Journal of health research in community

Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood, characterized by persistent patterns of inattention, hyperactivity, and impulsive behaviors [1]. Its prevalence has been estimated at 9.5% worldwide and 7.8% in Iran [2]. This disorder can significantly disrupt a child’s academic, social, and emotional functioning, with consequences that affect not only the child but also the family, especially mothers [3, 4]. Mothers of children with ADHD constantly face challenging child behaviors, academic difficulties, and family conflicts [5-7]. These conditions increase chronic stress and caregiver burnout and decrease satisfaction with the maternal role [8]. 
Meanwhile, resilience, defined as the capacity to maintain or restore psychological adaptation in the face of stressful situations, plays a key role in maternal mental health [9-11]. Resilience helps individuals maintain their effective functioning despite difficulties and prevent the negative consequences of stress [12]. 
Strengthening the resilience of mothers of children with ADHD is of particular importance [13, 14]. Spiritual care training is one effective approach to strengthening individuals’ internal resources [15]. By focusing on the search for meaning, hope, acceptance of difficult situations, and an inner connection with a transcendent source, spiritual care can help individuals redefine stressful experiences [16]. This type of intervention enables individuals to develop a more adaptive attitude toward life’s problems [17]. Spiritual care training can increase individuals’ ability to cope with psychological stress [18]. Also, spiritual care–based interventions play an effective role in improving psychological adjustment and promoting resilience among different groups of caregivers [19]. 

Methods
This quasi-experimental study used a pretest–posttest design with a control group and included 60 mothers of children with ADHD who were referred to Ayatollah Taleghani Hospital in Gorgan. Participants were selected using convenience sampling and randomly assigned to intervention and control groups. In the intervention group, six 45-minute sessions of spiritual care training were conducted based on the Richards and Bergin (2005) model. No intervention was provided to the control group. 
Data were collected using a demographic information form and the Connor-Davidson Resilience Questionnaire, which were completed before and after the intervention. 
Data were analyzed using SPSS software, version 24 utilizing a multivariate analysis of covariance (MANCOVA) at a significance level of less than 0.05.

Results
Most mothers in the intervention group were 25–35 years old, whereas those in the control group were 36–45 years old. The mean resilience score in the intervention group was 47.63±5.738 before the intervention and 83.50 ±5.029 after the intervention. In the control group, the corresponding scores were 47.47±7.459 and 50.33±7.063, respectively. The results of MANCOVA showed that spiritual care training significantly improved the total score of resilience and its dimensions in the intervention group compared to the control group (P=0.001). 

Conclusion
The results of the present study showed that spiritual care training resulted in significant improvements in all components of resilience, including competence, tolerance of negative emotions, relationships, control, spirituality in resilience, and the total resilience score. These findings indicate that the intervention can activate the internal and external coping resources of mothers in the intervention group and improve their psychological adjustment in the face of the pressures associated with parenting a child with ADHD. 
In this regard, Seddighi et al. showed that short-term spiritual care interventions can increase parents’ self-efficacy and self-confidence [26]. After the intervention, the participating mothers perceived the challenges associated with parenting less as an exhausting process and more as an opportunity for personal and emotional growth, which led to increased motivation, hope, and resilience. In addition, Seddighi et al. reported significant improvements in resilience and parenting competence, especially in the dimensions of accepting difficult situations and controlling negative emotions, after implementing spiritual counseling based on the “healthy heart” model for mothers of children with intellectual disabilities [1]. This finding is consistent with the results of the present study in terms of the mechanisms of effect. Zarei et al. [14] also confirmed the effectiveness of spirituality therapy, compared with acceptance and commitment therapy, in improving the resilience of mothers of children with physical and motor disabilities and reported significant increases in all resilience subscales [14]. These findings can be explained by the fact that spiritual care training can increase individuals’ sense of competence and empowerment by giving meaning to difficult experiences and fostering a positive attitude toward life’s challenges. 
Overall, the convergence of the results of domestic and foreign studies with the findings of the present study indicates that spiritual care training can sustainably improve mothers’ resilience by promoting spiritual connections, giving meaning to life experiences, and providing a framework for acceptance and calm in stressful situations. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Golestan University of Medical Sciences (Code: IR.GOUMS.REC.1404.131), and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20250610066N1).

Funding
This article was extracted from a master’s thesis of Faezeh Mansouri in the field of pediatric nursing at Islamic Azad University, Aliabad-Katoul Branch (code: 163104908. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgments
The authors would like to thank all the mothers who participated in this study for their cooperation. We also acknowledge the support and assistance provided by the staff of Ayatollah Taleghani Hospital in Gorgan.

