Arab and Jewish mothers’ decisions regarding treatment of their children with attention-deficit/hyperactivity disorder: A qualitative study

The use of medication for attention deficit hyperactivity disorder (ADHD) differs globally. Stimulant prescriptions for ADHD among Israeli Jewish children are four times higher than among Arab children. This qualitative study aimed to identify mothers and teachers’ attitudes regarding ADHD and what affects mothers’ decisions on whether to medicate their child diagnosed with ADHD. In-depth interviews were conducted with 23 Arab and Jewish mothers of children diagnosed with ADHD and 12 elementary school teachers. Data were analyzed using thematic analysis. Four themes were revealed, describing different perceptions of ADHD in the two ethnic groups: (1) medicalization of ADHD; (2) between guilt and sympathy: Mothers’ feelings toward ADHD; (3) social pressure and social norms; (4) stigmatization: Jewish mothers and teachers tended to perceive ADHD as a medical problem, whereas Arab mothers and teachers perceived it more as a childhood social behavior. Arab mothers reported guilt feelings relating to ADHD, whereas Jewish mothers felt sympathy toward their child. The social environment influenced Arab mothers more than Jewish mothers. Stigmatization was reported only by Arab mothers. Ethnic differences in ADHD perception may explain the differences in diagnosis and treatment. Educators and school psychologists should consider cultural factors when advising parents and planning educational programs for children with ADHD.


Introduction
Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in childhood (Rowland et al., 2002a). Throughout childhood and adolescence, ADHD is often associated with anxiety, aggressive behaviors, low self-esteem, learning disabilities, and may affect academic achievement (Cormier, 2008). The international guidelines for the management of ADHD in school-age children recommend a multidisciplinary approach that combines non-pharmacological approaches, as well as pharmacological treatment (Bachmann et al., 2017). Stimulant medications are often recommended as a first-line treatment for the core symptoms of ADHD. However, several factors are associated with poor ADHD medication adherence including parent/family factors, the belief that symptoms are not a disorder, distrust of the medical system, stigma, burden of the medication regimen, and concerns regarding medication safety (Charach & Fernandez, 2013). In addition, rates of adherence to medication vary depending on ethnicity, country and patients' perceptions of the medication, (Charach & Fernandez, 2013), as parents play a key role in making treatment decisions for their children (Brinkman et al., 2009).
The prevalence of ADHD varies among populations; in school-age children it ranges from 8% to 12% (Biederman, 2005). Findings from school-based samples indicate that rates of ADHD diagnosis and treatment are lower among ethnic minorities (Eiraldi et al., 2006;Rowland et al., 2002b). The differences in diagnosis and treatment rates are explained by differences in services, awareness of ADHD, lack of access to care, differences in incomes, education, occupation, cultural beliefs about health and illness and differences in the expansion of ADHD medicalization (Conrad & Bergey, 2014;Eiraldi et al., 2006;Geiger, 2003). Some sociologists argue that the increase in ADHD diagnosis and treatment is attributed to the medicalization process. Medicalization refers to the process by which previously nonmedical conditions are understood under the rubric of disease and behaviors are diagnosed and treated as a medical entity rather than a social one (Conrad & Potter, 2000). Today, ADHD is diagnosed in numerous countries across the globe. Yet, in some countries, such as France (Vallee, 2011) and Italy (Conrad & Bergey, 2014), there is resistance toward medicating children with ADHD.
Studies indicate that teachers are highly involved in the process of diagnosing and treating ADHD. They provide crucial information for diagnosis and advise parents regarding possible ways of dealing with the child's difficulties (Eiraldi et al., 2006). Given that most children with ADHD have academic, behavioral or social difficulties, teachers are among the most common sources of referral for ADHD, second to parents (DuPaul & Stoner, 2003). Therefore, it is important to understand how teachers view ADHD medication and their support or opposition to its use (Simoni, 2018).
In Israel, the increase in ADHD prevalence and treatment by medication in recent years may reflect changing attitudes and perceptions toward the disorder and its treatment (Davidovitch et al., 2017). Israel is a multiethnic country with a minority of Arab citizens. About 21% of Israel's population comprises Arabs (Central Bureau of Statistics, 2022), of them, about 85% are Muslims and 15% are mainly Christians and Druze. Approximately 70% live in the northern region, 10% in the central, and 20% in the southern area. The Arab population in southern Israel are Bedouin Muslims. They differ culturally from the Arabs in the northern part of Israel, they are also the poorest population group among the Arabs in Israel with lower education and income level (Abu-Saad, 2016). In our study, we focused on the northern population given the significant differences between the northern and the southern Arab population.
Generally, Arab children are less diagnosed and treated for ADHD than Jewish children. A study conducted in Israel in 2011 suggested that Jewish children were four times more likely to be prescribed stimulant medication compared to Arab children. These disparities may be partially explained by lower socio-economic status, education, and accessibility to secondary healthcare services within Arab populations (Davidovitch et al., 2017;Ornoy et al., 2016).
This qualitative study aimed to identify differences in attitudes and perceptions toward the diagnosis and treatment of ADHD among Arab and Jewish mothers and teachers, to understand what affects the parents' decision whether to medicate their child diagnosed with ADHD. Therefore, the research questions were as follows: 1. What are Arab and Jewish mothers' and teachers' attitudes and perceptions regarding ADHD, its diagnosis, and medical treatment? 2. What are the explanations for mothers' decision to diagnose and treat their child with ADHD in both ethnic groups?

