. Introduction and ethnic factors. About 1% to 13% of children and adolescents were
diagnosed with SAD (Canino et al., 2004; Bener et al., 2011; Abbo et al.,
Social anxiety disorder (SAD) also known as social phobia is a 2013; Ranta et al., 2009; Essau et al., 1999; Tillfors et al., 2009;
chronic mental disorder with an excessive fear in social settings and is Farshidfar et al., 2019; Knappe et al., 2011; Canals et al., 2019). Some
characterized by a fear of negative evaluation from others studies showed that females and older adolescents were at higher risk of
(American Psychiatric Association (APA), 2013; Heimberg et al., 2014). SAD (Bener et al., 2011; Abbo et al., 2013) while others reported no
This condition can significantly interfere with the relationships and life significant differences regarding gender (Canino et al., 2004;
of individuals and result in other psychiatric events. SAD is associated Ranta et al., 2009; Essau et al., 1999; Farshidfar et al., 2019) and age
with significant distress as well as impaired educational attainment and (Tillfors et al., 2009). The discrepancies in results can be due to using
financial independence (Stein and Stein,2008). different diagnostic criteria or different diagnostic thresholds along
SAD was found to be one of the most prevalent psychiatric disorders with dissimilar sampling methods (Knappe et al., 2011). Multiple stu-
(Kessler et al., 1994; Weiller et al., 1996). This condition is more dies showed that individuals with SAD were at higher risk of different
common among people of Western countries than Eastern ones psychiatric comorbidities. Other anxiety disorders including specific
(Wong et al., 2019). The difference can be due to the impact of cultural phobia (SP) and generalized anxiety disorder (GAD) were the most

⁎
Corresponding authors at: Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
⁎⁎
Corresponding author at: Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
E-mail addresses: [email protected] (M.R. Mohammadi), [email protected] (M. Salehi), [email protected] (M. Amanat).

https://doi.org/10.1016/j.jad.2019.12.015
Received 23 September 2019; Received in revised form 6 December 2019; Accepted 8 December 2019
Available online 09 December 2019
0165-0327/ © 2019 Elsevier B.V. All rights reserved.
M.R. Mohammadi, et al. Journal of Affective Disorders 263 (2020) 450–457