References

1. Sadeghi Z, Badieh Pima Z, Hojjat M. [Investigating the effect of spiritual care based on Sound-Heart model on pain, fatigue and life expectancy of hemodialysis patients (A Clinical trial study protocol) (Persian)]. Educ Ethics Nurs. 2024; 13(Special Issue on Health Promotion):148-55. [DOI:10.22034/ethic.2024.2043799.1136]  
2. Molai Asl R. [A review of new research in the treatment of attention deficit/hyperactivity disorder (ADHD) (parent-child interaction, drama therapy, artificial intelligence) (Persian)]. Paper presented at: The third national conference of child and adolescent clinical psychology. 5 December 2023; Ardabil, Iran. [Link]
3. Bayat M, Narimani A, Didar F, Soraya Taifeh Dalai K, Sabetroo M. [Evaluation of the prevalence of attention deficit / hyperactivity disorder (ADHD) and related demographic factors in students in 12th class of Ardabil in the academic year 2016-2018 (Persian)]. J Sch Psychol. 2023; 12(2):44-33. [DOI:10.22098/jsp.2023.2365]
4. Papalia DE, Feldman RD, Martorell G. Experience Human Development. New York: McGraw-Hill Education; 2014. [Link]
5. Imam Jomezadeh VS, Monshei GM. [The effectiveness of mindfulness-based therapy on self-esteem of mothers with children with attention deficit/hyperactivity disorder (Persian)]. Med J Mashhad univ Med Sci. 2023; 65(6):e22679. [DOI:10.22038/mjms.2022.66661.3936]
6. Sharifi-Agaladi M. [The effect of virtual English language learning on language learning motivation and symptoms of attention deficit/hyperactivity disorder in students with attention deficit/hyperactivity disorder (Persian)]. Educ Technol Learn. 2023; 7(25):183-203. [DOI:10.22054/jti.2024.81771.1506] 
7. Abdi S, Bayesteh S, Darabi M. [Examining the Effectiveness of Therapy Based on the Quality of Life on Improving the Psychological Wellbeing and Happiness of Mothers with Exceptional Children (Persian)]. Middle East J Disabil Stud. 2023; 13:38. [Link]
8. Treacy L, Tripp G, Baird A. Parent stress management training for attention-deficit/hyperactivity disorder. Behav Ther. 2005; 36(3):223-33. [DOI:10.1016/S0005-7894(05)80071-1]
9. Haji Babaei Ravandi A, Tajali P, Ghanbari Pana A, Shahriari Ahmadi M. [The effectiveness of a positive parenting program on the general health and marital adjustment of mothers with ADHD (Persian)]. Couns Psychother Cult. 2022; 13(51):207-30. [DOI:10.22054/qccpc.2022.65898.2881]
10. Besharatipoor M. [The Effects of Spiritual Intelligence Training on Resiliency in Mothers of Children with Attention-Deficit/Hyperactivity Disorder (Persian)]. J Except Child. 2018; 18(1):109-18. [Link]
11. Vithana KVGSG, Asurakkody TA. Spiritual practices as coping with mothers of children with attention-deficit hyperactivity disorder: A qualitative explorative study. BMC Psychol. 2025; 13(1):3.  [DOI:10.1186/s40359-024-02331-2] [PMID]
12. Elaleem AEDMHA, Osman ZAEH, El-Fatah WOA. Effect of a nursing educational program on competency and parenting practices among parents having children with attention deficit hyperactivity disorder: A randomized controlled trial. Middle East Curr Psychiatry. 2024; 31:54. [DOI:10.1186/s43045-024-00443-4]
13. Öztürk FÖ, Mine E. The effect of psycho-education given to mothers of children with attention deficit hyperactivity disorder on mother-child interaction and family functionality. J Child Adolesc Psychiatr Nurs. 2023; 36(4):299-306. [DOI:10.1111/jcap.12432] [PMID]
14. Zarei F, Hojjatkhah SM, Zabet M, Taheri S. [A comparing the effectiveness of therapy based on acceptance and commitment and spiritual therapy on increasing resilience and psychological flexibility of mothers with children with physical and motor disabilities (Persian)]. J Mod Psychol Res. 2024; 19(73):108-18. [DOI:10.22034/jmpr.2024.59270.5935]
15. Shaghaghi L. [Evaluate the effectiveness of the solution to the mothers of children with attention deficit hyperactivity and improve quality of life (Persian)]. J Psychol New Ideas. 2021; 7(11):1-15. [Link]
16. Hossein Alizadeh M, Taherabadi S. [Investigating the role of cognitive emotion regulation strategies in predicting psychological tolerance and perceived social distress in mothers of children with attention deficit/hyperactivity disorder (Persian)]. Disabil Stud. 2022; 12. [Link]
