Psychological Health and Quality of Life among Ultra-orthodox Mothers of Children with Attention Deficit Hyperactivity Disorder: Impact of Occupational Experiences

Abstract

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a common neuro-developmental health condition in children and adolescents. Parenting a child with ADHD can profoundly affect mothers’ health. Research is limited regarding occupational experiences and their impact on health among mothers of children with ADHD (MoCwADHD). Ultra-orthodox MoCwADHD may have unique cultural circumstances that have not been studied.

Aims

To broaden understanding of parental stress, psychological health, and quality of life (QoL) of ultra-orthodox MoCwADHD and explore a possible role of occupational experiences on these outcomes.

Methods

Ultra-orthodox MoCwADHD (N = 114) completed a sociodemographic questionnaire and measurements to assess child ADHD symptomatology, mother’s ADHD, parental stress, psychological health, QoL, and occupational experiences.

Results

Participants displayed moderate parental stress, and 54.9 percent also showed psychological distress symptoms, similar to the literature on MoCwADHD in the general population. Frequency of engagement in health promoting occupations reflected patterns in line with cultural beliefs. Structure Equation Modeling showed that child ADHD negatively affected mothers’ stress, psychological health and QoL. Importantly, occupational experiences directly and indirectly, via parental stress, impacted psychological health and QoL.

Conclusions

MoCwADHD impacts maternal health in the ultra-orthodox population and occupational experiences may be a modifiable target for promoting their health.

Keywords:

• ADHD
• maternal health
• culture
• occupation
• health promotion

Attention Deficit Hyperactivity Disorder (ADHD) is a chronic neurodevelopmental health condition characterized by a persistent pattern of inattention, hyperactivity, and impulsivity (American Psychiatric Association [APA], 2013). The prevalence of ADHD in children is estimated at 5–7% worldwide, making it one of the most common psychiatric disorders in children and adolescents (Ringer et al., 2020). ADHD can profoundly affect the family context, which has been described as chaotic, conflictual, and exhausting (Craig et al., 2020). A significant portion of the care involved in raising a child with ADHD falls on mothers. Mothers are more often responsible for the day-to-day caretaking, disciplining, and treatment seeking of their child (Avrech Bar et al., 2018). They are also nine times more likely to be the primary caregivers of children over fathers (U.S. Bureau of the Census, 2011).

There is substantial evidence documenting the physical, psychological, social, and functional burden of MoCwADHD. This burden includes higher rates of sleep problems (Mofokeng & van der Wath, 2017), higher alcohol consumption (Peasgood et al., 2020), less intimate relations (McIntyre & Hennessy, 2012), higher marital stress and divorce (Leitch et al., 2019), higher levels of parenting stress (Craig et al., 2020), higher social isolation due to perceived stigma (McIntyre & Hennessy, 2012), less advancement at work (Zhao et al., 2019), less professional and personal development (Hill et al., 2015), higher financial stress, lower income (Flood et al., 2016), difficulties managing everyday routines (Ringer et al., 2020), and less time to pursue personal self-care and leisure activities (Avrech Bar et al., 2018). This burden has been shown to negatively impact MoCwADHD’s psychological health (Craig et al., 2020) and quality of life (QoL) (Cappe et al., 2017). Factors that have been associated with the severity of negative psychological health and QoL outcomes include the severity of the child’s ADHD symptoms (Muñoz-Silva et al., 2017), the mother having a diagnosis of ADHD (Peasgood et al., 2020), her socioeconomic background (Dovgan & Mazurek, 2017), and her immediate social and cultural environment (Paidipati et al., 2017). The socio-cultural environment can influence understanding the caregiving role (Korb, 2010), beliefs regarding illness and treatment (Manor-Binyamini & Schreiber-Divon, 2021), health decisions, and impact accessibility to treatment (Paidipati et al., 2017). For example, mothers may experience barriers to effectively implementing evidence-based ADHD treatments for their children because of inequities regarding access to services, poor quality of care, and lack of culturally acceptable treatment (Paidipati et al., 2017). Therefore, understanding the impact of health conditions must consider cultural differences to reduce health disparities among diverse populations. This will aid in promoting inclusiveness and client-centered health services as well as help improve QoL outcomes (Hammell, 2013).

