Key words: ADHD, Self-Compassion, Quality of life, Occupational Therapy
Abstract
Background: Adults with Attention Deficit Hyperactivity Disorder (ADHD) experience multiple difficulties in functioning and quality of life (QoL). Biological factors have been shown to explain ~ 30% of QoL variance, yet according to a biopsychological perspective on health there is a need for additional research on psycho-social factors which may add to the explained variance of QoL. Self-compassion (SC) concerns the way people relate to themselves when they experience suffering and pain. SC has been associated with QoL in various populations with chronic health conditions, yet evidence of SC in adults with ADHD, and specifically in Israel is limited. Methods: Cross-sectional survey design. Convenience sample comprising 34 adults with ADHD and 26 without ADHD. Participants completed self-rated questionnaires: ADHD symptoms (ASRS) Adult ADHD self-report scale, ADHD related QoL (AAQoL), and the Self-Compassion Scale (SCS) comprising 6 scales: mindfulness, common humanity, self-kindness, over identification, isolation, and self-judgement. Results: Comparison between groups demonstrated that the ADHD group mean scores were significantly lower on AAQoL (F (1,58) = 20,84, p< .001) and on SCS (F (1,58) = 12.60, p< .001). Significant differences were found on five of six SCS subscales, with largest effects on over identification and common humanity. A positive significant correlation was found between total SCS and AAQoL total scores (r=.63; 69, p<.001). Additionally, SCS contributed to the explained variance of AAQoL beyond that accounted for by the ADHD group. Conclusions: SC may be a worthy intervention target to increase QoL among adults with ADHD.
Main message
- Positive aspects of self-compassion are lower, and negative aspects are higher in adults with ADHD compared to adults without ADHD.
- Self-compassion is significantly associated with quality of life.
- Self-compassion is modifiable and a worthy target to improve quality of life
This article is based on the research conducted by Yuval Lester-Keidar R.I.P. as partial fulfillment for his MSc Degree at the School of Occupational Therapy, Faculty of Medicine, Hebrew University. This work is also of part of the research conducted by Dr. Tamar Paley for her PhD thesis: “Occupational identity, quality of life and recovery processes among adults with ADHD”, supervised by Prof. Adina Maeir and Prof. Ron Shor.
In February 1999, during his military service, Yuval was seriously wounded. He lost both his hands and his vision was impaired. In addition, he sustained serious neurological damage. Despite this daunting situation, and perhaps because of it, he dedicated his life to broadening a public understanding of the handicapped and their functioning in an open society. This paper is based upon his research for his master’s thesis. He died in October 2019, from neurological complications, before he was able to bring this material to fruition.
Yuval contributed greatly to the Israeli Occupational Therapy community and he is sorely missed.
מילות מפתח: הפרעת קשב ופעלתנות יתר, חמלה עצמית, איכות חיים, ריפוי בעיסוק
תקציר
רקע: מבוגרים עם הפרעת קשב ופעלתנות יתר (ADHD) חווים קשיים מרובים בתפקוד ובאיכות החיים. גורמים ביולוגיים נמצאו מסבירים כ-30% מן השונות של איכות חיים, אך לפי תפיסה ביו-פסיכו-סוציאלית של בריאות, יש צורך להשלים מחקר על אודות גורמים פסיכו-סוציאליים שעשויים להוסיף להסבר השונות של איכות החיים. המחקר הזה מתמקד בחמלה עצמית, שקשורה לאופן שבו אדם מתייחס לעצמו כשהוא חווה סבל וכאב. חמלה עצמית נמצאה קשורה לאיכות איכות חיים בקרב מגוון קבוצות של אנשים המתמודדים עם מצבי בריאות כרוניים, אך חסר מחקר על חמלה עצמית אצל אנשים עם ADHD באופן כללי, ובישראל בפרט. שיטה: מחקר חתך מסוג סקר. מדגם נוחות שכלל 34 מבוגרים עם הפרעת קשב ו-26 ללא הפרעת קשב. המשתתפים מילאו שאלונים לדיווח עצמי של תסמיני הפרעת קשב, איכות חיים (AAQoL) וחמלה עצמית (SCS). שאלון ה-SCS כולל שישה סולמות: קשיבות, אנושיות משותפת, נדיבות עצמית, הזדהות יתר עם הקושי, בדידות והלקאה עצמית. תוצאות: השוואה בין הקבוצות הדגימה ממוצעים נמוכים יותר באופן מובהק בקרב קבוצת ה-ADHD בAAQoL- F(1,58) = 20.84, p< .001)) וב-SCS (F(1,58) = 12.60, p<.001). הבדלים מובהקים בין הקבוצות נמצאו גם בחמישה מתוך ששת תת-הסולמות של חמלה עצמית. עוצמת האפקט הגדולה ביותר נמצאה בהזדהות יתר עם הקושי ואנושיות משותפת. נמצא מתאם חיובי מובהק בין ציון כולל של SCS ל-AAQoL בשתי הקבוצות (r=.63; 69, p<.001). כמו כן, נמצא כי חמלה עצמית תרמה לשונות המוסברת של איכות החיים מלבד לאבחנת ADHD. מסקנות: חמלה עצמית עשויה להיות מוקד התערבות משמעותי לקידום איכות החיים למבוגרים עם ADHD.