17. Koosha M, Naghipour S, Fallahi Khesht Masjedi M. [The relationship between emotional intelligence and parenting stress in mothers of children with attention deficit hyperactivity disorder (Persian)]. J Guilan Univ Med Sci. 2021; 30(2):98-107. [DOI:10.32598/JGUMS.30.2.735.2]
18. Shah R, Grover S, Avasthi A. Clinical practice guidelines for the assessment and management of attention-deficit/hyperactivity disorder. Indian J Psychiatry. 2019; 61(Suppl 2):176-93.[DOI:10.4103/psychiatry.IndianJPsychiatry_543_18] [PMID]
19. Moradi F. [Lived experiences of mothers’ resilience in adverse life events (Persian)]. Res Ethics Comm. 2024; e17472. [Link]
20. Hajure M, Alemu SS, Abdu Z, Tesfaye GM, Workneh YA, Dule A, et al. Resilience and mental health among perinatal women: A systematic review. Front Psychiatry. 2024; 15:1373083. [DOI:10.3389/fpsyt.2024.1373083] [PMID]
21. Cojocaru A, Braha A, Anastasescu CM, Folescu R, Bugi MA, Puiu M, et al. A systematic review of resilience in at-risk youth for psychotic disorders: An analysis of protective and risk factors from recent literature. Behav Sci (Basel). 2024; 14(10):898. [DOI:10.3390/bs14100898] [PMID]
22. Löchner J, Ulrich SM, Lux U. The impact of parents’ stress on parents’ and young children’s mental health: Short- and long-term effects of risk and resilience factors in families with children aged 0-3 in a representative sample. Stress Health. 2024; 40(4):e3400.  [DOI:10.1002/smi.3400] [PMID]
23. Barkley RA. Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford press; 2006. [Link]
24. Connor KM, Davidson JR. Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD RISC). Depress Anxiety. 2003; 18(2):76-82. [DOI:10.1002/da.10113] [PMID]
25. Samani S, Jokar B, Sahragard N. [Effects of Resilience on Mental Health and Life Satisfaction (Persian). J Psychiatry Clin Psychol. 2006; 3(3):290-5. [Link]
26. Sedighi Z, Namjou Z, Pourmovahed Z. [Effect of Spiritual Care Training on Self-efficacy of Mothers with Premature Infants in Neonatal Intensive Care Units: A Randomized Clinical Trial Study (Persian)]. Avicenna J Nurs Midwifery Care. 2024; 32(3):196-205.  [Link]
27. Sheikhzakaryaie N, Azizi A, Moradi S, Khaledian N, Salawati Ghasemi S. [The effect of spiritual intervention on self-esteem and emotional adjustment of mothers with children with cancer (Persian)]. Iran J Pediatr Nurs. 2023; 9(4):10-18. [DOI:10.22034/JPEN.9.4.10]
28. Evgin D, Caner N, Alimoğlu EB, Sezer Efe Y. Being a parent of children with attention-deficit hyperactivity disorder. Rev Assoc Med Bras (1992). 2025; 71(1):e20241335. [DOI:10.1590/1806-9282.20241335]
29. Safara M, Khanbabaei M, Khanbabaei M. [The efficacy of Spiritual skills training in promoting quality of life and life hope of mothers Having Child with intellectual disability (Persian)]. Psychol Except Individ. 2020; 10(37):161-80. [DOI:10.22054/jpe.2020.43806.2009]
30. Dangmann CR, Skogli GKW, Holthe MEG, Steffenak AKM, Andersen PN. Life Gets Better: Important Resilience Factors When Growing Up With ADHD. J Atten Disord. 2024; 28(8):1198-209.  [DOI:10.1177/10870547241246645] [PMID]
31. Nababan R, Purba J, Daulay W. The Relationship of Self-Regulation and Resilience in Parents of Attention Deficit Hyperactivity Disorder (ADHD) at Special School-C Karya Tulus Tuntungan II. Contagion. 2024; 6(2):892-903. [DOI:10.30829/contagion.v6i2.20602]
32. Cheng S, Li X, Hu X. The Resilience of Parents of Children with Developmental Disabilities: An Effort in Self-Regulation and Spiritual Well-Being. Child Fam Soc Work. 2025; 31(2):922-31.  [DOI:10.1111/cfs.70018]
33. Moradi M, Benisi P, Zamerdi S. [The efficacy of cognitive-behavioral education on spiritual health and resilience of housewives Buin and miyandasht (Persian)]. New Approach Child Educ Q. 2021; 3(1):46-59. [DOI:10.22034/naes.2020.257120.1067]
34. George BB, Dangroo AA, Sahu KK, Arun P. Stress, coping, and resilience among mothers of children with attention deficit hyperactivity disorder. Indian J Psychiatr Soc Work. 2024; 15(1):17-27. [DOI:10.29120/ijpsw.2024.v15.i1.614]
35. Aggarwal S, Wright J, Morgan A, Patton G, Reavley N. Religiosity and spirituality in the prevention and management of depression and anxiety in young people: A systematic review and meta-analysis. BMC Psychiatry. 2023; 23(1):729. [DOI:10.1186/s12888-023-05091-2] [PMID]
36. Rahman M, Hussain A. Spirituality and resilience among mothers of ADHD children. Shodh Sanchar Bull. 2020; 10(38):190-4. [Link]