frequent co-morbid conditions (Canals et al., 2019). Mood disorders, personality pathologies, and specific DSM-IV clinical syndromes, we
oppositional defiant disorder (ODD), and substance use were also re- applied MCMI-III, which is a self-administrated psychological instru-
ported in people with SAD (Knappe et al., 2011). ment. It contains 175 true/false questions and takes 25–30 min to
Although SAD is a common debilitating mental condition, it is re- perform (Dadfar and Lester, 2017). It can provide an assessment tool for
mained under-rated in the current literature. In this nationwide re- both axis I clinical symptoms and axis II personality disorders. Validity
presentative study, we aimed to estimate the life-time prevalence of and reliability of the Farsi version has been reported to be sufficient
SAD among Iranian children and adolescents. The socio-demographic (Khwaja Mughi, 1993; Sharifi, 2002). The reliability by using test-retest
characteristics of affected individuals, comorbidities, and the SAD risk found to be 0.61–0.79 in individuals with psychiatric disorders and
factors based on parental psychological disorders and personality traits 0.79–0.97 in individuals without mental conditions. Cronbach's alpha
were also assessed. This data can be useful in both clinical aspects and was reported to be 0.64–0.89 (Chegini et al., 2013).
making policies regarding mental health issues. MCMI-III includes 24 scales: eleven clinical personality pattern
scales (e.g. schizoid (Cronbach's alpha: 0.68), avoidant (Cronbach's
2. Methods alpha: 0.73), depressive (Cronbach's alpha: 0.86), dependent
(Cronbach's alpha: 0.78), histrionic (Cronbach's alpha: 0.65), narcis-
2.1. Study design and participants sistic (Cronbach's alpha: 0.76), antisocial (Cronbach's alpha: 0.77), sa-
distic (Cronbach's alpha: 0.81), compulsive (Cronbach's alpha: 0.64),
This study was a subproject of Iranian children and adolescents negativistic (Cronbach's alpha: 0.83), and masochistic (Cronbach's
psychiatric disorders (IRCAP) program. IRCAP was a cross-sectional alpha: 0.81)), three severe personality pathology scales (e.g. schizo-
nationwide survey carried out on pediatric population based on typal (Cronbach's alpha: 0.84), borderline (Cronbach's alpha: 0.87), and
household face-to-face interview. All individuals aged 6 to 18 years paranoid (Cronbach's alpha: 0.79)), seven clinical syndrome scales (e.g.
who resided at least one year in a province of Iran and were able to anxiety (Cronbach's alpha: 0.80), somatoform (Cronbach's alpha: 0.78),
communicate in Farsi language were included in the study. Exclusion bipolar (Cronbach's alpha: 0.78), dysthymia (Cronbach's alpha: 0.83),
criteria were the presence of any restrictions or disabilities that pro- alcohol dependence (Cronbach's alpha: 0.75), drug dependence
hibited the participants or their parents from sufficiently completing (Cronbach's alpha: 0.80), and post-traumatic stress disorder (Cronbach's
the questionnaires, such as a severe developmental disorder, psychosis, alpha: 0.86)), three severe clinical syndrome scales (e.g. thought dis-
learning disabilities, or an inability to read and speak Farsi language. order (Cronbach's alpha: 0.87), major depression (Cronbach's alpha:
People who were not willing to corporate were also excluded. 0.89), and delusional disorder (Cronbach's alpha: 0.79)), and three
Sampling was carried out using a multistage cluster sampling modifying scales including disclosure, desirability and debasement
method (cluster and stratified random sampling). IT It was first used to (Millon, 1977; Chegini et al., 2013).
select children and adolescents from each of 31 provinces in Iran. Both
urban and rural areas were selected randomly as a cluster sampling. In 2.3. Procedure
the next step, six individuals of each cluster head –three participants of
each gender in different age groups (6 to 9, 10 to 14, 15 to 18) based on Data collection was carried out by trained clinical psychologists in a
the classification of world health organization (World Health face-to-face conducted interview at participant's place of residence.
Organization, 2019)– were placed in each block. Hundred and seventy Two hundred and fifty clinical psychologists with degrees of Master of
blocks were then, selected randomly according to postal code. The Science were invited to participate in a 5-day workshop held by the
detailed protocol of the study can be seen in Mohammadi et al. (2017). chief investigator of the survey in each province. The workshops in-
cluded presentations, roleplaying, interviews with real cases and dis-
2.2. Instruments cussions to cover all the essential skills for the psychologists until they
could apply the diagnostic tools and interpret the findings.
2.2.1. Socio-demographic form For interview, the method of study was first explained to all in-
Socio-demographic data including age, gender, type of settlement, volved and they were informed that participation was voluntary and
parental education and occupation, and their previous history of hos- they had the right to refuse to contribute to the study. Children and
pitalization at psychiatric wards were collected using questionnaire. parents were independently interviewed using K-SADS-PL. Children less
The section of background information in the kiddie schedule for af- than 11 years were interviewed while at least one of their parents was
fective disorders and schizophrenia for school-age children-present and present at the interview session. The psychologists, then, interpret the
lifetime version (K-SADS-PL) was used to gather the sociodemographic results and made a “summary rating” based on their “best estimate”
characteristics. The two questions about education and occupation judgment. Socio-demographic data were collected. MCMI-III was also
were added to this standardized questionnaire. used to assess the personality traits and psycho-pathologies of the
biological parents of children.
2.2.2. K-SADS-PL
K-SADS-PL is a semi-structure psychiatric interview based on DSM- 2.4. Ethics
IV. It takes 45–60 min to perform and provides diagnostic tool for
psychiatric disorders including: mood disorders, anxiety disorders, The parents provided written informed cc consent before initiation
psychotic disorder, behavioral disorders (e.g. attention deficit hyper- of the study. Informed consent was also obtained from adolescents aged
activity disorder, ODD, and conduct disorder), substance use, tic dis- above 15 years and assent was achieved from children less than this
orders, and elimination disorders (e.g. enuresis and encopresis). The age. Data was collected from each family in privacy. The ethics com-
inter-rater and test-retest reliability, negative (87%) and positive pre- mittee of the National Institute for Medical Research Development
dictive value (100%) as well as consensual validity (Kappa score: 0.91) approved the final protocol of the study (reference ethics code:
of the Farsi version of K-SADS-PL based on DSM-IV has been already IR.NIMAD.REC.1395.001).
assessed and reported to be adequate (Ghanizadeh et al., 2006). Ex-
cellent sensitivity (100%) and specificity (96.9%) were also reported 2.5. Statistical analysis
(Ghanizadeh et al., 2006).
Continuous quantitative variables including age and MCMI-III scales
2.2.3. Millon clinical multiaxial inventory, third edition (MCMI-III) were reported as mean with standard deviation (SD) and 95% con-
In order to assess parental clinical personality patterns, severe fidence interval (95%CI). Categorical variables (e.g. gender, age

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M.R. Mohammadi, et al. Journal of Affective Disorders 263 (2020) 450–457

Table 1
Distribution of social anxiety disorder based on socio-demographic characteristics.
Total With social anxiety disorder Regression logistic model

N (%unweighted) %weighted (95%CI) Univariate Multivariate

Socio-demographic characteristics N(%) OR(95%CI) OR(95%CI)