מסר עיקרי
- בקרב מבוגרים עם ADHD היבטים חיוביים של חמלה עצמית נמוכים יותר, ואילו היבטים שליליים שלה גבוהים יותר, לעומת מבוגרים ללא ADHD.
- חמלה עצמית קשורה במובהק לאיכות חיים.
- חמלה עצמית ניתנת לשינוי והיא בעלת משמעות ניכרת בקידום איכות חיים.
מאמר זה מבוסס על עבודת המוסמך של יובל לסטר-קידר ז"ל בנושא "חמלה עצמית ואיכות חיים בקרב מבוגרים עם וללא הפרעת קשב בישראל", בבית הספר לריפוי בעיסוק של האוניברסיטה העברית. המחקר נעשה במסגרת עבודת הדוקטורט של תמר פלי בהנחייתם של פרופ' עדינה מאיר ופרופ' רון שור בנושא: "זהות עיסוקית, איכות חיים ותהליכי החלמה בקרב מבוגרים עם הפרעת קשב".
ב-1999 במהלך שירותו הצבאי, נפצע יובל באורח קשה. הוא איבד את שתי ידיו, חלק מראייתו וניזוק נזק נוירולוגי ניכר. למרות מצבו הקשה, ואולי אף בגללו, הוא הקדיש את חייו להרחבת ההבנה הציבורית של אנשים עם אתגרים תפקודיים בקהילה. הוא הלך לעולמו באוקטובר 2019, לפני שהספיק לסיים את עבודתו זו.
יובל תרם תרומה רבה לקהילת הריפוי בעיסוק בישראל והוא חסר לנו מאוד.
Introduction
Attention deficit hyperactivity disorder (ADHD) is recognized as a lifespan neurodevelopmental disorder characterized by pervasive symptoms of inattention, impulsivity, and hyperactivity manifested in at least two occupational settings (American Psychiatric Association [APA] 2013; Kooij et al., 2019). Recent studies estimate ADHD prevalence to be 4% of the world's adult population (Song et al., 2021). The substantial functional impact of adult ADHD has been demonstrated in multiples domains such as instability and underachievement in major productive roles, difficulties to maintain and manage family life, health and finances (Adamou et al., 2021, 2013; Barkley, 2014; Faraone et al., 2015; Fayyad et al., 2017). These functional difficulties are pervasive, involving profound challenges and negative experiences that have an adverse effect on quality of life. Quality of Life (QoL) is a multidimensional concept that reflects one's subjective perception of his/her position in life in relation to their goals, expectations, standards, and concern. (WHOQOL Group, 1995). Specifically, Health Related Quality of Life (HR QoL) represents the impact of a specific health condition on QoL (Brod, 2005) and is a key factor in understanding the well-being of persons living with long term health conditions. There is strong evidence demonstrating lower QoL among adults with ADHD compared to adults without ADHD (Brod et al., 2015; Faraone et al., 2015; Fayyad et al., 2017; Goffer, Cohen, & Maeir, 2022). Interestingly, the effect sizes of the association between ADHD and QoL are moderate, indicating that Qol variance is not explained merely by symptom severity.
