Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent, lifelong neurodevelopmental disorder. It is characterised by behaviours of inattention, impulsivity and hyperactivity that interfere with social and/or academic/occupational functioning [1]. In modern society these behaviours are not typically perceived as positive and so are often met with high levels of criticism from others [2,3]. Although criticism has been referenced in previous qualitative research on children and adults with ADHD [4,5], it has not been explored as a topic in its own right, so there is limited understanding of how criticism is experienced in those with ADHD.

Criticism is defined as negative evaluative feedback that occurs during social interactions [6]. Criticism can be person centred, whereby a person’s traits or abilities are evaluated, or it can be process centred, in which the processes or strategies used by a person to succeed are evaluated [6]. Similarly to praise, criticism can be a positive intervention to improve motivation and encourage others to adapt their behaviours to improve success [7]; however, whether it is positive or not is dependent on the delivery of criticism. Criticism directed towards the person rather than their strategies is more likely to impact levels of contingent self-worth and result in patterns of behaviour characterised by enhanced negative emotions, attempts to avoid future criticism and a likelihood to degrade ability and intelligence with negative self-cognitions [6,8]. Yet, it is this type of destructive criticism that is more likely to be perceived by people [9]. Perceived criticism reflects the amount of criticism that “gets through” [10]. High levels of perceived criticism are associated with the recurrence of depression and anxiety, and lower levels of self-esteem [10–12].

ADHD is one condition that is associated with high levels of receiving and perceiving criticism [13,14]. ADHD is highly heterogeneous, with different people displaying different combinations and severities of ADHD-related behaviours [15]. These symptoms are proposed to be a consequence of two broad domains of executive functioning (EF) which include inhibition and meta-cognition (working memory, planning/problem solving and emotional regulation) [16]. More specifically, hyperactive and impulsive behaviours are speculated to be a consequence of deficits in inhibition, whereas symptoms of inattention are a result of variations, in different domains of meta-cognition (16). Thus, in adults, symptoms of impulsivity may manifest through behaviours such as saying inappropriate things at inappropriate times, talking over others or being accident prone. Symptoms of hyperactivity can be observed through behaviours such as, talking excessively, fidgeting, and restlessness, whilst symptoms of inattention can be observed through difficulty focusing on and finishing a task, difficulties in planning tasks or keeping to time, making frequent mistakes, losing things frequently or seeming distracted [17].

Irrespective of whether a person with ADHD symptoms is diagnosed or undiagnosed, the persistent pattern of behaviours associated with the condition, are typically evaluated negatively. Children with ADHD are less well-liked than their neurotypical peers [18] and are more likely to be bullied during their school years [19]. In experimental studies, undergraduate students have reported lower levels of liking and reduced willingness to interact with people demonstrating ADHD behaviours [2,20]. Furthermore, parents are more likely to show higher levels of criticism and less warmth towards children with traits of ADHD [3]. Negative evaluations of people with ADHD are not dependent on their success or ability, as adults with ADHD who are considered high functioning still report higher levels of judgement from others [21]. It is therefore unclear what ADHD behaviours encourage these higher levels of criticism.

There are numerous qualitative studies that have attempted to capture the lived experiences of children and adolescents with ADHD, and recently these studies have been synthesised through meta-reviews [4,5] and thematic synthesis [22]. Across both of these systematic reviews, children and adolescents with ADHD frequently describe experiences of stigma, rejection or bullying, through name calling from peers, being scorned by teachers, active acts of bullying or being denied opportunities to engage in friendships and games [23–25]. Consequently, children and adolescents with ADHD describe feeling different [21,26]–like “square pegs” attempting to fit into “round holes” [27]. Although there is less qualitative data from adults living with ADHD, the few studies that have been conducted describe similar experiences to the reports of young people. In-depth interviews with older adults with ADHD and the qualitative analysis of personal narratives posted online reveal that many adults with ADHD report feeling misunderstood and believe that their experiences of criticism from parents and teachers have had consequential effects on their self-esteem [28,29]. McKeague et al., [28] found that the stigma and negativity directed towards people with ADHD resulted in stigma and negativity towards the self. Similarly, interviews conducted with four children with ADHD revealed that participants used the same descriptive words to describe themselves that others had used to describe them, indicating that self-appraisals may be built around others’ perceptions of them [30].

Thus, the qualitative research conducted to date has identified that criticism is a common theme across adults, adolescents and children with ADHD, and that criticism may have detrimental effects on self-perceptions [4,5,14]. Beyond that, our understanding of how people with ADHD experience criticism is limited. Accordingly, further research that expands this knowledge could have important implications for understanding the lived experiences of people with the condition and may highlight areas for intervention to reduce levels of criticism and improve the well-being of this population. The main aim of this study is to explore the experiences of criticism that adults with ADHD experience in more depth. To accomplish this, the current study aimed to find common themes in the experiences of criticism that people with ADHD perceive from their nearest family, friends and/or colleagues.

