Coronavirus represents a large family of viruses that can cause respiratory infections, ranging from common colds to more severe respiratory illnesses such as MERS or SARS. The novel virus of this family has been called COVID-19, which broke out in Wuhan, China in December 2019. This virus may manifest mild to severe symptoms, including symptoms of infection such as fever, cough, and gasping. According to official statistics released by WHO, as of April 19, 2020, 237,987 cases of coronavirus have been identified worldwide, of which 16,3904 have died and 613,367 have recovered. This huge number of the infected and the deceased places a lot of pressure on government officials, doctors, nurses, and the general public. This epidemic not only poses a threat to physical health but also to the mental health of people (1). Accordingly, it is expected that the rising number of the infected and the deceased, the extension of lockdown and social distancing and the shutdown of schools and universities will wield influence on the mental health of children, adolescents and the youths. The effect of this epidemic on psychological indicators of the general population, patients, medical staff and adults has been the subject of growing scholarly attention (1). Huang and Zhao (2020) reported that during the outbreak of the COVID-19, anxiety and depression spiked in people under the age of 35 in China. These disorders are positively correlated with age and the degree of exposure to disease news (2), but scant attention has been paid to children anxiety during Coronavirus outbreak. Children seem to be especially vulnerable to anxiety, as most families are in home quarantine and constantly listen and discuss coronavirus statistics, which can create a stressful situation for children (3).Recurrent negative thoughts are a source of anxiety for children, which can exert deleterious effects on children in the long run. Anxiety has been shown to be linked to developmental, psychosocial, and psychological impairments. For example, anxiety has a detrimental effect on children's performance at school (4) and is the biggest risk factor for the development of other mental disorders such as depression (5). In addition, anxiety in childhood predicts psychological trauma in adolescence and youth (6). Therefore, it is important to identify factors that play a role in controlling childhood anxiety, both in terms of prevention and treatment.
It seems that the days of home quarantine and the outbreak of the COVID-19 have all the hallmarks of stressful situations, including preparation for stressful events, understanding the situation, uncertainty about the outcome, and coping with the stressor and its consequences (4). In general, anxiety can be assigned to three categories: trait anxiety, state anxiety, and situation-specific anxiety. Trait anxiety is defined as an enduring characteristic of a person. State anxiety denotes concerns about encountering a certain situation, and situation-specific anxiety describes the sense of fear and terror that one feels in a stressful situation (7). In this study, the anxiety induced by the outbreak of COVID-19 in children has been considered as situation-specific anxiety as it bears the hallmarks of a stressful situation, such as perceived fear of the virus, preparation for the stressful event, uncertainty about outcomes, coping strategies and its consequences (7). This type of stress may be symptomatic of physical and psychological distress in children. Meanwhile, there are huge individual differences between children in terms of the severity of stress they endure and the way they tackle these conditions. Therefore, by identifying the underlying factors of such individual differences we can strengthen them to better control the level of anxiety in future events so that children will experience less situation-specific anxiety in the event of similar crises in the future.
One of the factors that influence the level of situation-specific anxiety is executive function (8). Executive function is considered as a multi-dimensional goal-oriented system that regulates cognitive and behavioral processes of individuals to achieve desired goals (9). Cognitive aspects of executive function assessed by psychological tests include inhibition, perceptual motor speed, sustained attention, preservation, planning, reaction time, and working memory (10). So far, the bulk of studies have demonstrated the relation between cognitive aspects of executive function and anxiety (11). In this context, many studies have explored the relationship between poor working memory and elevated anxiety (12). However, Snyder et al. (2014) showed that cognitive impairment of executive functions like inhibition, working memory, attention switching, along with planning are the underlying causes of anxiety in children (13).
On the other hand, there are researchers who define executive functions as the cross-sectional organization of behaviors to attain future goals (14). It is unclear how psychology tests of executive functions, which are administered in clinics for only 5 to 30 min to assess executive functions, can endorse this aspect of executive function definition. These tests are usually conducted over a short period of time, as opposed to the enormous amount of time that individuals must dedicate to organizing and sustaining their activities for hours, days, or weeks to achieve their desired goals. Compared to tests that measure performance at the clinic, evaluating executive performance in the daily life, which measures behavior over a longer period of time, can probably be considered as an important indicator of organizing behaviors over a certain period of time and problem solving to achieve a specific goal. In other words, executive function is defined as a number of self-regulation skills such as emotional self-regulation, self-organization / problem-solving, self-restraint, self-motivation, and self-management to attain predefined goals (15). The following elaborates on the association between each of these related skills and anxiety.