Furthermore, Coghill, Banaschewski, Soutullo, Cottingham, and Zuddas (2017) reported that successful interventions to reduce ADHD symptoms did not necessarily increase QoL, and those that increased QoL among adults with ADHD did not necessarily decrease ADHD symptoms. Therefore, Coghill et al., (2017) suggested directly addressing increased QoL as a desired outcome, rather than as a by-product of ADHD symptom reduction. Further investigation is therefore needed in order to better understand which ADHD associated factors significantly impact QoL in adults with ADHD.
Aiming to increase QoL among adults with ADHD directed researchers to identify psycho-social resources with this potential (Coghill et al., 2017; Mahdi et al., 2017; Newark, Elsasser, & Stieglitz, 2016; Turgay et al., 2012). This was the innovative rationale for implementing the Recovery Paradigm from the field of psychiatric rehabilitation to the adult ADHD population in the overarching research project about occupational identity, quality of life, and recovery processes among adults with ADHD (Paley, 2021). The current study is part of this endeavor. The Recovery paradigm in mental health focuses on internal and external resources, such as finding meaning and hope that enhance positive identity changes and support participation in meaningful life roles alongside managing active symptoms (Antony, 1993; Doroud, Fossey, & Fortune, 2015; Leamy, Bird, Boutillier, Williams, & Slade, 2011). The potential of applying The Recovery paradigm in occupational therapy interventions among adults with ADHD is recognized (Adamou et al., 2021), yet there is a need to explore unique features of recovery among adults with ADHD. Searching for well-established constructs that measure internal resources associated with positive identity changes and QoL led us to include Self-Compassion as an operational as well as a theoretical measure relating to personal recovery among adults with ADHD in Israel (Paley, 2021).
Self-compassion (SC), originally grounded in Buddhism, concerns different aspects of self-relating while a person is facing difficulties, like different aspects of pain, going thru a hard time, experiencing failures, or dealing with one's inadequacies (Kabat-Zinn, 1994; Neff, 2003; Neff & Germer, 2017). Neff (2003, 2016) defined self-compassion as a multifaced construct with three distinctive intercorrelating components, with positive and negative poles representing, respectively, compassionate versus uncompassionate inclination: (1) mindfulness, perspectival awareness towards personal suffering, versus overidentification, disperspectival awareness resulting in negative self-attribution; (2) common humanity, accepting difficulties as inevitable elements of human life, versus isolation, experiencing personal difficulties as aberrations not experienced by others; and (3) self-kindness, offering oneself gentle caring and comfort, versus self-judgment, being harshly critical towards oneself.
The recent acceleration in SC studies articulates its significant contribution to health and QoL (Neff & Germer, 2017; Zessin, Dickhaüser, & Garbade, 2015). Most studies use Neff's Self-Compassion Scale (SCS), including its three positive-versus-negative subscales (Neff, 2016). Positive SC was found to associate with increased resilience and QoL during different external and internal stressors, such as wars, stressful life situations such as divorce and first-year academic studies, and among survivors of child abuse (Zhang, Luo, Che, & Duan, 2016; Hiraoka et al., 2015; Barlow, Turow, & Gerhart, 2017).
Greater SC is associated with higher QoL, resilience and better psychological and physical health (Homan & Sirois, 2017; Neff, Whittaker, & Karl, 2017), whereas uncompassionate inclinations is associated with more stress and psychopathological symptoms (MacBeth & Gumley, 2012; Neff, 2016). SC has predicted QoL and well-being among varied samples in the general population, as well as among people managing varied chronic mental and physical health conditions, such as depression, anxiety, diabetes and celiac to name a few (Zessin et al., 2015; Sirois, Molnar, & Hirsch, 2015; van Dam, Sheppard, Forsyth, & Earleywine, 2011; Dowd & Jung, 2017). Currently, there are few studies concerning SC among adults with ADHD, (Beaton et al., 2020; Beaton at al., 2021; Farmer et al., 2023). These studies indicate that ADHD symptoms are associated with more negative SC and lower self-compassion among adults with ADHD (Farmer et al., 2023), and that this affects their well-being (Beaton et al., 2020; Beaton et al., 2021; Farmer et al., 2023). This study aimed to compare SC among adults with and without ADHD and examine its relationships with QoL. The study hypotheses were: (a) SC total and positive subscale scores will be significantly lower among adults with ADHD compared to adults without ADHD. (b) SC negative subscales will be significantly higher among adults with ADHD compared to adults without ADHD. (c) QoL scores will be significantly lower among adults with ADHD compared to adults without ADHD. SC will significantly contribute to QoL variance beyond that accounted for by the ADHD diagnostic group.
