Four main themes emerged from data analysis regarding mothers’ experiences and attitudes towards their children diagnosed with ADHD and the teachers’ experience concerning diagnosing and treating children with ADHD: (1) Medicalization of ADHD; (2) Mothers’ feelings towards ADHD; (3) Social pressure and social norms, and (4) Stigmatization (see Table 2).
Medicalization of ADHD
This theme is composed of five sub-themes. Participants ranged in their perception of ADHD on the medicalization continuum, from one extreme, where ADHD is regarded as a medical problem that needs to be treated as a disease, to the opposite extreme, 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. The mothers’ position seems to be distributed differently in the two ethnic groups. Arab mothers and teachers were more skewed towards the non-medicalized side of the continuum, demonstrating resistance to the medicalization of ADHD. Jewish mothers and teachers tended to consider ADHD to be a medical issue that should be treated with medication, therefore positioning themselves towards the medical side of the continuum.
Mothers’ perceptions of ADHD on the continuum of medicalization
Most Arab mothers thought that ADHD is a behavioral problem rather than a medical problem 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). Most Jewish mothers thought that ADHD is a genetic disorder that the child is born with. Defining the problem in a medical language was more accepted among Jewish mothers. Moreover, part of them said that either the father or the mother had ADHD themselves, which strengthened their opinion that ADHD is a genetic problem, transmitted from generation to generation. 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 participant, 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’.
Teachers’ perception of ADHD on the continuum of medicalization
Arab teachers seemed to position themselves in the middle of the medicalization continuum, explaining that ADHD includes components of both a genetic disorder and a behavioral problem caused by the environment: ‘I think the environment has created the disorder, I don’t know if there are studies that prove genes for ADHD, but I think that the childhood environment can cause ADHD” (Arab teacher). Another Arab teacher said:
It is genetic and environmental, I don’t know what exactly causes ADHD, but we are in a generation that highlights these disorders, everything is digital and computerized today. I don't know the truth, but genetics certainly plays a role too.
Whereas most Jewish teachers regarded ADHD as a genetic, intergenerationally transmitted disorder, none of them mentioned that ADHD is a behavioral problem related to childhood: ‘Definitely it has something genetic, it is inherited’ (Jewish teacher). In addition, Jewish teachers defined ADHD using medical terms, as one participant said: ‘I know that ADHD is a neurological problem.’
Mothers’ lifestyle during pregnancy
This explanation of the causes of ADHD was provided only by the Arab mothers, including etiological attributions to the mothers’ life events. While in other parts of the interviews, the Arab mothers link the child's condition to behavior and not to medical condition; they indicate a connection between their lifestyle during pregnancy and the child's condition without reference to the nature of the phenomenon. For example, several Arab mothers thought that their child had ADHD because they did not maintain a healthy lifestyle during pregnancy: ‘I think that we, the Arab mothers, don’t take care of ourselves during pregnancy, I didn’t rest for a second’ (Arab mother); ‘The result is obvious; I used to drink 9 XL cans every day. I was addicted to it. It probably made an impact’ (Arab mother). Another Arab mother also thought that her lifestyle during pregnancy might have influenced her child:
Sometimes I return with my thoughts, that maybe the extra energies I had while I was pregnant, I was just too energetic, no one believed that I was pregnant; so maybe this has influenced my baby. I think pregnant women should always be relaxed (Arab mother).
Acceptance of the ADHD diagnosis
Another aspect of medicalization was reflected through 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 labelling it as madness, another 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’ (Arab mother).
To medicate or not to medicate
Both Arab and Jewish mothers and teachers reported their ambivalence towards 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. Most Jewish mothers favored medication, while most Arab mothers opposed it. Apparently, parental health beliefs affected the medical care sought for their children, as more Jewish mothers administered medical treatment, while Arab mothers 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 agreed that my kid will be in a special education class, but 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 the 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 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’ (Arab teacher).
Mothers’ feelings towards 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. As mentioned above, some mothers thought that their unhealthy lifestyle during pregnancy caused their child’s ADHD. Others 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 (Arab mother).
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 towards 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, teachers, and physicians, 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’ decision 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 medication. The medication is 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. Medicalization of ADHD is not accepted in Arab social discourse. The mother’s families opposed medication, though they 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).
Another Arab mother shared that her child stopped the medication because his aunt convinced him not to take it. She said: ‘his aunt kept digging in his head, she made him hate the medication, and he stopped taking it, she told me that there was a big issue running in the media that Ritalin causes an addiction.’ Arab mothers mentioned that even the pharmacist did not support the decision to treat with medication:
I heard that medication is harmful. Even the pharmacist told me “Haram” [meaning it’s forbidden, a taboo]. He is human, what are you doing to him? (Arab mother).
In the next quote, 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 quit? 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).
Moreover, Jewish mothers said that the educational system requires that all children study in similar frameworks: ‘All the educational frameworks want to have order; they want to put all the students into the same frame’ (Jewish mother).
The teachers reported being involved in the detection process 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.
Concern about stigma and prejudice towards 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 surly don't tell, otherwise he would be stigmatized for being mad’ (Arab teacher).
Conversely, most of the 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. They 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).