Gender Boy 14,626(48.9) 282(1.9) 1.8(1.6–2.1) Baseline

Girl 15,271(51.1) 303(2.0) 1.8(1.5–2.1) 0.98(0.79–1.21) 1.04(0.83–1.30)
Age 6–9 10,187(34.1) 174(1.7) 1.4(1.1–1.7) Baseline
10–14 10,455(35.0) 200(1.9) 1.8(1.5–2.2) 1.29(0.99–1.70) 1.30(0.98–1.72)
15–18 9255(31.0) 211(2.3) 2.2(1.9–2.6) 1.59(1.21–2.09)⁎⁎ 1.47(1.11–1.95)⁎⁎
Types of settlement Urban 24,932(83.4) 464(1.9) 1.8(1.6–2.0) Baseline
Rural 4965(16.6) 121(2.4) 1.8(1.3–2.5) 0.99(0.70–1.40) 0.88(0.61–1.28)
Father educations Illiterate 1299(4.5) 52(4.0) 3.5(2.4–5.1) Baseline
primary school 4640(16.1) 98(2.1) 1.8(1.4–2.4) 0.53(0.32–0.87)* 0.61(0.35–1.06)
Guidance & high school 6421(22.3) 139(2.2) 1.9(1.5–2.4) 0.55(0.35–0.87)* 0.63(0.36–1.11)
Diploma 8377(29.1) 150(1.8) 1.7(1.4–2.1) 0.49(0.31–0.77)⁎⁎ 0.68(0.38–1.22)
bachelor 6079(21.1) 94(1.5) 1.6(1.2–2.0) 0.45(0.28–0.73)⁎⁎ 0.61(0.32–1.15)
MSc or higher 1976(6.9) 33(1.7) 1.8(1.2–2.7) 0.54(0.31–0.95)* 0.79(0.38–1.66)
Missing 1105 19
Mother educations Illiterate 1701(5.8) 58(3.4) 2.8(1.9–4.1) Baseline
primary school 5496(18.9) 120(2.2) 1.9(1.4–2.4) 0.67(0.42–1.07) 0.78(0.46–1.31)
Guidance & high school 5676(19.5) 125(2.2) 2.3(1.8–2.8) 0.80(0.51–1.25) 0.96(0.56–1.65)
Diploma 9645(33.2) 164(1.7) 1.5(1.2–1.8) 0.53(0.34–0.81)⁎⁎⁎ 0.64(0.36–1.12)
Bachelor 5586(19.2) 90(1.6) 1.7(1.3–2.2) 0.60(0.38–0.95)* 0.70(0.38–1.31)
MSc or higher 991(3.4) 19(1.9) 1.5(0.9–2.7) 0.55(0.27–1.12) 0.59(0.25–1.39)
Missing 802 9
History of psychiatric hospitalization Mother Yes 90(0.3) 2(2.2) 3.1(0.9–1.1) Baseline
No 29,807(99.7) 583(2) 1.8(1.6–2.0) 0.58(0.14–2.45) .79(0.18–3.43)
Father Yes 108(0.4) 6(5.6) 10.2(4.7–20.5) Baseline
No 29,786(99.6) 579(1.9) 1.8(1.6–2.0) 0.16(0.07–0.37)⁎⁎ .17(0.07–0.41)⁎⁎
2
Father Job unemployed 990(3.4) 32(3.2) 2.1(1.2–3.6) X = 8.315, df = 7, Pvalue = 0.306
Labourer 16,509(57.2) 323(2.0) 1.8(1.6–2.1)
Farmer 985(3.4) 22(2.2) 1.9(1.0–3.6)
businessman 1053(3.6) 20(1.9) 1.7(0.9–2.9)
Retired 1691(5.9) 45(2.7) 3.0(2.1–4.2)
public sector 6649(23) 111(1.7) 1.6(1.3–2.1)
Teacher 802(2.8) 9(1.1) 1.7(0.8–3.5)
faculty member 174(0.6) 5(2.9) 1.7(0.5–5.9)
Missing 1044 18
Mother job Labourer 999(3.4) 23(2.3) 2.4(1.5–3.9) X2 = 5.078, df = 7, Pvalue = 0.534
businessman 218(0.7) 6(2.8) 2.4(0.8–6.8)
housewife 24,890(85.2) 490(2.0) 1.8(1.6–2.0)
retired 220(0.8) 7(3.2) 3.2(1.3–8.0)
public sector 1634(5.6) 33(2.0) 1.4(0.9–2.3)
teacher 1166(4) 13(1.1) 1.3(0.7–2.5)
faculty member 75(0.3) 3(4.0) 2.1(0.4–11.1)
Missing 695 10
Total 29,897(100) 585(2.0) 1.8(1.6–2.0)

