Abstract
Little is known about the attitudes of Negev Bedouin toward attention-deficit/hyperactivity disorder (ADHD) and its pharmacological treatment. This study examines the perspectives of Negev Bedouin teachers on pharmacological treatment. Thirty-six teachers are asked to consider how their views influence the way they relate to pupils’ parents. A grounded-theory analysis of semistructured interviews illuminates ambivalence in teachers’ attitudes. Teachers, like the rest of their community, when asked about the implications of an ADHD evaluation for their children, respond that ADHD and its pharmacological treatment cause dishonor. When asked what ADHD means when it is their pupils who are diagnosed and treated, however, teachers, like the education establishment, accept the need for medication. However, they fail to communicate this need to parents because their attempts to do so show parents that they consider their children “flawed”—causing parents to oppose treatment even more lest they succumb to social stigma.
Keywords
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric condition that begins in childhood and lasts into adulthood (American Psychiatric Association [APA], 2013). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5, APA, 2013)™ defines it as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Its symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities) and it negatively impacts directly on social, academic, or occupational functioning. Several symptoms must be present before age 12 (APA, 2013).
The rates of ADHD diagnosis among children will diverge widely, from 2% to 18% (Krull, Augustyn, & Torchia, 2018). In Israel, too, studies find different rates, from 3% to 14% (Davidovitch, Koren, Fund, Shrem, & Porath, 2017; Farbstein, Mansbach-Kleinfeld, Auerbach, Ponizovsky, & Apter, 2014; Israel Ministry of Health, Medical Administration, Health Division, 2010). The reason for the broad variance is that the extent of diagnosis depends on many factors including the evaluation criteria applied, the diagnostic tools used, and the attitude toward ADHD in the country and region where the evaluation is given. It also hinges dramatically on the ethnic origin of the children Krull et al., 2018; Liang, Matheson, & Douglas, 2016; Thomas, Sanders, Doust, Beller, & Glasziou, 2015).
ADHD may be treated in educational, psychological, and pharmacological ways (Wolraich & DuPaul, 2010). The recommended treatment combines pharmacology with other methods such as behavioral therapy, although often treatment is provided via pharmacology alone (Catalá-López et al., 2017; Wolraich & DuPaul, 2010). Pharmacological treatment of ADHD has been advancing in recent years (Conrad & Bergey, 2014; Davidovitch et al., 2017) in various communities, including the Arab ones (Alkhateeb & Alhadid, in press; Farah et al., 2009). Knowledge of the outcomes in the latter communities, however, is still lacking despite evidence in support of significantly, if not dramatically, positive changes to children’s mental health in these populations (Alkahntani, 2013; Alkhateeb & Alhadid, in press).
This study investigates attitudes toward ADHD and its pharmacological treatment among a subset of one such population: teachers in the Bedouin community of the Israeli Negev.
Teachers’ attitudes are crucial in decisions to evaluate children for ADHD and to treat the condition if diagnosed (Gwernan-Jones et al., 2015; Kern & Seabi, 2008; Kos, Richdale, & Hay, 2006; Kypriotaki & Manolitsis, 2010; Russell, Moore, & Ford, 2016). Although such decisions are made by parents on the basis of a doctor’s recommendation, doctors’ attitudes and decisions depend extensively on teachers’ reportage (Kypriotaki & Manolitsis, 2010). Furthermore, parents’ decision to consult a physician for ADHD evaluation and to use pharmacological treatment are strongly affected by reports that they receive from school (Gwernan-Jones et al., 2015; Kypriotaki & Manolitsis, 2010).
The Negev Bedouin population in Israel is a conservative Muslim one that, in recent decades, has been moving toward integration into the country’s Western-oriented society (Abu-Saad, 2010; Benyamin, Hadar, & Asher, 2011). Insights from this population may be helpful to professionals in similar settings, for example, caregivers in Muslim or indigenous societies that are in the midst of integrating into societies of Western orientation.
The attitude of the Negev Bedouin society toward ADHD and its treatment has not yet been researched. A fortiori, the beliefs of teachers in this population group are unknown to scholarship. Thus, the topic of this path breaking study concerns the attitudes and beliefs of teachers.
The Negev Bedouin Population of Israel
The Negev Bedouin community is regarded as an indigenous one that has traits similar to those of other indigenous communities (Manor-Binyamini, 2014). The term “Bedouin” denotes desert dwellers; today, it refers to tribes that trace their origins to a migratory desert Arab population.