Method

Research design

The data used to conduct this qualitative analysis was obtained via a larger pre-registered study: https://osf.io/uwekq (13). The study was hosted online using Qualtrics (www.qualtrics.com) between January and March 2019. Participants were recruited via online ADHD forums, social media, university disability services and posters displayed publicly. Ethical clearance for the study was obtained from The Department of Psychology’s Research Ethics Committee at The University of Sheffield. Participants initially accessed the information form and consent sheet via an online link to the study. In the study, participants completed a number of self-report questionnaires (see Beaton et al. [13] for more information) and were also offered the opportunity to respond to an open question that asked participants “…to share [their] experiences of criticism from the people in [their] nearest environment (e.g. family, friends, colleagues‡).” An open text question was used to collect the data because participants could respond anonymously without any researcher input. Participation in the study was completely anonymous; therefore, after participants submitted their responses we could not identify, nor contact participants to give feedback about the study or request follow-up information. This was to ensure that the responses would be free of any potential sampling, procedural, response, or interviewer bias that occurs with face-to-face qualitative research with a smaller group of participants.

As the study aimed to explore the experiences of people with ADHD, participants were screened for ADHD symptoms using The Adult ADHD Self-report Scale V1.1 (ASRS-V1.1) [31]. The ASRS asks participants to rate the frequency of ADHD symptoms on a scale ranging from 0 (never) to 4 (very often) on six items that reflect the clinical criteria in the DSM-IV (APA 2013). It is recommended that individuals who report “sometimes”, “often” or “very often” to the first three questions, or “often”/ “very often” to the final three questions more than 4 times in the questionnaire, have symptoms highly consistent with ADHD. This scale therefore provides a categorical classification of ADHD and identifies people with high levels of ADHD traits. We wanted to ensure that the experiences reported in this study were fully inclusive and did not discriminate based on access to clinical intervention, which can depend on location and wealth. Consequently, for this study, participants whose ASRS responses identified them as highly consistent with ADHD as defined above, were included in our sample. To be fully transparent, participants’ diagnostic status is reported alongside any quotes referenced below: ADHD+ reflects participants who self-reported as having a diagnosis of ADHD, and ADHD- identifies participants who self-reported that they did not have a diagnosis of ADHD but reached the cut-off for high ADHD traits on the ASRS. ADHD often has a high rate of co-occurrence with other conditions, such as mood disorders (e.g. depression, anxiety, bipolar, Obsessive Compulsive Disorder [OCD]), personality disorders (e.g. Borderline Personality Disorder), Autism Spectrum Condition (ASC), and other behavioural conditions (e.g. conduct disorder) [17,32,33]. However, we wanted to ensure that the experiences captured in this study were representative of responses towards ADHD specifically, and not a potential consequence of negative cognitive biases associated with mood disorders [34], or stigma towards symptoms of other conditions [35,36]. Therefore, to ensure the experiences reported were not a consequence of another condition, the responses from participants that self-reported a co-occurring condition were removed from the dataset. Finally, to ensure that the data included meaningful information, responses with less than 10 words were not included in the analysis.

In total 498 participants high in ADHD traits provided a free text response to the question. Of these, 298 responses were removed because participants reported at least one co-occurring disorder (ASD = 10, OCD = 2, Mood Disorder = 187, Behavioural Disorder = 1, Other = 22, multiple conditions = 76), a further 44 responses were removed because they had fewer than 10 words. Thus, the final sample consisted of responses from 162 individuals: 109 females, 52 males and 1 person who identified as other. Participants’ ages ranged between 18–62 (M = 33.80, SD = 10.60). In total 96 participants self-reported that they had a clinical diagnosis of ADHD with an average ASRS score of 18.97 (SD = 2.70), while 66 participants did not report a diagnosis of ADHD but their ASRS scores indicated high traits consistent with ADHD (M = 17.70, SD = 3.16). The severity of ADHD traits was significantly greater in those who self-reported an ADHD diagnosis (t (160) = -2.75, p < .05). The full demographic information of the sample is presented in Table 1.

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Table 1. The demographic details of the sample.

https://doi.org/10.1371/journal.pone.0263366.t001

Results

Five themes, divided into multiple sub-themes, were identified in the text. The themes and sub-themes are presented in Table 2. The responses of 11 participants did not contribute to any of the themes identified. Participant number (e.g. P1) and ADHD diagnosis are presented alongside quotes. ADHD+ represents participants who self-reported an ADHD diagnosis, ADHD- represents participants who did not self-report an ADHD diagnosis, but who met the criteria on the ASRS-V1.