Self-regulation is defined as the ability to suppress dominant impulses to moderate thoughts, behaviors, and emotions (16). Emotional self-regulation, which is based on the concept proposed by GROSS and THOMPSON 2007, comprises situation selection, situation modification, attentional deployment, cognitive change, and response modulation. It is likely that poor self-regulatory strategies will direct one's emotions toward other strategies that are not effective, which will ultimately lead to elevated levels of anxiety (17, 18). The results of a meta-analysis suggested that high levels of self-regulation are associated with lower levels of anxiety in children (16). Another study reported that children with less emotional self-regulation are more likely to experience anxiety and depression than other children (19). Barkelyanf Morphy (2011) showed that self-regulation was linked to anxiety (14).
Self-organization or problem-solving is a high-order cognitive ability that helps an individual deal with life's challenges (20). Based on the Bransford and Stein’s (1984) model of problem solving, the steps of a problem are as follows. The Input phase in which a problem appears and attempts are made to figure out the problem. The Dealing phase where different alternatives are generated and evaluated and finally the best solution is selected. The Output phase involves planning for and executing the solution. Finally, there is the Re-assessment phase in which the solution is tested and necessary modifications are made (21). It has been shown that impaired self-organization / problem-solving may lead to self-oriented rumination, which will eventually aggravate anxiety in individuals (20). The negative problem orientation and rational problem solving are assumed to be the sources of trait anxiety and depression (22). Gail, Thomas, and Dzurita 1998 revealed that disability in solving social problems is associated with state anxiety in the elderly (23). Studies have shown that people with poor problem-solving abilities experience higher levels of anxiety (22). Also, Barkely and Morphy 2011 suggested that there is a relationship between self-organization and anxiety.
Self-restraint is conceptualized as the ability to quickly suppress self-directed tendencies to promote one's long-term goals (24). According to Weiberger, self-restraint includes intra-personal (impulse control), interpersonal (anger suppression and caring for others) and communal (responsibility) factors (25). People who are more socially compatible exhibit better self-restraint because they engage in self-management practices to present a positive impression to people and are not overly inexorable or enlightened (25–27). Poor self-restraint has been depicted to increase the level of state anxiety in people (24).
Self-motivation is defined as a stimulus that arises from one's inner tendency to fulfill one's needs (7). Chean and Gao (2014) argue that children experience anxiety when their self-motivation is impaired. Therefore, there is an inverse relationship between self-motivation and anxiety in children. On the other hand, Chen, Huang and Shang (2014) have exhibited the relationship between self-motivation and mental health in the elderly (28). Also, Barkely and Morphy (2011) demonstrated the association between self-motivation and anxiety (14).
Self-management describes the optimal use of available time, which reflects planning, goal setting, prioritization of goals and proper and effective execution of activities (29, 30). Self-management is a factor that plays a key role in anxiety. As a result of improper time management, a person would not have sufficient time to perform tasks such as social activities. This in turn dwindles the person's self-satisfaction and amplifies anxiety state (29). Kaya et al. (2012) suggested that students' time management skills are undercut when they are stressed (30). Ghiasvandi et al. also reported that nurses with poor self-management suffer from more anxiety (29). Barkely and Morph (2011) illustrated that that self-management is correlated with anxiety (14).
In the literature, the relationship between executive function skills and state or trait anxiety has been studied. However, to the best of authors’ knowledge, no study has examined the relationship between anxiety level under a stressful global situation, such as the prevalence of a deadly disease, and executive function skills. A few studies have explored situation-specific anxiety in simulated environments. For example, exams or learning a second language test have been proposed as stressful situations. Certainly, the level of anxiety perceived by an individual during these conditions is not comparable to the real cause of a deadly epidemic. For example, a 1993 study by Zeidner found that state anxiety in students spiked significantly during the final semester exams (4). Therefore, under real-life conditions, one can accurately investigate the role of self-regulation skills in the level of disease anxiety. However, to the best of our knowledge, there is no study on the relationship between self-related skills of executive functions and situation specific anxiety. Therefore, the primary objective of this study is to investigate the association between self-related skills of executive functions and COVID-induced anxiety. The secondary goal is to predict COVID-induced anxiety based on the subscales of executive functions.