Ultra-orthodox Jews are a group of highly religious individuals that belong to an internally cohesive and segregated community where values, beliefs, and behaviors are greatly influenced by their society’s cultural codes. They under-utilize mental health services, partially due to the lack of culturally sensitive treatments and to their fear of stigma attached to receiving mental health services (Weiss et al., 2013). In addition, there is a general distrust and discomfort between the members of this community and health professionals (Freund & Band-Winterstein, 2013). The impact of having a child with ADHD on maternal psychological health and QoL has not yet been explored in this community. Despite differences between ultra-orthodox Jews with other highly religious groups there is a shared commitment among these groups to their specific religious values and adherence to their social codes (Novis Deutsch & Rubin, 2019).

Occupational science is founded on the relationship between occupation and health (Hocking & Wright-St. Clair, 2011). The Do-Live Well (Moll et al., 2015) is an example of an occupational health-promoting framework that links occupational experience to health outcomes. The message of the Do-Live-Well is that what people do every day and how they experience it impacts their health and QoL. The framework operationalizes occupational experience into eight interrelated occupational dimensions (e.g., taking care of yourself, connecting to others) and five activity patterns (e.g., meaning, balance) that have been linked to health outcomes. Occupational experiences may be a moderating variable between stress and positive psychological health and QoL (American Occupational Therapy Association [AOTA], 2020; Hammell, 2009; Kielhofner, 2008). This approach has been applied to mothers of children with disabilities. Studies have shown that enabling positive occupational experiences led to a reduction in negative health outcomes and increase in QoL (Bourke-Taylor et al., 2022).

Considering the known health risks of mothering a child with ADHD in the general population and the relationship between culture and health, the first goal of this study was to broaden understanding of this risk to psychological health and QoL of ultra-orthodox MoCwADHD. We hypothesized that similar trends in psychological health and QoL will be in ultra-orthodox MoCwADHD as found in the literature on MoCwADHD in the general population. Furthermore, in line with the Do-Live-Well framework, the second goal of this study was to examine the potential health promoting impact of occupational experiences on psychological health and QoL among these mothers. We hypothesized that engaging in health promoting activities will be associated with lower psychological symptoms, less parental stress and higher QoL, as represented in Figure 1.

Figure 1. A theoretical framework of factors related to the psychological health and QoL of mothers of children with ADHD.

Method

Study Design

This study used a quantitative design inclusive of both descriptive and correlational methods including Structural Equation Modeling (SEM) statistical methods. The study was approved by the University institutional review board (#2104202). Minimal sample size was calculated using G* power based on α = .05, a power of 80%, and correlations found in studies with similar populations (r = .47) (Peasgood et al., 2020), yielding a sample size of 30 participants. However, for a SEM, a minimal sample size of 100–150 participants is recommended (Tabachnick & Fidell, 2001).

Participants

A total of 114 ultra-orthodox MoCwADHD participated in this study. Inclusion criteria were (a) having a child diagnosed with ADHD between 6 and 18 years old and (b) defining themselves as ultra-orthodox in their religious affiliations. Exclusion criteria was having a major health condition among themselves or a family member (besides ADHD) that impacts their daily functioning (determined by self-report). Participants were recruited from child development centers in the ultra-orthodox communities and by the snowball method. Participants provided informed written consent. Mean age of participants was 37.7(SD 6.5); 75.5% of participants completed a post-secondary education or higher and 45.6% reported income below the national average. Six participants (5.3%) met the criteria for ADHD according to the Adult ADHD Self-Report Scale (ASRS) (Kessler et al., 2005). Description of the sample is provided in Table 1.

Table 1. Demographics of participants (N = 114).

Variable	M(SD)	Median	Min–Max	%
Age of mother	37.7(6.5)	37	27–56	–
Number of children	5.5(2.1)	5	1–11	–
Number of children with ADHD	1.3(.72)	1	1–5	–
1				82.1
2				10.9
3				4.0
4				2.0
5				1.0
	%
Mothers—ADHD	5.3
education
Primary	3.5
Secondary	21.0
Post-secondary or degree	55.3
Post-graduate	20.2
Gender of child with ADHD
Male	59.2
Female	40.8
Income
Below national average	45.6
National average	36.9
Above national average	17.5
Employment
None	17.7
Part-time	39.8
Full-time	42.5

Notes. ADHD: Attention Deficit Hyperactivity Disorder; National average monthly income per household of seven individuals in Israel is reported at 18,667 nis (Central Bureau of Statistics, 2022).