Methods
A cross-sectional survey research design with three participant-rated questionnaires was used to examine study hypotheses. The sample of adults with ADHD that is presented in this study was part of a larger sample study on recovery processes among adults with ADHD.
Sample size was calculated based on a previous study in the United Kingdom whereby an effect size of .44 was found comparing SCS scores between groups with and without ADHD (Beaton et al., 2020). Accordingly, a sample of n=45 was required for each group, with 80% power and alpha = .05. (Thus, the current sample is considered underpowered).
Procedure
The Hebrew University Ethical Research Board approved this study (# 122015). All participants signed informed consent forms. Both groups were recruiting via convenience sampling method, from adult volunteer participants ages 18-60 that responded to advertisements on social media and met inclusion criteria.
The inclusion criteria for the study group were: Self-report ADHD diagnoses conducted by a certified medical professional confirmed by the Adult ADHD Self-Report Scale (ASRS) (Kessler et al., 2005) clinical cutoff score 51 or above. Inclusion criteria for the control group was an ADHD symptom score below the cutoff on the ASRS. Exclusion criteria for both groups was the presence of other major health conditions that impact on daily functioning and quality of life as determined by self-report. Both inclusion and exclusion criteria were included in a demographic questionnaire, along with main demographic variables, such as age, gender. education etc.
Instruments
Adult ADHD Self-Report Scale (ASRS), version 1.1 (Kessler et al., 2005). The ASRS is an 18-item self-report checklist for ADHD symptoms developed in cooperation with the World Health Organization to assist with ADHD diagnosis. Participants rate ADHD symptoms on a 5-point Likert scale (from 1= never to 5= very often) according to their frequency in the past 6 months. In the English version, the score of the first six items best serves to screen for ADHD, and of the next 12 items to assess the symptoms’ severity. However, in the Hebrew version, a higher sensitivity for ADHD diagnosis was found in the total score. Therefore, a total ASRS score above 51 was considered the cutoff for confirming participants' self-reported ADHD diagnosis (Zohar & Konfortes, 2010). The Hebrew version has high test–retest reliability (r= 0.60-0.90), a significant discriminant validity and
good internal consistency (alpha= 0.82–0.89) (Zohar & Konfortes, 2010).
Adult ADHD QoL (AAQoL) Scale (Brod et al., 2006). The AAQoL is an established self- report measure for HRQoL among adults with ADHD (Brodd et al., 2015). All 29 items rated on a 5-point scale describing frequency and intensity of occurrences during the last 2 weeks of the participant’s life, yielding a total score and four subscale scores: productivity, life outlook, relationships, and psychological health. Negative scores are reversed, transforming all item scores from a Likert to an interval scale (in which a score of 1 indicates 0 and a score of 5 indicates 100). The total and four subscale means are calculated accordingly. This instrument was found to have good internal consistency (α = .93) and test–retest reliability (intraclass correlation coefficient = 5.86; Brod et al., 2006; Matza, Johnston, Faries, Malley, & Brod, 2007; Matza, Van Brunt, Cates, & Murray, 2011). The Hebrew version used here has demonstrated validity in Israeli adults with ADHD (Stern & Maeir, 2014).
SCS (Neff, 2003). The SCS is a self-report questionnaire that addresses self-relating during difficult times. Its 26 items are scored on a Likert scale according to the frequency best matching personal conduct (1= never to 5= always). Scores are calculated for the total mean and the means of the three positive-versus-negative subscales: self-kindness (items 5, 12, 19, 23, and 26) versus self-judgment (items 1, 8, 11, 16, 21), common humanity (items 3, 7, 10, 15) versus isolation (items 4, 13, 18, 25), and mindfulness (items 9, 14, 17, 22) versus overidentification (items 2, 6, 20, 24).