⁎
: P Value < 0.05
⁎⁎
:P Value < 0.01

groups, place of residence, parental educations, and psychiatric hospi- were diagnosed with SAD based on K-SADS-PL criteria. The weighted
talization) and discrete quantitative variables (e.g. SAD prevalence and lifetime prevalence rate of 1.8% was estimated for this event (Table 1).
co-morbidities) were described in form of percentage with 95%CI. All Multivariate analysis of the socio-demographic characteristics revealed
the rates were adjusted based on the population of each province; using that SAD was significantly associated with aging (Fig. 1). The odds of
the Iranian population in the 2017 as the standard population. The odds this condition among older adolescents (15 to 18 years) were statisti-
ratio (OR) and multiple logistic regression analyses were used to assess cally higher than individuals aged 6 to 9 years (OR: 1.47; 95%CI:
which variables across diagnostic groups were statistically significant 1.11–1.95). History of previous psychiatric hospitalization in father was
risk factors of SAD. SPSS version 20 (SPSS Incorporation, Chicago, USA) also associated with higher odds of SAD (OR: 2.96; 95%CI: 1.29–6.79).
was used for statistical analyses and P-values less than 0.05 were con- Our study showed lower prevalence of SAD among individuals with
sidered significant. higher parental education. It was, however, not significant using mul-
tivariate analysis (Table 1). Other characteristics including gender, type
of settlement, parental jobs, and history of maternal psychiatric hos-
3. Results pitalization were reported to have no significant impact on the odds of
SAD among children and adolescents (Table 1).
This was a cross-sectional national survey, carried out from October Our data indicated that about 70 percent of individuals with the
14, 2016 to November 21, 2017. From the primary sample with 30,534 diagnosis of SAD had at least one psychiatric co-morbid condition
eligible candidates, 29,878 individuals aged 6 to 18 years took part in (Table 2). It was observed that 145 individuals had one co-morbidity
our study (response rate: 92%). The mean age of participants was while the rest (233 participants) were diagnosed with >1 co-morbid-
11.8 ± 3.8. (mean ± SD). The socio-demographic characteristics of ities. Other anxiety disorders (54.9%) were the most common co-oc-
participants were presented in Table 1. curred events in people with SAD. GAD (26%), separation anxiety
A total number of 585 individuals including 282 boys and 303 girls

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M.R. Mohammadi, et al. Journal of Affective Disorders 263 (2020) 450–457

Fig. 1. Rates of social anxiety disorder by age trends and sex groups.

disorders (24.5%), and SP (18%) were the most frequent subtypes disorders were, however, less common in adolescents aged 15 to 18
(Fig. 2). Behavioral (29.5%) (e.g. ODD) and mood disorders (14.5%) years (OR: 0.13; 95%CI: 0.04–0.045). The differences in the odds of co-
(e.g. depressive disorders) were other frequent psychiatric conditions morbidities among males and females were not statistically significant.
observed in children and adolescents with SAD. The data on the effects of parental personality patterns and
The effects of sex and age groups on the odds of co-morbid disorders pathologies on the odds of SAD among their children and adolescents
were presented in Table 3. Mood disorders were significantly more showed that based on MCMI-III, higher means of persistent depressive
prevalent among individuals aged 15 to 18 years compared to 6 to 9 disorder (OR: 1.009; 95%CI: 1.000–1.018) and melancholic personality
year-old-participants (OR: 3.78; 95%CI: 1.38–10.37). Elimination trait (OR: 1.007; 95%CI: 1.001–1.014) in mothers were statistically

Table 2
Rates of psychiatric co-morbidities in children and adolescents with social anxiety disorder based on sex and age groups.
Psychiatric disorders Total Sex: Male (1), Female (2) Age group: 6–9(1), 10–14(2), 15–18(3)

Weighted (95%CI) Weighted (95%CI) OR (95%CI) Weighted (95%CI) OR (95%CI)

Mood disorders 14.5(11.1–18.6) 1 11.9(7.7–17.8) Base line 1 5.9(2.5–13.0) Base line