Measures

Adult ADHD Self-Report Scale (ASRS) (version 1.1) Symptom Checklist (Kessler et al., 2005) assesses current ADHD symptoms and consists of 18 items based on the DSM-IV (APA, 2013). Items are measured on a five-point scale (0 = never to 5 = very often), yielding scores ranging from 0 to 90 and found to be predictive of symptoms consistent with ADHD. The ASRS has good internal consistency (α = .78), convergent validity, and significant discriminant validity. This measure was used to screen for adult ADHD among mothers.

Conners Third edition (Conners 3) Parent Long Form (Conners et al., 1998) assesses ADHD and related learning, behavior, and emotional problems in children and adolescents. Includes 110 items that are directly linked to the DSM-IV-TR. Items are measured on a four-point scale (0 = not true at all to 3 = very much true). Raw scores are converted to T-scores. A T-score of 65 and above indicate impairment, and higher scores indicate greater severity of symptoms. It is comprised of teacher, parent, and self-report rating scales. In this study only the parent rating scale, ADHD index, was used. It has good internal consistency coefficients, high test–retest reliability, and effective discriminatory power (Conners et al., 1998).

Parenting Stress Items (PSI) (Pearlin & Schooler, 1978) measures parental stress, by asking parents to consider how “tense” or “frustrated” they feel about parenting their children. Includes 11 items scored on a four-point scale (1 = not at all to 4 = very much so), yielding scores ranging from 11–44, with higher scores indicating greater levels of parenting stress. It is a validated and reliable measure that has been used to measure parenting stress among parents of children with ADHD (Miller, 2018), and has displayed good internal consistency (α = .81).

Patient Health Questionnaire-4 (PHQ-4) (Kroenke et al., 2009). Four-item self-report questionnaire consisting of a two-item depression scale and two-item anxiety scale. Items are measured on a four-point scale (0 = not at all to 3 = nearly every day), yielding scores ranging from 0–12, with higher scores indicating greater psychological distress (0–2 = none, 3–5 = mild, 6–8 = moderate, 9–12 = severe). It has displayed good internal consistency (α = .88) and validity as a measure of depression and anxiety symptomatology (Löwe et al., 2010).

WHOQoL- BREF (Angermeyer et al., 2006) assesses self-perception of QoL in context of the culture and values systems in which one lives and in relation to one’s goals, expectations, standards, and concerns. It is an abbreviated version of the WHOQOL-100, developed by the World Health Organization. Includes 26 items that assess four domains including physical health, psychological health, social relationships, and environment. Items are measured on a five-point scale, yielding a total score ranging from 26 to 130, where higher scores represent higher levels of QoL. In addition, each QoL domain has a separate transformed score ranging from 0 to 100. The WHOQOL-BREF has displayed good discriminant validity, internal consistency, and test–retest reliability. It has been used in research on MoCwADHD (Azazy et al., 2018).

Health Promoting Activities Scale (HPAS) (Bourke-Taylor et al., 2012) is an eight-item measure that assesses frequency of participation in social, emotional, physical, and spiritual leisure activities on a seven-point scale (1 = never to 7 = once or more every day). Scores range from 8 to 56, with higher scores indicating more frequent participation. It has good internal consistency (α = .78). Construct validity was supported by moderate correlations with subjective maternal mental health and general health in both mothers of children with disabilities and in the general population (Bourke-Taylor et al., 2012, 2014).