All negative item scores must be reversed before calculating the total mean (i.e., old 1 = new 5). Good internal consistency was found for all scales (Cronbach’s α ranges from .75 – .92), as well as good test–retest reliability (from .80 – .93; Neff, 2016). The validated Hebrew translation was used (Gerber, Yolmacz, & Doron, 2015).
Data analyses
The data were analyzed with SPSS.23 (2015). The study variables met criteria for normal distribution. Descriptive statistics were employed to profile means and standard deviations of variables. Multiple Analyses of Variance were computed to examine group differences on SCS and AAQoL and ASRS. Pearson correlations were computed to examine correlations within groups. Exploratory multiple regression analysis was computed to examine the contribution of ADHD group, SCS and their interaction (Group X SCS) to the explained variance of the AAQoL. Statistical significance was determined at p<.05.
Results
Demographic characteristics of both the study and the control groups are presented in table 1. The study group included twenty-six participants (16 women and 10 men) with ADHD with a mean age 38.81 years (SD= 7.64). The control group included thirty-four participants (23 women and 11 men) with mean age 42.32 years (SD= 7.37).
Table 1 presents the demographic characteristics of both the study and the control groups. No significant differences were found between the groups on age and gender, yet significant differences were found on level of education, with slightly higher education levels in the study group. As expected, highly significant differences were found between groups on ADHD symptomatology (ASRS).
Table 1
Participants Characteristics
| Study (n = 26) | Control (n = 34) | p* | ||||||||
| Range | Mean (SD) | Range | Mean (SD) | |||||||
| Age (Years) |
29-73 – |
38.81 | (7.64) | 31-59 | 42.32 | (7.37) | .06 | |||
| ASRS (total) | 51-73 | 62.92 | (6.70) | 23-50 | 36.44 | (8.58) | <.001 | |||
| N (%) | N (%) | p** | ||||||||
| Education: | .04 | |||||||||
| High School Graduate | 2 | (7.70) | 0 | |||||||
| Bachelor’s Degree | 12 | (46.20) | 13 | (38.20) | ||||||
| Master’s Degree | 12 | (46.20) | 14 | (41.20) | ||||||
| PhD | 2 | (7.70) | 7 | (20.60) | ||||||
| Gender: | .62 | |||||||||
| Male | 10 | (38.50) | 11 | (32.40) | ||||||
| Female | 16 | (61.50) | 23 | (67.60) | ||||||
Notes. SD = Standard Deviation. * Mann Whitney. ** Pearson Chi-Square.
Table 2 provides comparisons between groups on SCS and AAQoL, reporting results of MANOVA analyses. Significantly lower AAQoL scores were found among the study group compared to controls with medium to very large effect sizes on all subscales. Similarly, adults with ADHD had significantly lower SCS total scores than controls, with a large effect size. Regarding SCS subscales the trend was consistent, with the ADHD group lower than controls on positive SC subscales (Self Kindness, Common Humanity and Mindfulness) and higher than controls on negative subscales (Self Judgement, Isolation and Over identification). All comparisons were statistically significant except for the Self-Kindness subscale.
Table 2
MANOVA comparisons between ADHD and control group on study outcomes: AAQoL and SCS (N = 60)
| Outcome measures | M (SD)
|
|||||||||
| Study group
n=26 |
Control group n=34 |
F1,58 | Partial eta squared | |||||||
| AAQoL Total | 48.90 (11.63) | 66.67(17.02) | 20.84** | .26 | ||||||
| Life productivity | 41.12(11.12) | 65.58 (18.25) | 36.34** | .38 | ||||||
| Psychological health | 48.08 (19.19) | 63.34 (22.54) | 7.68* | .11 | ||||||
| Relationships | 57.5 (18.07) | 67.5 (19.74) | 4.06* | .06 | ||||||
| Life outlook | 55.81 (17.74) | 67.09 (20.37) | 5.04* | .08 | ||||||
| SCS Total | 2.68 (0.68) | 3.32 (0.74) | 12.60** | .17 | ||||||
| Common humanity | 2.48 (0.81) | 3.23 (0.87) | 11.45** | .16 | ||||||
| Self-kindness | 2.75 (0.86) | 3.16 (0.92) | 3.19 | .05 | ||||||
| Mindfulness | 3.00 (0.85) | 3.60 (0.92) | 6.75* | .10 | ||||||
| Isolation | 3.24 (0.83) | 2.65 (1.03) | 5.63* | .08 | ||||||
| Self-judgment | 3.35 (0.92) | 2.71 (0.81) | 8.12* | .12 | ||||||
| Overidentification | 3.61 (0.77) | 2.81 (0.94) | 12.29** | .17 | ||||||
Notes. SD = Standard Deviation. M = Mean. AAQoL= Adult Attention-Deficit/Hyperactivity Disorder Quality-of-Life Scale. SCS = Self-Compassion Scale.