Study design
A qualitative approach was used, enabling in-depth exploration of the phenomenon as the research participants perceive it (Creswell et al., 2007).

Participants
From March 2019 to November 2019, 23 Arab and Jewish mothers (12 Arab, 11 Jewish) of children aged 7-12 diagnosed with ADHD, and 12 Arab and Jewish teachers in elementary schools (6 Arab, 6 Jewish) were interviewed. All participants were women living in various towns and villages in northern Israel, varying in size and socioeconomic status (see Table 1).

Procedure
Ethics. The study was approved by the university's committee for ethical research with humans and the ethics committee of the Ministry of Education.
Recruitment and procedures. Mothers were recruited through several elementary schools. The schools' principals contacted mothers of children diagnosed with ADHD and after obtaining their agreement to participate, the principal researcher contacted them to introduce the study and to schedule an interview. Teachers were also recruited through several elementary schools' principals. The participation of mothers and teachers was voluntary.
All the teachers who participated in the study were homeroom teachers with at least halftime job and 5 years of seniority and had experience with children with ADHD. Our interest was not to compare the mothers' and teachers' experiences regarding a specific child. Therefore, the teachers who participated in the study were not the teachers of the children with ADHD whose mothers participated in the research. It was ethically important to guarantee anonymity and to avoid any discomfort to the mothers and the teachers. Interviewees' recruitment continued until data saturation was achieved and the researchers noted that no new themes emerged during the interviews (Morse, 2000). The processes of data collection and data analysis took place simultaneously. Analysis of the first few interviews updated subsequent interviews; when key issues were uncovered, they were then integrated into future interview guides, obtaining wider information in subsequent interviews. This process was repeated until no supplementary topics were revealed, both by code as well as by meaning, and further data became superfluous, achieving both data and meaning saturation (Hennink et al., 2017). Data saturation also determined the sample size (Trotter, 2012). In the current study, saturation was achieved after 35 participants were interviewed. When data from other participants repeated itself, the researchers decided that data saturation was attained, and data collection stopped.
The interviews were conducted in Arabic for Arab participants and in Hebrew for Jewish participants. Twenty-seven interviews were conducted face to face, at a time and place of the participants' choice; eight interviews were conducted via telephone according to the participants' request. The interviews' duration ranged from 25 to 60 min. All interviews were audio-recorded and transcribed verbatim. The nationality of the principal researcher is Arab. She is bilingual and fluent in both languages, Arabic and Hebrew, and performed all interviews as well as translated the Arabic transcripts into Hebrew. To validate the translations, the Arabic transcripts were translated by another professional translator. These two versions were compared and changes were made in case of discrepancies between the two. The two other authors are Jewish. All authors conducted data analysis after translation of the interviews to Hebrew.