Experiencing Day-to-Day Life Questionnaire (EDLQ) (Budman, 2020) assesses the experience of engaging in health promoting occupations in adults. Item development was based on the Do-Live-Well framework (Moll et al., 2015) and triangulated with the human needs’ theories of SDT (Ryan & Deci, 2000) and Maslow’s hierarchy of needs (Maslow, 1970). The occupational categories are taking care of physical needs, financial security, spirituality, pleasure and joy, connecting with others, contributing to community and society, and developing and expressing capabilities. For each category, the experience of satisfaction with frequency, importance, and competence, are rated on a five-point scale (1 = not at all to 5 = completely). Raw scores are used for individual occupational categories and overall mean scores are calculated for each occupational experience. Internal consistency for frequency was α = .68, importance was α = .64, and competence was α = .81.

Procedure

The study was advertised in outpatient clinics and social media groups, after receiving permission from clinic and group administrators. The advertisement contained an explanation of the study and researchers’ contact details. An initial phone call with each respondent examined the participant’s suitability for the study and provided assurance of anonymity. Ten respondents were excluded due to additional major health conditions of themselves or other family members. After obtaining written consent, the participant provided an anonymous number before the link was sent to them, allowing tracking of completion rate of questionnaires. The participant was then sent a link to the questionnaires to be completed. Printed questionnaires were offered upon request. All participants that received a link completed questionnaires.

Data Analyses

Data analyses was performed using the SPSS statistical software Version 25.0 (IBM Corp, Armonk, NY) and statistical significance was set at p<.05. Descriptive statistics, including frequencies [means and percentages] of demographic data and measures’ scores was analyzed. Missing data were treated according to guidelines for each measure, with no more than an overall of 4.4% missing data. For example, in the Conner’s Parent Long Form, for missing data, the average of other answers in its group was used (Conners, 1998). The distribution of all variables was tested by calculating z-scores of the skewness and the kurtosis, and for most of the variables they were within ±2.58. After using a square root transformation for PHQ4, WHOQoL-BREF total score, psychological QoL and social QoL they have a normal distribution. Parametric Pearson’s correlation analyses were performed to explore relationships among study variables (socio-demographics, child symptoms, maternal stress, psychological health, QoL and occupational experiences). The Structural Equation Modeling (SEM), with maximum likelihood estimation, was used to examine the impact of severity of child ADHD symptoms, parental stress, and occupational experiences on MoCwADHDs’ psychological health and QoL outcomes (WHOQoL-BREF total score). A SEM is a statistical method used to determine complex relationships between variables, combines correlations and regression analysis and can test theoretical models using the collected data. Model fit was assessed using the following goodness-of-fit indices: Chi-square, Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and Root-Mean-Square Error of Approximation (RMSEA). A non-significant chi square, CFI and TLI equal to or greater than .95, and RMSEA equal to or less than .06 (Hu & Bentler, 1999; Tabachnick & Fidell, 2001) are indicative of an acceptable fit. The standardized path coefficients were assessed to examine the statistical significance and directions of path estimates that exist between the variables in the model.

Results

The PSI mean score indicated moderate maternal stress as represented by mid-range mean score (M = 28.1, SD = 5.8). Regarding QoL in the specific domains, the lowest mean score was found in the psychological domain (M = 70.2, SD = 17.0) and highest in the physical domain (M = 73.7, SD = 14.6). In addition, 54.9% of mothers reported mild to severe negative psychological symptoms on the PHQ-4. Descriptive results of maternal stress, QoL, and psychological symptoms are reported in Table 2.

Table 2. Maternal stress, quality of life, and psychological symptoms (N = 114).

Domain	Mean(SD)	Median	Min–Max
PSI	28.1(5.8)	28.0	11–40
WHOQoL-BREF
Total score	99.5(14.7)	101.0	54–128
WHOQoL-BREF domains
Physical	73.7(14.6)	71.4	32–100
Psychological	70.2(17.0)	70.1	13–100
Social	71.3(22.1)	75.0	17–100
Environment	72.3(15.8)	71.9	25–100
PHQ-4	3.0(2.9)
Severity of psychological symptoms	%
None	45.1
Mild	40.7
Moderate	8.0
Severe	6.2

Notes. PSI: Parental Stress Items, possible range 11–44, higher score indicates a greater level of stress; WHOQoL-BREF total score, possible range 26–130, higher score indicates greater level of QoL; WHOQoL-BREF domains, possible range 0–100, higher score indicated greater level of QoL; PHQ-4: Patient Health Questionnaire-4, possible range 0–12, higher score indicates lower psychological health; severity of psychological symptoms from PHQ-4.