2 19.1(13.8–25.9) 1.79(0.96–3.35) 2 18.0(12.2–25.8) 3.44(1.26–9.43)*
3 19.3(13.1–27.5) 3.78(1.38–10.37)⁎⁎
Psychosis 2.7(1.4–5.0) 1 2.4(0.9–6.0) Base line 1 – Base line
2 2.5(1.0–6.2) 1.02(0.26–3.97) 2 1.6(0.5–5.8) 4.92(0.08–29.47)
3 5.8(2.9–11.6) 19.24(0.39–97.15)
anxiety disorders 54.9(49.6–60.1) 1 50.6(43.0–58.3) Base line 1 56.6(45.9–66.8) Base line
2 64.1(56.4–80.0) 1.76(1.13–2.74) 2 66.1(57.4–73.9) 1.49(0.84–2.63)
3 49.1(40.2–58.1) 0.74(0.42–1.31)
Behavioral disorders 29.5(24.9–34.6) 1 33.9(27.2–41.4) Base line 1 33.7(24.7–44.0) Base line
2 26.4(20.2–33.6) .69(0.43–1.12) 2 26.8(19.8–35.3) 0.70(0.39–1.27)
3 31.1(23.5–39.9) 0.86(0.48–1.54)
Elimination disorders 8.6(6.0–12.0) 1 8.4(5.1–13.6) Base line 1 17.1(10.6–26.2) Base line
2 9.3(5.7–14.7) 1.07(0.50–2.30) 2 9.0(5.1–15.4) 0.48(0.21–1.11)
3 2.5(0.9–7.2) 0.13(0.04–0.45)⁎⁎
Eating disorders 2.4(1.2–4.6) 1 3.1(1.3–6.9) Base line 1 3.5(1.2–9.8) Base line
2 1.9(0.6–5.4) .51(0.11–2.34) 2 4.1(1.8–9.2) 1.42(0.31–6.57)
3 – –
Smoking 2.7(1.4–4.9) 1 1.8(0.6–5.1) Base line 1 2.2(0.6–7.6) Base line
2 3.6(1.6–7.5) 1.67(0.43–6.48) 2 .8(0.1–4.4) 0.42(0.04–4.96)
3 4.9(2.3–10.2) 2.79(0.51–15.27)
Total comorbid disorders 69.9(64.8–74.6) 1 69.1(61.7–75.4) Base line 1 77.3(67.5–84.8) Base line
2 76.2(69.2–82.1) 1.42(0.87–2.32) 2 74.2(65.8–81.1) 0.86(0.45–1.63)
3 67.8(58.8–75.7) 0.62(0.33–1.16)

Comorbid disorders number: 0 = 205n, 1 = 147n, 2 and more = 233n.

⁎
: P Value < 0.05.
⁎⁎
: P Value < 0.01.

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M.R. Mohammadi, et al. Journal of Affective Disorders 263 (2020) 450–457

Fig. 2. Rates of comorbid conditions in social anxiety disorder.

associated with higher rates of SAD in their children (Table 3). Fur- of the previous studies performed in children and adolescents of
thermore, higher means of schizophrenia spectrum (OR: 1.014; 95%CI: Western countries including Australia (2.3%) (Spence et al., 2018),
1.001–1.1.027) and anxiety (OR: 1.010; 95%CI: 1.010–1.021) in fathers Puerto Rico (2.5%) (Canino et al., 2004), Finland (3.2%) (Ranta et al.,
were statistically associated with higher rates of SAD in their children 2009), Chile (3.7%) (Vicente et al., 2012), Spain (4%) (Canals et al.,
(Table 4). 2019), Sweden (4.4%) (Tillfors et al., 2009), the United States (6.6%)
(Knappe et al., 2011), and Brazil (11.6%) (Baptista et al., 2012). A
4. Discussion nationwide study in the United States with over 10,000 participants
aged 13 to 18 years reported that about 9% of individuals were diag-
4.1. Summary of results nosed with SAD (Merikangas et al., 2010). An international survey with
around 19,000 participants aged over 15 years from the United
To our knowledge, this is the first national survey assessed the Kingdom, Germany, Italy, Spain and Portugal also revealed a pre-
prevalence, risk factors, and co-morbidities of SAD among Iranian valence point of 4.4% for SAD (Ohayon and Schatzberg, 2010). The
children and adolescents. Our analysis revealed that the lifetime pre- discrepancies in results can be due to the geographical and cultural
valence of this condition was about 2%. SAD is more common among factors. It seems that people of Eastern countries are at lower risk of
older adolescents. HHgH History of psychiatric hospitalization in father SAD than individuals of Western countries (Wong et al., 2019). The
was shown to be a risk factor of this event. Other anxiety disorders, differences in the age ranges in studies can also be another reason as
behavioral, and mood disorders were the most prevalent co-morbid increasing age can lead to higher SAD prevalence rate. The prevalence
conditions in pediatric population with SAD. Among parental MCMI-III of SAD among children and adolescents of Qatar as a neighboring
scales, maternal melancholic and persistent depressive disorder as well country of Iran was also higher than our observed results (12.7%)
as paternal anxiety and schizophrenia spectrum disorder were observed (Bener et al., 2011). We found two studies with lower SAD prevalence
to be risk factors of SAD on statistical standpoint but no clinical sig- rates than ours (Essau et al., 1999; Leung et al., 2008). A population-
nificance can be considered due to the low reported ORs. based study with 1035 children and adolescents in Germany reported
the SAD prevalence of 1.6% (Essau et al., 1999) and another study in
4.2. Previous studies China with 541 adolescents showed that the prevalence of SAD was
lower than 1% (Leung et al., 2008). Previous studies at subnational
4.2.1. Prevalence of social anxiety disorder level of Iran indicated that the prevalence rates of SAD varied from
The reported prevalence of SAD in our survey was lower than most 0.2% in Hamedan province to over 20% in Abhar city

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Table 3
The odds of social anxiety disorder in children and adolescents based on maternal psychiatric disorders.
Mean (SD) Univariate Multivariate