The Negev Bedouin maintain a clan structure based on close extended kinship relations. Marriages are arranged by parents; children live near parents and defer to their influence even after marrying (Benyamin et al., 2011). The community is patriarchal and practices polygamy (Abu-Saad, 2010; Benyamin et al., 2011). Few women work outside the home; most care for their large families. Generally speaking, the community continues to adhere strongly to the Bedouin code of personal and collective honor. The code obliges all members of the clan to defend the clan’s interests and, in turn, anything interpreted as the honor of its offspring (Tamari, Katoshevski, Karplus, & Dinero, 2016). The provisions of the code for men and women, however, are different. Women, for example, must maintain their modesty above all; therefore, they must abide by strict dress codes and avoid contact and relations with male strangers. Men must display courage and generosity. Sometimes they are called upon to defend the clan’s interests and honor physically, for example, to act in unison against anything construed as a dishonor to the women members of the clan (Al-Krenawi & Jackson, 2015; Patai, 2002).
The Negev Bedouin are Israel’s poorest population group, with 60% of households under the national poverty line. Bedouin settlements suffer from infrastructure deficiencies that include health care and education (Abu-Saad, 2010). Scholastic achievements, reflected in domestic and international standardized tests, are relatively low. Only 28% of all pupils of Bedouin origin pass the matriculation exams as against 58% of Jewish youngsters who do so (Kaplan, Assor, & Alsayid, 2014). Dropout rates are high (Abu-Saad, 2010).
Medical services, including psychiatry, are ostensibly available to all Israel residents at no charge by law. In practice, however, socioeconomically disadvantaged population groups suffer from poor access to these services. The Negev Bedouin are one such group (Benyamin et al., 2011). Several factors limit their access to psychiatric treatment and diagnosis. Members of the community find it difficult to communicate with doctors who are unversed in this society’s ways of thinking and who, in some cases, cannot speak and understand Arabic. The Negev Bedouin localities are far from psychiatric facilities. The community tends to rely on itself and the family when assistance is needed. Furthermore, the Bedouin population stigmatizes psychiatric illness (Benyamin et al., 2011). Accordingly, Bedouin society’s code of honor may prevent recourse to psychiatric treatment, especially where women are concerned (G. Katz et al., 2012). All of these, plus stigmatization of psychiatric illnesses, may inhibit cooperation with the psychiatric and psychological services and impair diagnosis and treatment (Benyamin et al., 2011).
In addition, cooperation between the Negev Bedouin and the Israeli establishment is poor and extends to the education system, especially in regard to youngsters with special needs (Dinero, 2002; Manor & Binyamini, 2014).
All these factors may inhibit cooperation with the psychiatric and psychological services and impair diagnosis and treatment (Benyamin et al., 2011).
Acculturation and Change in Bedouin Society
Bedouin society is in flux, its attitudes changing under the influence of the majority society of Israel (Manor-Binyamini, 2014). It is undergoing acculturation, a social process in which one group acquires and adjusts itself to another group’s culture and values pursuant to contact between them. Such a change usually typifies the weaker of the two societies, which adopts the culture of the dominant one (Berry, 1997).
The change in Bedouin society sometimes includes the revision of venerable traditions. For example, female genital mutilation, highly prevalent 20 years ago, is no longer practiced at all (Halila, Belmaker, Abu Rabia, Froimovici, & Applebaum, 2009). Conversely, consumption of alcohol, once uncommon among young Bedouin due to the injunction in Islam, has become common in recent years (Diamond et al., 2008). Change of attitudes under the influence of Israeli society is typical mainly of individual Bedouin who leave the Bedouin community, for example, to attend Israeli institutions of study (Aburabia-Queder, 2011; Grodofsky & Soffer, 2011; Kalagy, 2017; Kass & Miller, 2011; Raz, Atar, Rodnay, Shoham-Vardi, & Carmi, 2003). Therefore, teachers in Bedouin society may be exposed to acculturation and, accordingly, widely held Israeli social attitudes may influence their views more strongly than they would others (Kass & Miller, 2011; Raz et al., 2003).
Attitudes Toward ADHD and Its Pharmacological Treatment
A child evaluated with ADHD in Israel is entitled to focused treatment including medication—a matter that educational professionals in various countries, including Israel, consider important if not crucial for his or her mental health (Hinshaw et al., 2011). Pharmacological treatment of ADHD, particularly with methylphenidate—best known by its most common commercial name, Ritalin—rapidly improves attentiveness and mitigates hyperactivity among of individuals who suffer from the disorder (Catalá-López et al., 2017; Charach & Fernandez, 2013; Prasad et al., 2013). It is also effective in improving the functioning of children with ADHD in the absence of behavioral intervention (Catalá-López et al., 2017; Prasad et al., 2013). Furthermore, the effect of behavioral intervention without pharmacological treatment falls short of that of pharmacological treatment alone (Catalá-López et al., 2017). Thus, it is unsurprising that both the evaluation of ADHD and its pharmacological treatment have become much more common in recent years (Catalá-López et al., 2017; Davidovitch et al., 2017; Farbstein et al., 2014).
The growing use of medication has, however, encountered much resistance, mainly because it involves side effects, some of which are serious (Cortese et al., 2013). It has also been charged that pharmacological treatment reflects the biases of the medical system and impairs parents’ and children’s right to make their own decisions on treating ADHD (Comstock, 2011). Furthermore, the very diagnosis of ADHD has a stigmatizing effect (Bussing & Mehta, 2013; Mueller, Fuermaier, Koerts, & Tucha, 2012).