In respect to the frequency of engagement in health promoting activities, mean scores on the HPAS indicated moderate frequency as represented by mid-range mean score (M = 31.3, SD = 9.4). Percentage of weekly engagement in health promoting activities were calculated by adding together the percentages for “1–3× per week” and “everyday” and had a range of 24.0–59.8, with the lowest in the category of “physically active recreational pursuit, with others” and highest in “quiet, physically inactive leisure, alone.” Results of frequency of engagement in health promoting activities are described in Table 3.

Table 3. Percentage of frequency spent in health promoting activities, HPAS.

Categories of activities	Almost never	1–3× per month	1–3× per week	Everyday
Personal healthcare tasks	26.7	18.8	36.6	17.9
Physically active recreational pursuit, alone	31.9	31.0	30.1	7.0
Physically active recreational pursuit, with others	37.1	39.0	22.1	1.8
Spiritual/rejuvenating personal time	30.4	26.8	27.7	15.1
Social activities with people important to you	35.4	29.2	31.0	4.4
Time out for yourself	26.5	29.2	31.0	13.3
Quiet, physically inactive leisure, alone	17.0	23.2	38.4	21.4
Quiet, physically inactive leisure pursuit, with others	37.1	34.6	23.9	4.4

Note. HPAS: Health Promoting Activity Scale.

Regarding occupational experience variables of the EDLQ, the overall ratings of satisfaction with frequency was reported to be lowest (M = 3.0, SD = 0.7) and highest in the ratings of importance (M = 4.1, SD = 0.5). Specifically, frequency ratings were lowest in the occupational category of “taking care of physical needs” (M = 2.3, SD = 1.2) and “developing and expressing capabilities” (M = 2.8, SD = 1.4). For all occupational categories, except for contributing to community and society (49.5%), the majority of participants (63.9%–90.9%) wanted more engagement. The highest category was taking care of physical needs. The highest mean score for importance was in the category of “spirituality” and lowest in “contributing to community and society.” The highest mean score for rating of competence was in the category “pleasure and joy” and lowest in “taking care of physical needs.” Descriptive results on occupational experience variables of the EDLQ are reported in Table 4.

Table 4. Satisfaction of engagement in health promoting occupations, EDLQ (N = 114).

Occupational Categories	Frequency M(SD)	Importance M(SD)	Competence M(SD)	Want more %	Want less %	No change %
Taking care of physical needs	2.3(1.2)	4.2(1.0)	3.3(1.0)	90.9	0	9.1
Financial security	3.4(1.2)	4.3(.9)	3.6(1.1)	63.9	9.3	26.9
Spirituality	3.1(1.2)	4.5(.8)	3.8(1.0)	84.8	0	15.2
Connecting with others	3.1(1.0)	4.1(.9)	3.7(1.0)	78.2	0	21.8
Contributing to community and society	3.5(1.3)	3.6(1.2)	3.5(1.2)	49.5	4.6	45.9
Pleasure and joy	2.9(1.2)	4.4(.8)	3.9(1.0)	85.8	0	14.2
Developing and expressing capabilities	2.8(1.4)	4.0(.9)	3.7(1.1)	69.6	0.9	29.5
Overall score	3.0(.7)	4.1(.5)	3.7(.7)	–	–	–

Note. EDLQ: Experiencing Day to Day Life Questionnaire, possible range 1–5, higher scores indicate greater satisfaction of participation.

Correlation analysis between child ADHD symptomatology, parental stress, occupational experience, psychological health and QoL outcomes are presented in Table 5. Child ADHD symptomatology showed a small yet significant positive association with parental stress (r = .24). Parental stress showed significant positive associations with psychological health (r = .55) and negative associations with WHOQoL-BREF total score as well as in all four QoL domains (r= −.29 to −.44). Occupational experience variables of EDLQ competence and frequency showed negative associations (r= −.33 and −.43) with psychological health. Associations between competence and frequency with QoL measures (WHOQoL-BREF total score and all four QoL domains) were positive (r= .42– .56), and the HPAS showed the same pattern yet with smaller effect sizes (r = .26–.33). EDLQ importance showed a small significant negative association (r= −.19) with psychological health only.