With Social phobia Without Social phobia OR (95%CI) OR (95%CI)

Personality scales Schizoid 27.27(23.04) 21.11(21.75) 1.012(1.007–1.06)⁎⁎

1.004(0.996–1.012)
Avoidance 24.98(23.94) 20.05(19.99) 1.011(1.006–1.016)⁎⁎ 0.997(0.987–1.007)
Melancholic 27.64(28.29) 37.81(32.23) 1.011(1.008–1.015)⁎⁎ 1.007(1.001–1.014)*
Dependent 21.79(21.31) 16.28(16.54) 1.015(1.010–1.020)⁎⁎ 1.005(0.996–1.014)
Histrionic 61.11(21.57) 60.53(22.39) .999(0.994–1.004) 1.003(0.996–1.010)
Narcissistic 39.99(19.43) 39.74(18.44) 1.001(0.995–1.007) 0.996(0.988–1.004)
Anti-social 26.82(21.01) 23.27(19.72) 1.008(1.003–1.014)⁎⁎ 0.995(0.986–1.004)
Sadistic 27.54(20.19) 22.42(18.62) 1.013(1.008–1.019)⁎⁎ 1.002(0.993–1.012)
Obsessive compulsive 46.28(24.74) 45.33(24.43) 1.002(0.997–1.006) 0.998(0.993–1.003)
Negativistic 31.72(25.01) 24.23(22.28) 1.013(1.009–1.018)⁎⁎ 1.002(0.993–1.012)
Masochistic 23.83(21.67) 18.37(18.58) 1.013(1.008–1.018)⁎⁎ 0.999(0.989–1.009)
Schizotypal 23.97(20.89) 19.07(18.28) 1.013(1.007–1.018)⁎⁎ 0.996(0.985–1.007)
Borderline 27.53(19.83) 22.39(18.25) 1.014(1.008–1.020)⁎⁎ 0.999(0.988–1.010)
Paranoid 35.69(22.47) 28.92(21.59) 1.014(1.009–1.019)⁎⁎ 1.008(0.999–1.017)
Clinical syndrome Anxiety 30.64(23.24) 24.28(22.07) 1.012(1.007–1.017)⁎⁎ 1.005(0.996–1.013)
Somatoform 28.90(25.91) 21.98(22.91) 1.012(1.007–1.016)⁎⁎ 1.009(0.999–1.019)
Bipolar Spectrum 22.94(22.11) 17.39(18.83) 1.013(1.008–1.019)⁎⁎ 1.007(0.998–1.015)
Persistent Depression Disorder 22.78(25.67) 15.80(20.95) 1.013(1.008–1.017)⁎⁎ 1.009(1.000–1.018)*
Alcohol dependence 19.76(12.74) 17.42(12.11) 1.014(1.006–1.022)⁎⁎ 1.001(0.987–1.015)
Drug dependence 16.44(13.29) 15.10(13.15) 1.007(0.999–1.015) 0.988(0.976–1.001)
Post-traumatic stress disorder 19.21(22.95) 14.24(19.56) 1.011(1.006–1.016)⁎⁎ 0.994(0.984–1.004)
Schizophrenia Spectrum 30.82(22.54) 24.25(21.09) 1.014(1.009–1.019)⁎⁎ 1.005(0.995–1.016)
Major Depression Disorder 26.15(22.88) 21.01(20.93) 1.011(1.006–1.016) 0.987(0.975–0.999)*
Delusional disorder 25.02(20.07) 19.87(18.47) 1.014(1.008–1.019)⁎⁎ 1.006(0.997–1.015)

⁎
: P Value < 0.05.
⁎⁎
:P Value < 0.01.

Table 4
The odds of social anxiety disorder in children and adolescents based on paternal psychiatric disorders.
Mean (SD) Univariate Multivariate

With social phobia Without social phobia OR (CI 95%) OR (CI 95%)