The Pearson correlation analysis between SCS and AAQoL total scores within each group revealed positive, moderate and significant correlations r=.63, p<.001 in the ADHD group and r= .69, p<.001 in the control group. In order to further explore the association between self-compassion and QoL, beyond that accounted for by ADHD, we conducted an exploratory regression analysis (see Table 3). AAQol Total score was the dependent variable and we entered the following independent variables: ADHD group, Self-Compassion (SCS -Total) and an Interaction variable Group x SCS. Results revealed a significant model (F 2,57 = 41.89, p<.000; R Square = .595) with both variables providing unique explanation to AAQoL variance. The Interaction Group x SCS was not significant, i.e., the association between Total Self Compassion with AAQoL was not different between the groups.
Table 3
Exploratory multiple regression on Adult Attention-Deficit/Hyperactivity Disorder Quality-of-Life Scale (AAQoL) (N=58)
| Beta | t (p) | R-square change | Sig. F Change | |
| Groupa | -.25 | -2.64 (.01) | .26 | <.001 |
| SCS b | .53 | 5.53 (<.001) | .33 | <.001 |
| Interaction Group x SCS | -.35 | -.98 (.33) | .007 | NS.329 |
| Overall R-square= .595; Adj. R-square = .581; F 2,57 = 41.895, p<.000 | ||||
Notes. aGroup = Study/Controls. b SCS = Self-Compassion Scale.
Discussion
The purpose of this study was to compare SC and Qol among Israeli adults with and without ADHD. Results revealed significantly lower overall SC and QoL among adults with ADHD compared to controls. Regression model demonstrates the unique impact of SC on QoL beyond that accounted for by the ADHD group. Furthermore, no significant interaction between groups was found, indicating a similar impact of SC on Qol in both groups. These findings add to the body of evidence, considering psychological factors such as SC as significant for understanding the variance of QoL among adults with ADHD, as well as in the general adult population without ADHD.
To the best of our knowledge this is among the first studies comparing SC among adults with and without ADHD in Israel. The mean SC scores of the participants with ADHD in our study are similar to those found in four recent studies, two conducted on college students (Willoughby & Evans, 2019; Farmer et al., 2022) and two others with large samples of adults in the UK (Beaton et al., 2020; 2022). In these studies, a similar pattern was found with higher scores for uncompassionate self-responding versus compassionate ones, and that ADHD traits were associated with higher self-criticism, isolation, and overidentification (i.e. uncompassionate self-responding) but not with self-compassionate responding (i.e. self-kindness, common humanity or mindfulness). Similarly, our results show between-group effects on levels of SC, using clinical cutoff scores of ADHD symptomatology. Taken together, these studies provide support for an emerging unique pattern of SC among adults with ADHD.
Regarding the positive and negative SC scores, it is noteworthy that the study group also showed a greater inclination for negative SC, especially for identifying themselves with their failures and not considering their difficulties, faults and such, as a shared human experience.
These findings have important implications in understanding the pervasive functional challenges across many occupational domains (Kosheleff, Mason, Jain, Koch, & Rubin, 2023). Following is an example, using the SC lens to understand the possible implications of a common ADHD related time-management challenge. Considering the uncompassionate stance we can predict self-criticism (How could I be late again? condemning oneself and deserving punishment), along with a self-isolating belief (I’m probably the only person in the world that is always late, even to important meetings), and an over self-identification (“I am messed up; always late). Indeed, prevalent associated features among adults with ADHD include negative psychological and self-identification features such as low self-esteem, lack of control, low self-efficacy and self-stigma (Cook et al., 2014; Fayyad et al., 2017; Kooij et al., 2019; Newark et al., 2016; Turgay et al., 2012). Furthermore, researchers point out the challenge and the need to change the mindset of adults with ADHD (Ramsay & Rothstein; 2014; Ramsay, 2020; Toner et al., 2006; Schott, 2012; Stenner, 2019; Schrevel et al., 2016; Mahdi et al., 2017).