Table 5. Associations between child ADHD symptomatology, parental stress, occupational experience, psychological health, and quality of life (N = 114).

	WHOQoL-BREF total	Phys QoL	Psych QoL	Social QoL	Environ QoL	PHQ4	PSI	Conners ADHD Index
Conners ADHD Index	−.17	−.26*	−.16	−.04	−.14	.23*	.24*	–
PSI	−.44***	−.43***	−.38***	−.29**	−.30***	.55***	–	.24*
HPAS	.33***	.26**	.14	.11	.31***	−.29**	−.17*	.05
EDLQ Imp	.07	.13	.10	.17	.10	−.19*	−.04	.06
EDLQ Com	.49***	.42***	.43***	.48***	.51***	−.33***	−.23*	.05
EDLQ Freq	.56***	.51***	.53***	.46***	.48***	−.43***	−.36***	.08

Notes. Pearson correlation, *p < .05; **p < .01; ***p < .001; Conners ADHD Index, T-score 65+ indicates impairment, higher score indicates greater severity of symptoms; PSI, Parental Stress Items, possible range 11–44, higher score indicates a greater level of stress; HPAS, Health Promoting Activity Scale, possible range 8–56, higher scores indicate greater participation; EDLQ, Experiencing Day-to-Day Life Questionnaire, possible range 1–5, higher scores indicate greater satisfaction of participation; WHOQoL-BREF total score, possible range 26–130, higher score indicates greater level of QoL; WHOQoL-BREF domains, possible range 0–100, higher score indicates greater level of QoL; PHQ-4, Patient Health Questionnaire-4, possible range 0–12, higher score indicates lower psychological health.

Regarding demographic variables and study outcomes, no significant effect was found for maternal education and income level on study outcomes (p >.05), number of children was not correlated with study outcomes, mothers’ age showed a significant but small negative association with WHOQoL-BREF domains of social and environmental QoL (r= −.21, −.22; p < .05).

To examine the impact of child ADHD symptoms severity, parental stress, and occupational experiences, on MoCwADHDs’ psychological health and QoL, the SEM statistical method was used. Only significant variables, coefficients and correlations are reported in Figure 2. All fit indices for the model indicated that it was suitable fit to the data (Χ²(4)=2.649, p = .618, CFI = 1.000, NFI = .989, RMSEA = .000 and TLI = 1.032).

Figure 2. A structural equation model (SEM) analysis of the effect of child ADHD symptomatology, occupational experiences, and parental stress on mothers’ quality of life and psychological health. Conners: Conners ADHD Index; EDLQ: Experiencing Day-to-Day Questionnaire, competence and frequency scores; PSI: Parental Stress Item; WHOQoL: WHOQoL-BREF total score; PHQ-4: Patient Health Questionnaire-4.

There was a small negative correlation between the Conners and the WHOQoL- BREF total score. More severe child ADHD symptoms is related to lower parental QoL since a higher score on the Conners is reflective of more symptoms (a negative) and a higher score on the WHOQOL- BREF total score is reflective of higher QoL (a positive). In addition, there was a small positive correlation between the Conners and the PHQ4. A higher score on the Conners is reflective of more symptoms (a negative) and a higher score on the PHQ4 is reflective of more negative psychological symptoms (a negative), reflecting that more severe child ADHD symptoms were related to lower parental psychological health. More severe child ADHD symptoms (higher score on the Conners) also had a positive significant effect on parental stress since a higher score on the PSI depicts more parental stress (negative). Occupational experiences had a significant effect on MoCwADHDs’ psychological health and QoL. The EDLQ frequency had a larger contribution to the model then competence. Frequency had a direct and strong effect on parental stress, QoL and psychological health. As EDLQ frequency increases, QoL and psychological health are better and stress levels are lower. EDLQ competence only had a direct effect on QoL.