Data collection
Data were collected through in-depth semistructured interviews led by an interview guide. Prior to conducting the interviews, the interviewees signed an informed consent form and completed a short questionnaire eliciting basic demographic data on age, gender, education, country of birth, place of residence, religion, religiosity, number of children in the mothers' questionnaire, and professional seniority in the teachers' questionnaire.
The semistructured interview guide comprised open-ended questions that covered topics such as mothers' and teachers' attitudes and perspectives regarding diagnosing and treating ADHD and the issues related to diagnosis and care. In the teachers' protocol, questions that dealt with the teachers' experience when teaching children with ADHD (e.g., "Please tell me about an event that occurred in the classroom with a child with ADHD. In which ways do you deal with their behaviors in the classroom?"), their ways of coping (e.g., "Describe the way you act when you suspect a child in your class has ADHD"), and their involvement in the parents' referral process for diagnosis and treatment (e.g., "Tell me about your involvement in the parental referral process for diagnosis and treatment").
The mothers' protocol included questions about how they made the decision whether to medically treat their child's ADHD (e.g., "What do you think about medicating children as a treatment for ADHD?", "Tell me about the positive and negative sides of the medication, in your opinion"), and questions about factors that make it easier or harder for them to cope with their children (e.g., "Have you shared your child's diagnosis with your relatives or other people? If so, how did they react when you informed them of your child's diagnosis?" "How did their reaction make you feel?")

Data analysis
The interviews were analyzed using thematic analysis (Clarke & Braun, 2018) in several stages: (1) familiarizing with the data: transcribing, reading, and re-reading the data; (2) generating initial codes for mothers and teachers and for each ethnic group, separately; (3) collating codes into potential themes; (4) comparing the interviews to find similarities and dissimilarities between the two ethnic groups and between mothers and teachers; (5) reviewing and defining the themes arising within each of the four groups. The themes that emerged from the thematic analysis enabled capturing the differences between Arab and Jewish participants' experiences regarding the same phenomenon, thus obtaining a broader perspective of participants' attitudes toward ADHD, its diagnosis, and its treatment.

Rigor
The researchers discussed their perspectives on the research topic throughout the research process, aiming to reflect on and attain insight regarding their subjective views, thus avoiding biases (Tufford & Newman, 2012). To reduce bias and improve credibility, additionally to the first author's comprehensive data analysis, each researcher conducted a separate thematic analysis of the data, keeping their interpretative notes separate. This analysis yielded themes based exclusively on participants' narratives (King & Horrocks, 2018). Subsequently, it can be assumed that these themes represent participants' experiences and narratives, instead of the researchers' any earlier assumptions or opinions.

Findings
Four main themes emerged from data analysis regarding mothers' experiences and attitudes toward their children diagnosed with ADHD and the teachers' experience concerning diagnosing and treating children with ADHD: (1) medicalization of ADHD; (2) between guilt and sympathy: Mothers' feelings toward ADHD; (3) social pressure and social norms, and (4) stigmatization.

