The story begins with the Holistic Scale of Wellbeing-Preliminary, or HSW-P, a 29-item questionnaire developed as an indigenous wellbeing measure for Pakistani young adults. Indigenous in this context does not simply mean locally translated; it means that the very architecture of the scale, the domains it covers and the way it frames a flourishing life, was built around the cultural realities of the population it serves. That includes domains that mainstream Western scales often treat as peripheral, most notably religiosity and spirituality, which the final scale retains as one of its seven core dimensions alongside purpose, psychological health, vitality and satisfaction, physical health, finances, and relationships.

The central task of the new study was confirmatory factor analysis, a statistical technique that puts a proposed structure of a questionnaire through a formal trial. Unlike exploratory methods, which hunt for patterns in data after the fact, confirmatory factor analysis starts with a specific hypothesis about how many underlying factors exist and which items belong to which factor, then tests whether the observed responses from real participants fit that blueprint. In this case, the researchers hypothesized a second-order structure: seven first-order factors corresponding to the seven domains of wellbeing, which themselves load onto a single higher-order factor representing overall holistic wellbeing. This kind of hierarchical model is statistically demanding, because it requires the seven domains to be correlated with one another in a pattern that can be summarized by one overarching construct.

To run that test, the team administered the 29-item preliminary scale to 464 young adults recruited through convenient sampling from three cities in Punjab: Faisalabad, Rawalpindi and Bahawalpur. Sampling across multiple urban centers rather than a single campus matters, because a scale that only works for one narrow student population is of limited value as a national research tool. The participants completed the questionnaire, and their responses fed into the confirmatory models as well as a battery of classical reliability analyses. The study received ethics approval from the Advanced Studies and Research Board of Government College University, Faisalabad, in 2024, and all participants signed informed consent forms describing the purpose, risks and benefits of the research, with procedures conducted in accordance with the Declaration of Helsinki.

The reliability results were strikingly strong. Cronbach’s alpha, the most widely cited index of internal consistency, came in at 0.91, indicating that the items hang together remarkably coherently as measures of a common construct. Split-half reliability, which checks whether the two halves of the test produce equivalent scores, reached 0.87, and test-retest reliability, which examines whether people score similarly when assessed on separate occasions, stood at 0.77. For readers outside psychometrics, these numbers matter because a scale that is unreliable cannot be valid: if the instrument produces wildly different readings for the same person or mixes unrelated content into a single score, no downstream conclusion drawn from it can be trusted.

The confirmatory factor analysis itself delivered the study’s headline verdict. The model fit statistics told a nuanced but broadly favorable story. Indices such as the standardized root mean square residual, the root mean square error of approximation, and the ratio of chi-square to degrees of freedom all indicated good fit, meaning the hypothesized seven-factor structure reproduced the observed data closely. Other indices, including the goodness-of-fit index, the adjusted goodness-of-fit index, the comparative fit index and the incremental fit index, showed acceptable fit. Two indices, the normed fit index and the Tucker-Lewis index, fell just slightly below conventional acceptability thresholds, a detail the authors report transparently rather than gloss over. In practical terms, the evidence supports the scale’s proposed architecture while acknowledging that model fit is always a matter of degree rather than a binary pass or fail.

Beyond overall fit, the study examined the behavior of individual items and the quality of each factor. Every item showed positive factor loadings in the medium to strong range, which means each question pulled its weight as an indicator of its intended domain rather than measuring something off-target. The researchers also computed composite reliability and average variance extracted, two statistics favored in structural equation modeling circles. Composite reliability asks whether the items within a factor collectively measure it dependably, while average variance extracted asks how much of the variation in the items a factor actually explains; values for both were reported as reasonable, reinforcing the picture of a well-behaved measurement model.

One item did not survive the refinement process. The final Holistic Scale of Wellbeing contains 28 items rather than the preliminary version’s 29, organized into the seven subscales of purpose, psychological health, vitality and satisfaction, physical health, finances, relationships, and religiosity and spirituality. The retention of religiosity and spirituality as a full subscale is arguably the scale’s most distinctive feature from an international perspective. In Pakistan, where religious and spiritual practice is deeply woven into daily life and social identity, a wellbeing measure that omits this dimension risks missing a major component of how young people evaluate their own lives. The HSW treats it not as an afterthought but as a core pillar, on equal statistical footing with physical health or finances.