Discussion

There is substantial evidence regarding the health risks of mothering a child with ADHD in the general population (Peasgood et al., 2020; Ringer et al., 2020). Considering the relationship between culture and health (Hammell, 2013) the first aim of this study was to broaden the understanding of these known health risks among the general population to ultra-orthodox MoCwADHD. When comparing health outcomes of ultra-orthodox MoCwADHD to the literature on MoCwADHD in the general population, overall results were consistent with the research evidence except for QoL, which was found to be higher. Results of this study depicted that on average there is moderate maternal stress and mild to moderate negative psychological symptoms among these mothers. These results replicated findings in the general population (Craig et al., 2020; Miller, 2018). Ultra-orthodox MoCwADHD reported higher mean levels of QoL (∼70) than those reported among MoCwADHD in the general population (∼51) (Azazy et al., 2018; Kim et al., 2014). In this study, the psychological domain of QoL was slightly lower among the participants, than other QoL domains which is similar to the trend in the general population (Cappe et al., 2017). Consistent with previous findings regarding explanatory variables of health outcomes, the present study found that child ADHD symptomology was associated with maternal stress, psychological health and QoL (Cappe et al., 2017; Peasgood et al., 2020). Regarding the explanatory role of maternal ADHD symptoms on health outcomes (Babinski et al., 2016), since only six mothers met criteria for ADHD, further analysis of this variable’s was not feasible. Interestingly, these health above outcomes were not associated with more children or lower income level, which are generally characteristic of this population (Novis Deutsch & Rubin, 2019). Furthermore, higher overall QoL was found which may point to the potential positive impact of spirituality in ultra-orthodox mothers (Korb, 2010) on this outcome (Moll et al., 2015).

Concerning the profile of engagement in health promoting occupations among MoCwADHD, the current study expands on the limited research in several ways. The total Health Promoting Activities Scale (HPAS) mean score was similar to that of a large sample of mothers of typically developing children (M = 31.3, 32.2 respectively) (Bourke-Taylor et al., 2014) and higher than mothers of children of disabilities (M = 21.7) (Bourke-Taylor et al., 2012). Analysis of the frequency patterns reveled that less than 50% of the sample were engaged on a weekly basis in most of the health promoting activities (HPAS) except for “personal healthcare tasks” and “quiet, physically inactive leisure, alone.” A comparison of frequency patterns in our study to those of mothers of typically developing children revealed that higher frequencies were found in “spiritual/rejuvenating personal time,” “time out for yourself,” and “quiet, physically inactive leisure, alone” and lower in all other activities (Bourke-Taylor et al., 2014). This may suggest a cultural influence on activity categories, for example ultra-orthodox women typically perform at least one daily prayer (Neriya-Ben Shahar, 2019) which may provide a means of engagement in the above-mentioned categories of activities.

Regarding the Experiencing Day-to-Day Life Questionnaire (EDLQ), low mean satisfaction scores were found on the experience of frequency in “taking care of physical needs” and “pleasure and joy” in ultra-orthodox MoCwADHD. This is similar to those reported by MoCwADHD in the general population regarding self-care and leisure activities (Avrech bar et al., 2018; Peasgood et al., 2020). This study also provides new information concerning additional health promoting occupational categories depicted in the EDLQ among this study population. A high percentage of mothers expressed a desire to participate more in all occupational categories except for “contributing to community and society.” It is possible that the high emphasis on the centrality of the mothering role in the home (Korb, 2010) may explain the relatively lower percentages of wanting more communal engagement. Regarding the occupational experience of importance, these mothers gave high ratings of importance for all occupational categories (EDLQ). These high ratings suggests that the health promoting occupational categories of the EDLQ, based on the Do-Live-Well framework, are applicable to this minority group as well. In addition, it may provide additional support in broadening this health promoting occupational perspective across cultures.