Medicalization of ADHD
This theme is composed of three sub-themes. Participants ranged in their perception of ADHD on the medicalization continuum, from one side, where ADHD is regarded as a medical problem that needs to be treated as a disease, to the opposite side, where ADHD is regarded as a social behavior during childhood wherein children's misbehavior is not perceived to be a medical problem. The mothers' decision about their child's treatment depended on their position on this continuum.
Mothers' and teachers' perceptions of ADHD on the continuum of medicalization. The mothers' and teachers' position seems to be distributed differently in the two ethnic groups, as most of the Arab mothers and teachers were more skewed toward the nonmedicalized side of the continuum. They referred to ADHD in behavioral terms rather than medical terms, and that the child is simply misbehaving: "I attributed his behaviors to childhood, children want to be naughty, and they want to try everything" (Arab mother). While most Jewish mothers and teachers tended to consider ADHD to be a medical issue and a genetic disorder that the child is born with, and should be treated with medication, therefore positioning themselves toward the medical side of the continuum. None of them attributed ADHD to a behavioral problem: "ADHD is totally genetic, it's something that the boy was born with, and he didn't choose it" (Jewish mother). Another Jewish mother described ADHD as a disease, comparing it to other diseases that should be treated "they can't control it, it's really physiological, an organic problem, just like diabetes, I don't think it's behavioral." Also, Jewish teachers defined ADHD using medical terms, as one participant said: "I know that ADHD is a neurological problem." Acceptance of the ADHD diagnosis. Another aspect of medicalization was reflected in the way mothers accepted the diagnosis and how they felt about it. Jewish mothers reported that they were not worried about the diagnosis itself. Moreover, some even reported feeling a certain relief when they discovered that it was ADHD. Defining their child's situation in medical terms made it easier for them to accept it: "When the doctor told me [the diagnosis], I felt relieved, I sat in front of the doctor, and everything she said was so accurate, it's like putting a mirror in front of yourself" (Jewish mother).
In contrast, Arab mothers reported significant difficulties accepting their children's diagnosis and opposed the medicalization of their child's behavior: "When the doctor told me [the diagnosis] I was completely shocked, I lost control, I denied it, I said that my boy is just fine, he has nothing" (Arab mother). This mother also said: "I thought he has a kind of madness." Whereas this mother reported being shocked, followed by denial of her son's worrisome condition and later labeling it as madness, another Arab mother was also completely stunned, but tried to rationalize the reason for her offspring's condition as determined by divine providence: "When my son was diagnosed, I was really shocked, I cried a lot and asked myself why God gave me such a son".
To medicate or not to medicate. Both Arab and Jewish mothers and teachers reported their ambivalence toward medication. The response to drug treatment varied markedly between the two ethnic groups. Fewer Arab participants, compared to Jewish participants, rated medication interventions as appropriate.⍰ In our study, 25% of the Arab parents reported medicating their child compared to 72% of the Jewish parents. Most Jewish mothers favored medication, while most Arab mothers opposed it and used alternative treatments such as behavioral techniques, horseback riding and swimming classes, or did not treat their children at all: I explained to the teacher that until recently she was in the kindergarten, playing the whole time, and suddenly the whole issue of discipline at school, it's not taken for granted. ADHD does not hurt her health, anyone can suffer from ADHD at a certain time in his life for different reasons … medication for me is not an option, I take her to music class, ballet (Arab mother).
Some of the Arab mothers and teachers regarded the medication as poison: I refused to give him medication because of the adverse effects, such as infertility, autism and addiction. I won't agree to give him poison, so that he won't bother the teacher during the class (Arab mother).
Most of the Jewish mothers and teachers described the benefits of medication, the enormous contribution to the child, and the positive changes that occurred due to the medication, such as more social improvement in relationships with peers, and more social involvement: There has been an enormous improvement in the social aspect. Now she knows better how to deal with conflicts. She wasn't a zombie at all, and she eats well, things are easier, and for me it's wonderful, we use the medication for its purpose only (Jewish mother).
Jewish teachers expressed similar attitudes to those of Jewish mothers on this issue. They strongly supported medication and its contribution to the child: There is a huge difference between a treated child and an untreated child, you can see it in their eyes. When they don't take the pill, they are distracted, restless, hyperactive, it's out of their control. I'm in favor of drug treatment (Jewish teacher).
Arab teachers were less supportive of medication, as most of them were against it. One Arab teacher stressed the dramatic impact of medication on the child: "I'm against medication … I don't want a grade of 100, I'm afraid of the adverse effects. It's like 'turning him off.' No, no, I'm against medication." Another Arab teacher pointed the effects of the medication beyond the purpose of calming the child down: "It's a chemical (the medication) that might affect other aspects of the child, you just see them too quiet that you feel pity for them." Between guilt and sympathy: mothers' feelings toward ADHD Feelings of guilt. This theme emerged mainly from Arab mothers' narratives, expressing guilt feelings for being responsible for their children's problematic behaviors and for being treated with medication, even though reporting that the child benefited from the medication. Some expressed guilt feelings for treating their children with medication: "I stopped giving him the medication, till today he doesn't get the medication … I clear my conscience of guilt feelings and am free of my sin" (Arab mother). Another Arab mother depicted her guilt feelings while justifying that she gives her child the medication only when necessary: I give him medication only from Sunday to Thursday, there are mothers who don't care but I am not capable of that, because he is my own boy. If I won't be patient with him, then who will, on Friday and Saturday I don't give him medication.
Mothers sympathize with their ADHD child. Most Jewish mothers appeared to understand their children with ADHD and even sympathized with them. They considered their behavioral problems to be a medical problem that a few decades ago their own parents had not been aware of. Most Jewish interviewees reported that one of the parents has ADHD, which enhanced feeling empathy toward their children. Those parents were not diagnosed in the past and struggled with difficulties at school and with other social problems. They wanted to spare their children their own suffering. This seemed to be a strong incentive for Jewish parents to diagnose and medically treat their children: "We decided to give her medication, because I know the frustration that my husband had until he treated himself with medication, and you can see the improvement, it helped him a lot" (Jewish mother). Another Jewish mother narrated her own experience with ADHD: 'From my own experience, I also have ADHD, and when I was a little kid, it wasn't something that you could put your finger on, I can see myself through my kids, we are identical.' She also said: "One of the things that helps me deal with my two children with ADHD, is understanding them, and since I have ADHD, I'm capable of understanding their behaviors."