Personality scales Schizoid 29.74(23.35) 21.80(21.52) 1.015(1.009–1.021) ⁎⁎

1.005(0.995–1.016)
Avoidance 31.11(21.83) 24.91(19.60) 1.015(1.008–1.022)⁎⁎ 0.995(0.982–1.009)
Melancholic 34.58(28.72) 24.63(25.15) 1.014(1.008–1.019)⁎⁎ 1.000(0.989–1.011)
Dependent 22.95(21.38) 16.22(17.35) 1.017(1.010–1.023)⁎⁎ 1.003(0.992–1.014)
Histrionic 64.06(23.50) 63.97(22.61) 1.000(0.994–1.007) 1.002(0.992–1.011)
Narcissistic 44.04(17.89) 42.05(16.64) 1.007(0.998–1.016) 0.998(0.986–1.010)
Anti-social 26.14(20.96) 20.91(19.58) 1.012(1.005–1.019)⁎⁎ 0.994(0.981–1.006)
Sadistic 30.32(20.84) 23.62(19.22) 1.016(1.009–1.023)⁎⁎ 1.004(0.991–1.017)
Obsessive compulsive 55.62(21.66) 52.72(21.85) 1.006(0.999–1.013) 1.005(0.997–1.014)
Negativistic 35.50(25.42) 25.81(23.36) 1.016(1.010–1.022)⁎⁎ 1.009(0.997–1.021)
Masochistic 25.93(23.00) 17.85(20.12) 1.016(1.010–1.023)⁎⁎ 1.004(0.992–1.016)
Schizotypal 26.55(22.03) 18.48(19.56) 1.018(1.011–1.024)⁎⁎ 1.011(0.997–1.025)
Borderline 30.26(20.79) 22.51(19.92) 1.018(1.011–1.024)⁎⁎ 1.003(0.989–1.017)
Paranoid 32.78(22.09) 25.65(22.00) 1.014(1.007–1.020)⁎⁎ 0.993(0.981–1.006)
Clinical syndrome Anxiety 33.10(26.24) 23.48(23.65) 1.015(1.010–1.021)⁎⁎ 1.010(1.001–1.021)*
Somatoform 27.00(25.36) 19.74(23.36) 1.012(1.006–1.018)⁎⁎ 0.997(0.985–1.009)
Bipolar Spectrum 20.77(23.38) 13.97(20.37) 1.013(1.007–1.019)⁎⁎ 1.003(0.993–1.013)
Persistent Depression Disorder 26.01(23.37) 19.32(20.77) 1.013(1.007–1.020)⁎⁎ 0.998(0.985–1.011)
Alcohol dependence 19.47(18.64) 15.37(17.25) 1.012(1.004–1.019)⁎⁎ 0.994(0.981–1.006)
Drug dependence 22.48(20.90) 17.74(18.20) 1.012(1.005–1.019)⁎⁎ 1.004(0.993–1.014)
PTSD 19.77(23.09) 13.51(20.49) 1.012(1.006–1.018)⁎⁎ 0.992(0.980–1.005)
Schizophrenia Spectrum 35.02(24.01) 25.57(22.37) 1.017(1.011–1.024)⁎⁎ 1.014(1.001–1.027)*
Major Depression Disorder 28.32(24.06) 20.57(22.23) 1.014(1.008–1.020)⁎⁎ 1.007(0.994–1.021)
Delusional disorder 22.12(20.26) 16.81(18.63) 1.013(1.006–1.020)⁎⁎ 0.998(0.987–1.009)

⁎
: P Value < 0.05.
⁎⁎
: P Value < 0.01.

(Ahmadpanah et al., 2018; Jalali and Pourahmadi, 2012; SADS-PL used in our study (Kessler et al., 2009). Further surveys are
Mozafari et al., 2009; Hajiamini et al., 2012). Methodological differ- needed to have a better perspective about the prevalence of SAD among
ences can somewhat justify the discrepancies in results. Sample size, different nations.
sampling methods, age ranges of study population, as well as diagnostic
tools and their thresholds can all change the results of studies. It ap- 4.2.2. Demographic associations and risk factors
pears that estimated prevalence rate of any disorder based on World This survey showed that SAD prevalence was significantly higher
Health Organization Composite International Diagnostic Interview among older adolescents. This is in line with most prior studies con-
(CIDI) is over 8% higher than the estimated prevalence rate based on K- ducted in Europe (Ranta et al., 2009; Essau et al., 1999; Canals et al.,

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M.R. Mohammadi, et al. Journal of Affective Disorders 263 (2020) 450–457