Considering these challenges presented by ADHD and lack of psychological resources, it is fitting that results point to significantly lower QoL among the ADHD group compared to controls. These findings are compatible with previous studies, consistently revealing lower QoL among adults with ADHD compared to controls (Kooij et al., 2019; Agarwal, Goldenberg, Perry, & IsHak, 2012). Considering the importance of QoL as an ecological estimate of the daily life experiences of individuals with health conditions, these findings underscore the significant adverse impact of adult ADHD (Faraone et al., 2021). Research findings have demonstrated a significant association between QoL and neurological impairments represented by ADHD symptomatology or neuropsychological deficits (Quintero, Morales, Vera, Zuluaga, & Fernández. 2019; Sjöwall & Thorell, 2022; Stern, Pollak, Bonne, Malik, & Maeir 2017). Thus, the findings of this study pointing to the significant contribution of the psychological factor SC to the explained variance of QoL, beyond that accounted for by ADHD diagnoses, are somewhat novel with only sparce additional evidence, such as Beaton et al., (2022) showing that both ADHD and SC were unique predictors of mental health.
The clinical implications of these findings are manifold. Firstly, they substantiate the current need to adopt an integrative and holistic approach to understanding the personal recovery processes of individuals with ADHD. According to the recovery paradigm, we focus on how individuals with ongoing symptoms can develop positive internal resources, such as SC, that will support positive identity and QoL. This approach has been expressed in recent ADHD literature: “Holistic and person-centered assessment is increasingly seen as vital. Research and practice focused solely on symptoms is limiting, as it neglects the QoL “(Sonuga-Barke et al., 2023 p. 512). In addition, findings highlight SC as a worthy target for intervention. Treatment studies have shown that SC is not a static trait but a modifiable factor. Ferrari and colleagues (2019) conducted a meta-analysis of 27 randomized controlled trials (RCTs) of SC interventions (many of which were short term) and found increases in SC and reductions in psychopathology with medium to large effect sizes. Thus, SC intervention has the potential to magnify the effect of other treatment approaches. To the best of our knowledge, SC interventions have not yet been studied among adults with ADHD.
Regarding the control group, we did not find an interaction effect between groups for the impact of SC on QoL, indicating that SC was similarly significant among individuals without diagnosed ADHD or other psychopathologies. This finding is supportive of the application of SC interventions for non-clinical populations as well as clinical ones (Neff, 2023).
Summary
To the best of our knowledge this is among the first studies comparing SC among adults with and without ADHD in Israel. This study broadens our understanding of factors underpinning QoL among adults with ADHD. The current study adds to the emerging evidence pointing to a lack of SC which is a unique contributor to QoL outcomes, beyond those accounted for by ADHD symptomatology. Broadening our lens of ADHD beyond the biological implications may improve clinical outcomes for this large population.
Study limitations
The current study has several limitations which could impact generalizability of findings. The sample size was small and the groups differed in level of education. In addition, the setting of data collection was different for both groups, as the study group data collection was conducted in a face-to-face setting and the control group, remotely. Finally, group allocation to ADHD or controls was based on self-report of diagnoses and on clinical cutoff scores for the ASRS. A note of caution is required since these scores were based on self-report only and did not include a DSM guided diagnostic interview to verify ADHD as well as examine other comorbidities which may have influenced the findings.
Further studies are needed with larger, more representative samples to better understand the relationship between ADHD, SC and QoL. Such studies will potentially shed light on the different dimensions of SC and their mediating role between ADHD and QoL
Clinical implications
Firstly, a routine assessment of SC among adults with ADHD is recommended. Secondly, interventions designed to raise SC among adults with ADHD are needed. The Cognitive Functional intervention for adults with ADHD has incorporated this approach in its integrative approach to treating individuals with ADHD. Initial findings are promising, yet further research is required (Kastner et al.,2022; Simchon-Galili & Maeir, 2023).
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