Social pressure and social norms
This theme emphasizes the fact that ADHD can be seen through contrasting lenses from different social standpoints, including family, relatives, and teachers, as it seems to be a social matter that reflects the parents' experience within the cultural context, norms, and society. Data analysis revealed the high impact of social pressure on parents' decisions whether to diagnose their children with ADHD and medicate them. It also emphasized major differences between the two ethnic groups.
Relatives' involvement in the mothers' decision. Evidently, for most Jewish mothers the social environment did not play a role in their decisions whether to medicate. Some of them did not discuss such decisions with their relatives, nor did they allow them to interfere in private issues: My family knows that she's treated with Ritalin. It's on the microwave in the kitchen, we don't make an issue out of it, we talk about it as a casual thing, just like we talk about the basketball club, but they don't interfere (a Jewish mother).
Contrariwise, Arab mothers reported that their social environment strongly affected their decision and that they found it hard to treat their children with medication because of social pressure. The mother's families opposed medication, though some of them were aware of the medication's benefits: They [my relatives] tell me not to give him medication, because it may cause him damage in the future. I feel stuck in the middle, I see his relapse at school every time I stop giving him the medication; it's obvious there's a significant drop in his grades (Arab mother).
In the next quote from an Arab mother, the whole surrounding is not supportive when considering medical treatment. Hence, the mother who gave her daughter Ritalin needs to conceal her act: They [my relatives] tell me: "Why has your child become so quiet? You probably did something to her. I can't tell them that she's on Ritalin. Many times during parents' gatherings at school I hear other parents say that we shouldn't treat our kids with Ritalin. But I'm convinced that if this drug wasn't necessary they wouldn't have invented it" (Arab mother).
Teachers pressure parents to treat their children with medication. Both Arab and Jewish mothers reported that the teachers were involved in the diagnosis and treatment process. However, more Jewish mothers than Arab mothers reported that teachers were pressuring them to treat their children with medication: There were times that I felt enormous pressure, it's like the whole time, "give him, give him." I was very scared to get a zombie boy, but in the fifth grade, I was unable to resist the pressure from his teachers, so I gave him medication, and I regret that I didn't give it to him earlier. The medication has done him good (Jewish mother).
The teachers reported being involved in the process of identification and referring to diagnosis in both ethnic groups. Yet, the two groups differed concerning the treatment-Jewish teachers were convinced that the medication was an optimal solution for their students, while Arab teachers were reluctant to use medication and preferred handling ADHD in alternative ways or accepting the child the way he was: "Today, I am very much in favor of medication; I do not see it as a negative thing … once there is some difficulty, I see how drug treatment improves achievement and how it does magic" (Jewish teacher). Conversely, an Arab teacher reported: "I don't believe in medication, I want an active boy, his behavior doesn't bother me." Another Arab teacher shared that she preferred to deal with a "naughty" student rather than that student would be treated with medication. She used a variety of descriptive words that characterize a student who is treated with medication: I was used to him as hyperactive, and all of a sudden, he is tired, drowsy, and too quiet. It is depressing. I wish he would be hyperactive again; I don't care if he is naughty, it's better than being under the drugs' influence.