The study went one step further than many validation efforts by converting raw scores into interpretable categories. Using the mean and standard deviation of the distribution, the researchers established score ranges corresponding to five levels of wellbeing: Poor, labeled as needing immediate improvement; Below Average, needing improvement; Average, which should be improved; Good, which can be improved; and Exceptional, requiring no improvement. This kind of categorical framework is what turns a statistical instrument into a practical tool, giving clinicians, counselors and researchers a shared vocabulary for describing where an individual or a group stands. It also creates benchmarks that future studies can compare against, which is essential for building a cumulative literature on youth wellbeing in the country.

The broader significance of the work lies in what it unlocks. With a validated, culturally grounded measure in hand, researchers in Pakistan can now assess youth wellbeing with an instrument whose structure has been formally tested rather than assumed, and intervention programs can be evaluated with outcome measures that resonate with the population they serve. The authors position the HSW as a foundation for further indigenous work on wellbeing enhancement, and the open-access publication means the tool is available to the wider research community. As the global psychology establishment continues to grapple with the limits of exporting Western measures to the majority of the world’s population, studies like this one offer a concrete template: build the scale locally, then hold it to the same rigorous statistical standards that any international instrument must meet. By that standard, the Holistic Scale of Wellbeing has now earned its place in the toolkit.

Subject of Research: Confirmatory factor analytic validation of an indigenous holistic wellbeing scale for Pakistani young adults

Article Title: Refining the Holistic Scale of Wellbeing-Preliminary (HSW-P) into Holistic Scale of Wellbeing (HSW) through confirmatory factor analysis

Article References: Keshf, Z., & Nadeem, A. (2026). Refining the Holistic Scale of Wellbeing-Preliminary (HSW-P) into Holistic Scale of Wellbeing (HSW) through confirmatory factor analysis. Discover Mental Health. https://doi.org/10.1007/s44192-026-00600-7

Image Credits: AI Generated

DOI: 10.1007/s44192-026-00600-7

Keywords: wellbeing, psychometrics, confirmatory factor analysis, scale validation, young adults, Pakistan, reliability, model fit, mental health, indigenous psychology, quality of life, Discover Mental Health

The median ferritin concentration in the children with ADHD was 7.71 micrograms per litre, with an interquartile range of 7.34 to 15.22, while the control group’s median stood at 30.52 micrograms per litre, spanning 23.38 to 37.66. That is roughly a fourfold gap between the two groups, and the difference was statistically significant at P less than 0.001. Zinc told a similar story. The ADHD group’s median serum zinc was 49.93 micrograms per decilitre, against 86.06 micrograms per decilitre in controls, again with a P value below 0.001. When the researchers applied conventional cutoffs, the picture became even more dramatic: 62.1 percent of the children with ADHD had ferritin below 15 micrograms per litre, a threshold often used to flag depleted iron stores, whereas not a single control child fell below that line. Using the reference interval supplied with the zinc assay kit, every one of the 66 children with ADHD had zinc below 70 micrograms per decilitre, compared with 14.5 percent of controls.

What makes these findings particularly noteworthy is that the children with ADHD were treatment-naive, meaning they had not yet received stimulant medication or other pharmacological therapy. This matters because some prior studies of nutrient status in ADHD have been confounded by the possibility that medication itself, or the appetite suppression it can cause, alters nutritional status. By measuring morning fasting blood samples before any treatment began, the Iraqi team reduced that concern, although it cannot be eliminated entirely in an observational design. All children in the ADHD group had parent and teacher Vanderbilt rating scales available, providing a standardized behavioral anchor for the diagnosis alongside the psychiatrist’s confirmation under DSM-5 criteria.

The statistical approach also deserves attention. Rather than running simple comparisons, the researchers used biomarker-specific Firth logistic regression, a method that performs well when outcome categories are unevenly distributed and when the goal is to estimate adjusted associations. After accounting for age and sex, higher concentrations of both ferritin and zinc remained associated with lower odds of being classified as having ADHD. In other words, the nutrient differences were not simply artifacts of the children with ADHD being younger or of a different sex distribution than the controls. The authors also reported a strong positive correlation between ferritin and zinc within the ADHD group itself, with a Spearman rank correlation coefficient of 0.861 and a P value below 0.001, suggesting that the two biomarkers tended to rise and fall together in these children.

Why would iron and zinc matter for a neurodevelopmental disorder? The biological rationale is grounded in decades of neuroscience. Iron is an essential cofactor for enzymes involved in the synthesis of dopamine, the neurotransmitter most closely implicated in ADHD pathophysiology, and it also supports myelination of neurons and the function of the basal ganglia circuits that regulate attention and motor control. Iron deficiency, even at subclinical levels, has been shown in animal models to alter dopaminergic signaling and to produce behavioral changes that resemble aspects of ADHD. Zinc, meanwhile, plays a role in neurotransmitter release and receptor function, including modulation of N-methyl-D-aspartate receptors, and it participates in the regulation of synaptic plasticity. Zinc deficiency has also been linked to disturbances in dopamine metabolism. The strong correlation between the two biomarkers in this study raises the possibility of a shared underlying cause, such as a common dietary pattern, but the researchers did not measure diet directly, so that interpretation remains speculative.