2019) and the United States (Merikangas et al., 2010). It can be due to 4.3. Strengths
the transitional stage of physical and psychological development in
adolescence that starts from puberty period until adulthood. The The IRCAP study was the first epidemiological survey of psychiatric
changes in physical appearance and emotions can lead to SAD in this disorders with a large sample of children and adolescents from all
population. Noted, few studies conducted in Sweden and Chile revealed provinces of Iran and the presented results can be generalized to other
no significant association between age and SAD prevalence children and adolescents of country. Face-to-face household interview
(Tillfors et al., 2009). using semi-structured questionnaire (K-SADS) is other strength of the
Our study showed that no specific gender significantly increased the study and is more acceptable than using self-reported questionnaires.
odds of SAD. Most previous studies, however, revealed that females
were at higher risk of SAD occurrence than males (Canino et al., 2004;
4.4. Limitations
Bener et al., 2011; Abbo et al., 2013; Spence et al., 2018; Vicente et al.,
2012; Baptista et al., 2012; Merikangas et al., 2010). In line with our
Several limitations apply when interpreting the findings. The IRCAP
study, surveys in Finland (Ranta et al., 2009) and Germany (Essau et al.,
did not survey the detained or homeless children and adolescents. The
1999) and other studies conducted in Iran (Farshidfar et al., 2019;
cross-sectional analysis does not enable analyses of possible causal as-
Hajiamini et al., 2012) reported no significant association between
sociations. Lacking control group and follow-up periods were other
gender and SAD prevalence. Possible explanations for discrepancies can
major limitations that should be resolved in future studies. As SAD
be methodological differences as well as the cultural and societal di-
cannot be objectively assessed, the outcomes of the study were reliant
versity across different countries. Our results also demonstrated that
on reports from children or their parents which could lead to in-
there is no significant difference in SAD prevalence between people of
formation bias. This study was carried out using the Farsi version of K-
urban and rural areas. This is in line with multiple previous studies
SADS-PL based on DSM-IV. There have been multiple important
(Canino et al., 2004; Merikangas et al., 2010; Magee et al., 1996). Few
changes between DSM-IV and DSM-V in definition and diagnosis of SAD
studies, however, detected a higher prevalence of psychiatric disorders
that can affect our reported prevalence (Crome et al., 2015). No data on
in urban areas (Tillfors et al., 2009; Vega et al., 1998; Kringlen et al.,
validity and reliability of the Farsi version of K-SADS-PL based on DSM-
2001). A population-based study in Hamedan province of Iran reported
V are yet available.
a higher prevalence of anxiety disorders including SAD in children of
the rural places (Jalali and Pourahmadi, 2012). Further studies are
required to resolve our ambiguities. Our data also showed that parental 4.5. Future directions
jobs and education had no significant effect on the odds of SAD which
has been reported in prior studies too (Abbo et al., 2013; Spence et al., Conduction of national prospective cohort studies will provide
2018). abundant data about this underestimated mental condition. Long
The history of paternal psychiatric hospitalization was found to be a follow-up periods of the participants can determine the process of event
risk factor of SAD in children and adolescents. Some parental clinical and identify if SAD can affect the quality of lives of individuals in later
syndromes and personality traits were also observed to be associated years.
with this event. The risk factors and triggers of SAD were assessed in Current therapies in people with SAD had no significant efficacy and
multiple prior studies. Genetic and environmental factors were both the pathophysiology of condition remained unknown. The identifica-
identified to play important roles in SAD development (Bandelow et al., tion of SAD demographic associations and co-morbid conditions can
2004; Hudson and Rapee, 2000). Substantial number of surveys in- have clinical implications. Trying to understand the pathophysiologic
vestigated the role of heritability in SAD occurrence. It was reported links between SAD and its co-morbidities may help to find new treat-
that children of parents with SAD were more susceptible to experience ments for this event.
this condition (Elizabeth et al., 2006) and this can be due to both ge-
netic and shared environmental triggers (Spence and Rapee, 2016). A
recent meta-analysis of 13 cohort studies with twin data reported that 5. Conclusion
genetic and non-shared environmental factors were the most prominent
contributors in SAD development among youths and genetic contribu- Our findings revealed that SAD is an important public health issue
tion in adults was half than that in younger individuals (Sciani et al., and can be detected early in life. Clinicians and researchers need to
2014). To date, no specific gene in association with SAD was identified continue studying this condition at all levels and in all developmental
and future studies are needed in this area. periods.

Funding sources
4.2.3. Co-morbid conditions
Over two third of our participants with SAD had at least one psy-
This work was supported by the National Institute for Medical
chiatric co-morbidity. High prevalence of other anxiety events
Research and Development(grant number 940906), who had no role in
(Ranta et al., 2009; Essau et al., 1999; Knappe et al., 2011; Spence et al.,
study design, data collection, analysis, or interpretation of data, in the
2018; Wittchen et al., 1999), mood disorders (Ranta et al., 2009;
writing of the report, or in the decision to submit the article for pub-
Essau et al., 1999; Ohayon and Schatzberg, 2010; Wittchen et al.,
lication.
1999), behavioral disorders (Knappe et al., 2011), and substance use
(Ranta et al., 2009; Knappe et al., 2011; Wittchen et al., 1999) in people
with SAD was described in prior studies. Impaired social interactions Author statement
and educational attainment in children with SAD can increase the risk
of other mental disorders. Shared pathophysiological mechanisms may All persons who meet authorship criteria are listed as authors, and
also justify this association. It has been recognized that people with all authors certify that they have participated sufficiently in the work to
psychiatric disorders are at increased risk of developing other mental take public responsibility for the content, including participation in the
conditions (Lai et al., 2015; Buckley et al., 2008). The exact underlying concept, design, analysis, writing, or revision of the manuscript.
mechanisms are, however, not clear and evidence is lacking in this area. Furthermore, each author certifies that this material or similar material
has not been and will not be submitted to or published in any other
publication before its appearance in the Journal of Affective Disorders

456
M.R. Mohammadi, et al. Journal of Affective Disorders 263 (2020) 450–457

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