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Table 2. Themes identified, sub-themes, how many references correspond to each sub-theme, and an example of each sub-theme.

https://doi.org/10.1371/journal.pone.0263366.t002

Discussion

The main aim of this study was to attain a rich understanding of how criticism is experienced in adults with ADHD. Conducting a thematic analysis of open text responses to the question, “…share your experiences of criticism from the people in your nearest environment”, enabled us to attain an insight into the criticism associated with ADHD traits and its impact. Our findings highlight what behaviours are most commonly criticised in people with ADHD traits, what people with ADHD traits perceive as criticism, what consequences arise from criticism, how people with ADHD traits cope with the criticism, and the important role that understanding plays towards the presence of criticism.

The first theme identified what traits participants felt were criticised, which has not been revealed in previous research but has implications for social, educational and personal intervention. Importantly, there was a high degree of overlap in what participants felt they were criticised for, which suggests that particular ADHD behaviours are perceived negatively, and warrant judgement from others. Some participants perceived criticism toward numerous qualities or felt that they felt they were criticised for ‘everything’, but the majority of participants reported criticism towards specific traits and behaviours. This provided an insight into what symptoms of ADHD may be most vulnerable to the negative evaluation of others. The behaviours and qualities reported are characteristic of the differences in executive functioning that are theorised to underpin ADHD. In particular, behaviours that are theorised to embody differences in meta-cognition, and therefore inattention, were reported as the most criticised. Reports of criticism towards behaviours of organisation, focus, forgetfulness and time management made up 90% of the behaviours that were reported in the first theme. This could suggest that behaviours of inattention are the symptoms most negatively evaluated by others, or that criticism towards these behaviours are perceived with a greater sensitivity by those with ADHD traits. It is possible that difficulties in planning, organisation, memory, and time management are not well-known consequences of inattention to neurotypical others, and therefore are misjudged as a consequence. This is supported by the critical adjectives that were reported to describe the participants, such as: “unfocused”, “careless”, “forgetful”, “lazy”, “disorganised” and “messy”. Consequently, this may indicate that improved education around what characteristics arise as a consequence of ADHD, could reduce the level of criticism towards those with high traits of the condition.

Another important pattern identified was that the majority of the critical characteristics represented difficulties in social interaction, including interrupting others, being too loud/quiet or saying inappropriate things. Previous research has found that adults with ADHD feel that they struggle in social situations for similar reasons as reported here [26]. However, the responses from participants in this study indicated that it is the feedback they perceived from others that made them feel that they are behaving in a non-typical fashion. Misunderstanding around these behaviours were described by some participants as a catalyst to ending relationships–a finding similar to that reported by Nyström et al. [26]. This is also in line with evidence that adults and children with ADHD are more likely to be socially rejected by their peers [18]; therefore, it is possible that these criticised behaviours contribute to the social rejection that people with ADHD are vulnerable to. However, it is still unclear why these behaviours in particular are negatively evaluated by others. Future research could consider investigating what neuro-typical individuals’ perspectives are of these behaviours in order to understand why they may warrant criticism and potential rejection.

Prior to this study, little was known about what adults with ADHD perceive as criticism. However, the second theme of this study clarified that criticism is perceived via multiple means, which may have implications for the self-worth of those with ADHD. Burhans & Dweck’s [38] contingent worth model suggests that people document self-worth via the judgements and evaluations of others to meet certain standards, so any behaviours that provide evidence of negative evaluation could be seen as a threat towards, or confirmation of, an individual’s contingent worth. The second theme identified that criticism was perceived through jokes, comparisons with others, judgement, rejection and other peoples’ expectations. This highlights that criticism was not just perceived through verbal reproach, but that people with ADHD traits are sensitive to exchanges that may not be intended as criticism. Over time, this could contribute towards the reduced levels of self-worth that participants reported in the study, and in other studies [5,39,40]. What is more, people with ADHD respond with heightened sensitivities to reward and punishments [41]. Consequently, parenting interventions such as the well-known Triple-P positive parenting program [42] advocate that negative behaviours should be ignored, and positive behaviours praised. The results of this second theme could have important implications for the efficiency of such behavioural interventions because the results show that criticism is perceived where punishment may not be intended. Thus, it may be important for parents of children with ADHD to ask the child what they perceive as criticism. This also extends into adulthood to maintain good romantic relationships, friendships and work relationships. Overall, this theme suggests that family members, friends and employers or teachers of people with ADHD should be particularly attuned to how they communicate their frustrations or annoyances towards people with ADHD and adjust accordingly.