Stigmatization
Concern about stigma and prejudice toward psychiatric disorders is a major barrier to diagnosing and medically treating children with ADHD. This theme emerged more frequently among Arab participants than among Jewish participants, as most of the Arab mothers and all of the Arab teachers reported that children with ADHD were stigmatized. Keeping the diagnosis and treatment a secret was highly important for Arab mothers, because they were afraid of the stigma that could arise: I insist that my child won't find out [that he is taking medication for ADHD], because of the environment. In his class there is stigma about children with medication. I made a complete show, I took him to a blood test, made a deal with the doctor to tell him that he has anemia, and until today, he thinks that he takes medication for treating anemia (Arab mother).
Arab teachers shared their own experience with parents' fear to reveal the fact that their children are treated with medication due to the risk of stigma: "Of course other children mustn't know that this child is on medication; we surely don't tell, otherwise he would be stigmatized for being mad" (Arab teacher).
Conversely, most Jewish mothers did not feel their child was stigmatized. Jewish mothers did not seem to mind sharing or talking about their child being diagnosed with ADHD, nor did they mind talking about the medication. Many Jewish mothers did not make an issue out of it, and the children themselves shared information with each other and did not keep it a secret: I think that because the discourse is very embracing and containing, and the children know those who go individually out of the classroom for corrective teaching. They see it as normal; as part of the routine; they do not even consider it important. They ask each other, "Did you take your pill today?" (Jewish teacher).

Discussion
Our results present major differences in social, ethnical, and cultural factors that are vital to understanding trends in ADHD diagnosis and treatment among Arabs and Jews in Israel. Studies have shown that social and cultural factors are keys to understanding trends in ADHD diagnosis and medical treatment. Consumption rates of medication have increased dramatically across the world over the past decades. However, differences in diagnosis and treatments among different countries also have been observed (Moon, 2012). Cultural attitudes in relation to children's behavior have a profound impact on how parents and teachers perceive a child with ADHD and decide to treat that child.
The Israeli-Arab society is considered a collectivist-communal, conservative culture as well as a minority group, whereas Israeli-Jewish society is more Western-oriented and individualistic culture (Dwairy et al., 2006). These differences may explain why Arabs and Jews differ in their attitudes and perceptions toward diagnosis and treatment of ADHD, and consequently, may partially explain the difference in the prevalence and treatment of ADHD between the two groups.
Medicalization ADHD medicalization is defined as a normalization process within Western societies (Malacrida, 2004). Normalization relates to the use of medication to bring mental functioning in line with a common cultural norm (i.e., academic normalcy), fixing lost functions, and increasing performance beyond socially desirable norms (Simoni, 2018). Our study revealed that the medicalization of ADHD is far more prevalent and entrenched in Jewish society. Jewish participants, like people in other Western societies such as Britain and the United States, tend to perceive ADHD as a medical problem that should be treated with medication (Conrad & Bergey, 2014;Lusardi, 2019). Western society has become less tolerant of deviant behaviors that were once accepted as part of a child's development and are now regarded as problems to be resolved through medical practice. In addition, their positive attitude toward medication seems to facilitate their decision to medically treat the child (Coletti et al., 2012).
Conversely, Arab participants tended to perceive ADHD as a childhood behavioral problem and demonstrated resistance to the perception that ADHD is a medical matter. Similarly, previous studies worldwide supported this perception even when the child was diagnosed by a medical specialist (Coletti et al., 2012;Loh et al., 2016). In those studies, the participants attributed ADHD behavior to childish and naughty behavior, rather than to a psychiatric disorder requiring diagnosis and treatment (Coletti et al., 2012;Loh et al., 2016). They reported hesitancy toward medicating children with ADHD and often preferred non-pharmacological intervention (Loh et al., 2016).
Our study implies that the degree to which mothers accept ADHD as a medical condition varies by ethnicity and cultural differences. Furthermore, acceptance of the diagnosis and treatment may predict parents' compliance with medical treatment. Acceptance is typically lower when individuals are not comfortable with a medical approach (Brown et al., 2005). Studies supporting our findings suggest that parents who related to ADHD as a medical matter were more open to the prospect of medication and initiated medication treatment for their child (DosReis et al., 2009). Mothers' acceptance of the ADHD diagnosis as a medical matter allowed them to understand their child's problems and this helped them accept medication for their child.