This study also explored the association of occupational experiences with psychological health and QoL. Moderate correlations between measures of engagement in health promoting occupations to psychological health and QoL were found. This helps support the claim “what you do matters” (Moll et al., 2015), the foundational tenant of occupational science, connecting occupation with health (AOTA, 2020). When comparing the measures of engagement in health promoting activities, the associations with health outcomes were smaller for the Health Promoting Activities Scale (HPAS) than the EDLQ frequency. Engagement frequency was measured differently in the HPAS and EDLQ. The HPAS measures objective frequency spent in health promoting activities while the EDLQ measures subjective satisfaction with frequency spent in occupational categories. This study may support the added value of subjective experience in explaining psychological health and QoL. This finding is in line with Hammell (2013) and Moll et al. (2015) regarding the link between subjective experience with positive health outcomes. Also, the HPAS was developed for mothers of children with a variety of disabilities which may be somewhat different than the EDLQ which was developed for MoCwADHD (Budman, 2020). Regarding the positive association of EDLQ competence to outcomes, this is line with research showing that a sense of competence may be experienced and expressed through occupations and thus contribute to QoL (Hammell, 2009). EDLQ importance showed a small significant correlation with psychological health, which is in line with the claim that importance attached to, and meaning derived from, engagement in an occupation has been linked to psychological health (AOTA, 2020).

Structure equation modeling (SEM) allowed for expanding the understanding of the above occupational health promoting perspective to include factors unique to MoCwADHD. The SEM delineates the multiple effects of occupational experience, child ADHD, maternal stress, and the relationships between these factors on both health outcomes; psychological health and QoL. Findings revealed that child ADHD symptoms were significantly associated with parental stress, psychological health and QoL and were not associated with occupational experience (EDLQ). However, there was a significant effect of occupational experience on parental stress, psychological health and QoL, revealing a moderating role of occupational experience on the health risks of parenting a child with ADHD. This model may represent the health risks of caring for individuals with health conditions and the direct and indirect impact of occupational experience on health outcomes. Interestingly, engaging in health promoting activities can impact the actual caregiving stress despite the presence of biological symptoms, thereby pointing to modifiable factors in health promotion of caretakers. Further research is needed to validate this model among family caretakers of a variety of health conditions and cultural contexts.

Implications for Practice

This study broadens the body of literature on the health risks of MoCwADHD by exploring this relationship in a minority population. Culturally competent practice can be informed by this line of research thus helping to reduce health disparities among minority groups and improve quality of services and health outcomes (Golos et al., 2021). From a clinical perspective, (a) ultra-orthodox MoCwADHD need to be screened for psychological health risks, (b) the EDLQ may be used to evaluate their occupational experiences, and (c) engagement in health promoting occupations is a worthy intervention target in these mothers.

Limitations

The study group may not have been fully representative of the diversity among the ultra-orthodox population. The manner the study was advertised, and data collected may have limited participation of mothers who did not have access to computers. This limitation was addressed by offering printed questionnaires upon request however, this may have prevented mothers from initially pursuing participation in the study. Furthermore, data were collected over the period of Covid-19 and therefore it may have been a contributing factor on mothers’ stress, psychological health, and occupational experiences. Since this study did not have a comparative group and results were compared to the literature on MoCwADHD in the general population, further studies in the ultra-orthodox population and the general population are recommended.

Conclusion

Occupational experiences were found to have a significant effect on parental stress, psychological health, and QoL outcomes in these mothers. These findings validate the theoretical foundation of occupational therapy and may aid in culturally competent practice in identifying psychological health risks and promoting engagement in health promoting occupations in this population. Engagement in health promoting occupations is a worthy intervention target in ultra-orthodox MoCwADHD.

Ethics Statement

The Hebrew University Institutional Review Board (No. 2104202).

Consent Form

Procedures were followed in accordance with the ethical standards of the university institutional review board. All participants were told that their participation was voluntary, that their identity would not be disclosed and provided written consent. All questionnaires were handled in accordance with the University’s Institutional Review Boards requirements for handling of confidentiality and data security.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Jennifer R. Budman

Jennifer R. Budman is a licenced and registered occupational therapist and PhD student at the School of Occupational Therapy at the Hebrew University of Jerusalem.

Haya Fogel-Grinvald

Haya Fogel-Grinvald is a bio-statistician and a lecturer at the Hebrew University of Jerusalem and Tel Aviv University. She is also currently a PhD student at the School of Occupational Therapy at the Hebrew University of Jerusalem.

Adina Maeir

Prof. Adina Maeir is an academic member in the School of Occupational Therapy of the Faculty of Medicine at Hebrew University and served as the Chair of the school from 2013–2019.