The authors are careful, and rightly so, to frame their results as evidence of association rather than causation. A case-control design like this one can show that two groups differ at a point in time, but it cannot establish whether low ferritin and zinc contribute to the development of ADHD, whether having ADHD somehow depletes these nutrients, or whether a third factor drives both. Children with ADHD may eat differently, sleep differently, or experience different levels of stress, any of which could influence nutritional biomarkers. The researchers also note that their subgroup findings remain exploratory, and they explicitly state that the study demonstrates no therapeutic benefit. That caveat is important because headlines about nutrient deficiencies in ADHD sometimes fuel unproven supplementation fads, and the study provides no evidence that giving iron or zinc to children with ADHD would improve their symptoms.

There are also clinical safety considerations that any discussion of supplementation must confront. Iron is not a benign substance; excess iron causes oxidative stress and organ damage, and indiscriminate supplementation in children who are not deficient can be harmful. Ferritin is also an acute-phase reactant, meaning it rises during inflammation, infection, or stress, so a single measurement can overestimate or underestimate true iron stores depending on the child’s health at the time. The study’s methodology acknowledged this challenge: the authors list C-reactive protein and erythrocyte sedimentation rate among their abbreviations, markers of inflammation that researchers in this field typically use to screen out children whose ferritin readings might be inflated by inflammatory processes. Zinc measurements, too, can be affected by recent meals, time of day, and hemolysis of the sample, which is why the fasting morning blood draws used in this study represent a methodological strength.

The Iraqi setting adds both value and context to the findings. Most of the existing literature on iron and zinc in ADHD comes from North America, Europe, Turkey, Iran, and East Asia, and the results across those studies have been heterogeneous, with some reporting significant differences and others finding none. Local data from Iraq have been limited, and nutritional deficiencies remain a public health concern in many parts of the region. The consistency and magnitude of the differences in this sample, particularly the complete absence of control children below the ferritin cutoff, suggests that iron depletion may be a genuinely common feature among children with ADHD in this population, or that the local dietary environment makes both groups vulnerable in ways that sharpen the contrast. Either way, the study provides a regional data point that global reviews of nutrition and ADHD have lacked.

The study’s design was ambispective, combining retrospective inclusion of eligible clinical and laboratory data collected before the study’s ethics approval with prospective recruitment and assessment afterward. It was conducted from January 2025 to April 2026 in Al-Najaf City and received approval from the Scientific Research Ethics Committee of the College of Medicine at the University of Kufa, with verbal informed consent obtained from parents or legal guardians for the prospective component. The research received no specific external funding, and the authors declared no competing interests. The sample size, while modest, is respectable for a single-center case-control study, and the use of validated behavioral rating scales from both parents and teachers strengthens the diagnostic assessment.

Where does this leave the field? The findings add weight to the hypothesis that peripheral iron stores and zinc status are linked to ADHD, at least in some populations, and they justify further research with longitudinal designs that follow children over time, measure dietary intake directly, and test whether correcting deficiencies changes clinical outcomes. Randomized controlled trials of supplementation in children with documented deficiency, rather than in unselected groups of children with ADHD, would be the logical next step, and such trials would need to monitor iron status carefully for safety. Until then, the practical takeaway for clinicians is nuanced: the study supports checking ferritin and zinc in children being evaluated for ADHD, particularly where deficiency is plausible, but it does not support empirical supplementation as a treatment for the disorder itself. The association is real and, in this Iraqi sample, remarkably strong; the therapeutic implications remain, for now, an open question that only intervention studies can answer.

Subject of Research: Serum ferritin and zinc concentrations in children with attention-deficit/hyperactivity disorder in Iraq

Article Title: Serum ferritin and zinc levels in Iraqi children with attention deficit hyperactivity disorder

Article References: Hashim, A. A., & Balasim, M. S. (2026). Serum ferritin and zinc levels in Iraqi children with attention deficit hyperactivity disorder. Discover Mental Health. https://doi.org/10.1007/s44192-026-00609-y

Image Credits: AI Generated

DOI: 10.1007/s44192-026-00609-y

Keywords: ADHD, ferritin, zinc, iron deficiency, children, Iraq, case-control study, neurodevelopmental disorders, dopamine, micronutrients, pediatrics, Discover Mental Health