Social environment
Israeli-Jewish society is based on an individualistic nuclear family system characterized by democratic relations, similar in many ways to other Western societies. In contrast, Israeli-Arab society is a relatively collectivist-communal cultural group (Dwairy et al., 2006). Moreover, Arab families rely on a collectivist perspective, where the self is a component of the group rather than an independent entity. This may explain the high influence of the social environment on Arab parents' decisions. Studies indicated that the interactions individuals have with members of their social network affect the way they perceive health problems and comply with medical advice (Pescosolido, 1992). In addition, the degree of support and beliefs about the disorder and its treatment influence the decision of whether to medicate or not (Eiraldi et al., 2006).
Teachers' involvement in the diagnostic procedure and the pressure they apply on parents to medicate shows the contribution of public social institutions to the medicalization process. Research indicates that the education system has a critical impact on reducing parents' resistance to administering medication and encouraging them to diagnose and treat their ADHD child (Gesser-Edelsburg & Hamade Boukai, 2019). In our study, Arab teachers may be described as gatekeepers who hesitate to administer medication. A study in the United States has shown that African American teachers were less approving of medication use for ADHD compared with white teachers, implying potential mistrust toward medication use and health institutions in society (Simoni, 2018). This finding may help to partially explain racial disparities in medication use.

Stigmatization
Our study revealed that Arab participants are concerned about stigma, which seems to be a barrier to diagnosing and medically treating ADHD. These fears are consistent with prior studies (Coletti et al., 2012), which have shown that stigma and embarrassment about seeking help is one of the most prominent barriers to obtaining assistance for mental health problems (Gulliver et al., 2010).
Numerous studies show that large population groups still characteristically stigmatize individuals who have ADHD, no matter how prevalent the disorder is. This attitude may be expressed in their approach to the diagnosis and treatment of ADHD (Lebowitz, 2016). The stigmatization of persons diagnosed with ADHD is associated with cultural attitudes and perceptions among various ethnic origins. In America, the stigmatization of a psychiatric diagnosis may be typical of individuals associated with minority groups. If members of minority groups stigmatize ADHD, the evaluation and treatment of those who have the disorder may take place on a much smaller scale (Liang et al., 2016).

Research and educational implications
A future quantitative study can complement the current study by examining the knowledge, attitudes and perceptions of a large sample of Arab and Jewish parents and teachers toward the diagnosis and treatment of ADHD. Such a study may yield a better understanding of how parents make decisions whether to treat their child with ADHD or not.
Our study emphasizes cultural variation in perceiving the behavior of children with ADHD. It provides evidence that social and cultural factors are vital for understanding trends in ADHD diagnosis and treatment because cultural beliefs play a key role in determining parents' perceptions and attitudes. School managers, school psychologists, counseling staff and teachers should be aware of such cultural factors when advising parents and planning educational programs for children with ADHD. Intervention programs by policy-makers are required to minimize the gaps between the different ethnic groups and bring the contrasting positions to a middle point on the scale, where under-diagnosed children are detected and over-diagnosis is limited.

Limitations
This was a qualitative study. Thus, the sample was not representative. However, despite the small number of participants, the in-depth interviews provided rich information that can be considered a trade-off for the modest sample size. This rich information exposed the decision-making process of whether to medicate their child diagnosed with ADHD and reflected the differences between Arab and Jewish societies in explaining the gaps in rates of diagnosis and treatment existing between these societies.

Ethical approval
The study was approved by the university's committee for ethical research with humans (approval number 448/18) and the ethics committee of the Ministry of Education (approval number 10402).

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/ or publication of this article: This work was supported by the Education University of Hong Kong, (grant number Project No. RG 26/2021-2022R).