The third theme identified the effects that criticism had on the participants. Firstly, the findings revealed that participants felt they had lower levels of self-worth as a result of the criticism. Thus, this current study adds to a body of research that suggests that the criticism from others may lead to low self-esteem [43], increased self-criticism [44], and heightened feelings of self-shame [26], all of which have important implications for the development of self-concept, self-esteem and mental health. Secondly, the emotional responses to the criticism were reported to be more intense than expected and many participants reported a heightened awareness and paranoia of criticism, judgement or rejection. This is in line with many ADHD information websites that refer to a phenomenon called ‘rejection sensitivity dysphoria’, which suggests that people with ADHD have more severe emotional responses to criticism and rejection than others [45]. When neurotypical people experience recurring negative feedback they are more likely to develop an oversensitivity towards the criticism [46]. Accordingly, it is possible that adults with high traits of ADHD are more sensitive to criticism because they experience it more frequently. However, being more sensitive to criticism can have detrimental effects on wellbeing and mental health [47,48]. Moderating the criticism towards individuals with ADHD may be important to protect the mental health of this population.

Despite research suggesting that people with ADHD experience higher levels of criticism compared to others [2,3], this is the first study we are aware of to provide insight into how people with ADHD cope with that criticism. Some participants coped with criticism by trying to observe it as a more positive concept and not seeing it as a true representation of them. Those who have a more adaptive, mastery-oriented, response to criticism are more likely to perceive criticism as a helpful aid, which is associated with reduced negative affect in response to the criticism and an increased persistence and motivation to succeed through constructive changes [6,38]. Many participants used self-awareness and self-acceptance as a way to alter how they perceived and responded to criticism to this more positive and potentially healthy pattern of behaviours, however others coped with criticism by avoiding situations that could evoke criticism and/or people who were more likely to be critical. ADHD is highly stigmatised and people can respond negatively to the label of ‘ADHD’ before even observing any ADHD symptoms [2,49,50]. This provides a rationale as to why participants in this study and in previous interviews [51] reported that they attempted to hide parts of themselves to prevent others’ judgement and criticism. One interpretation of this behaviour is that some people with ADHD believe the criticism is indicative of something ‘wrong’ with them that they need to eliminate in themselves. The findings also indicated that this has costs associated with it, through reduced wellbeing, inhibited academic, occupational or personal achievement and overexertion of energy, therefore it could be argued that this is not a positive way of coping with criticism. In contrast, other participants avoided criticism by surrounding themselves with people who were supportive and understanding and rejecting people who were more critical of them. One interpretation of this behaviour is that some people with ADHD believe the criticism is not indicative of something ‘wrong’ with them, but they just need others around them who are more accepting and supportive of diversity. It could be argued that this method of avoidance is a more positive way of coping with criticism.

The importance of understanding and acceptance towards ADHD was a prominent theme across participants’ responses, with some participants discussing the positives of others understanding, and others describing the negatives when others do not understand. From participants’ responses, it was found that not understanding why certain behaviours may be present appeared to result in criticism or judgement that the respondents felt were misrepresentative of their character and ability. Feeling misunderstood and misjudged due to ADHD behaviours has been reported previously [29], emphasising that people in the general population may not understand how ADHD presents itself. On the other hand, some respondents defended critical behaviour when they felt that others were also understanding, which may be an indication that understanding mitigates or outweighs criticism. This proposal is consistent with research examining adolescents with ADHD who stated that they inform others of their ADHD diagnosis so that if they were criticised, the other person would understand why they do that behaviour [4]. Overall, the results of the current study suggest that understanding the behaviours of someone with ADHD encourages more supportive behaviour in place of criticism. This conclusion has been drawn from multiple other qualitative studies interviewing people with ADHD [28,30,52], thus, this study contributes to the popular theory that improved understanding of ADHD will ultimately change the negative perceptions that people have of the condition, and may subsequently alter the level of stigma towards them [49,50,53]. This is a particularly important consideration for adults with ADHD who report that positive, accepting and supportive relationships with others contributes to improved self-esteem and wellbeing [29].

Conclusions

Overall, this study has provided an in-depth understanding of the experiences that people with ADHD traits have of criticism. The findings highlight the need to consider what individuals with ADHD perceive as criticism, how they respond to criticism, and what potential effects this may have on their wellbeing. The results also identify several gaps in the literature and directions for future research, including: how neurotypical people perceive neuro-diverse individuals; if people with ADHD are inherently reactive to criticism or if sensitivity to criticism is a consequence of environmental factors; and, whether changing how people with ADHD respond to criticism improves levels of wellbeing and/or educational and occupational outcomes. Importantly, the study demonstrates that levels of understanding are a fundamental factor in the negative evaluations that others have of people with ADHD. In turn, the results suggest that improving understanding may lead to more positive and supportive relationships, and that the level of knowledge and understanding that neuro-typical people have of ADHD may help to reduce criticism towards those with the condition. The current findings also highlight the importance of advocating for a more flexible society that is accepting of individuality and neurodiversity.

Supporting information

Acknowledgments

Thank you to all the participants who chose to share their experiences with us.