Numerous studies show that large population groups still characteristically stigmatize individuals who have ADHD, no matter how prevalent the disorder is. This attitude may find expression in their approach to the very diagnosis of ADHD or to the impulsive and absent-minded behavior of those who have the condition, some of whom remain undiagnosed (Justman, 2015; Lebowitz, 2016). The combination of stigmatization and the attribution of negative traits to persons diagnosed with ADHD is associated with the cultural attitude of, and with perceptions associated with, population groups of various ethnic origins. In America, the stigmatization of a psychiatric diagnosis may be typical of individuals associated with minority groups, of all people (Liang et al., 2016). If members of minority groups stigmatize psychiatric disorders including ADHD, the evaluation of those who have the disorders may take place on a much smaller scale, to the detriment of the treatment of children who need evaluation for treatment purposes (Liang et al., 2016).
Acculturation may mitigate the stigmatization of ADHD evaluation (Araujo, Pfiffner, & Haack, 2017; Liang et al., 2016). For example, parents of Hispanic origin in the United States whose views changed due to acculturation adopted a less stigmatic attitude toward ADHD that evinced by Hispanic-origin parents who are less acculturated and thus less adjusted to American social values (Araujo et al., 2017; Liang et al., 2016). For treatment of ADHD to succeed, teachers need to adopt an accommodative, accepting, and nonstigmatic approach to children who have the disorder (Kos et al., 2006). It is found, however, that even teachers, including those trained in special education, are prejudiced against pupils with ADHD (Bell, Long, Garvan, & Bussing, 2011; Bussing et al., 2012). Stigmatization of behaviors typical of children with ADHD may even aggravate the youngsters’ condition (Mikami, Chong, Saporito, & Na, 2015).
Stigmatization of ADHD may also spill into stigmatization of pharmacological treatment of the disorder, influencing individuals who have the condition, or their parents, to assent or object to such treatment (Bussing et al., 2012; Ferrin et al., 2012; Gajria et al., 2014). Stigmas against ADHD evaluation and pharmacological treatment are particularly strong among communities in the Arab world (Farah et al., 2009). This may explain why the rates of ADHD diagnosis and pharmacological treatment in Israel are much lower among the country’s Palestinian Arab population than among its Jewish population (Farbstein et al., 2014).
Parents are strongly influenced by the public debate over medication for ADHD treatment and are hesitant to use it (Bussing & Mehta, 2013). Some, however, may welcome diagnosis and pharmacological treatment (Bull & Whelan, 2006) because the unconventional behavior of individuals with ADHD may subject them and their families to criticism on the ostensible grounds of flawed character (Mueller et al., 2012). Evaluation provides an alibi that can be used to soften social censure (Jastrowski, Berlin, Sato, & Davies, 2007; Mueller et al., 2012).
Parent–Teacher Relations
An important factor in persuading parents to have their children evaluated for ADHD and then medicated is concern about the youngsters’ functioning in school. This is why teachers figure crucially in parents’ decisions on whether to refer their youngsters to ADHD evaluation and how to treat them insofar as the diagnosis is positive (Berger, Dor, Nevo, & Goldzweig, 2008; Gwernan-Jones et al., 2015; Odenbring, Johansson, & Hunehall Berndtsson, 2017; Russell et al., 2016).
Teachers’ attitude toward pharmacological treatment depends heavily on how education system in the country where they work views the matter. In countries such as Israel (Hinshaw et al., 2011), where this form of treatment of ADHD is accepted, teachers are favorably disposed to it (Gwernan-Jones et al., 2015; Hinshaw et al., 2011), evidently because it is a practical and convenient way to restrain the unruliness of ADHD pupils (Curtis, Pisecco, Hamilton, & Moore, 2006; Kern & Seabi, 2008). Such an approach may trigger conflicts with parents who disapprove of pharmacological treatment and construe it as signifying that teachers have shirked their educational duty (Breggin, 2001; Gwernan-Jones et al., 2015).
To detect difficulties among pupils that may be suggestive of ADHD, and to break the news to parents so that the youngsters may be referred to evaluation for the disorder, teachers need to acquire knowledge and develop balanced and well-founded attitudes (Kos et al., 2006). Thus, they must have and deploy knowledge regarding the clinical use, efficacy, and prevalence of medication. However, teachers generally (Fabiano et al., 2013; Mahar & Chalmers, 2007) and those in Arab societies particularly (Alkahntani, 2013; Al-Sharbati, Al-Sharbati, Al-Lawatiya, & Al-Jahwari, 2012), sometimes lack such knowledge.
The extent of understanding of ADHD and attitudes toward the disorder and its treatment among teachers in the Negev Bedouin community remain unknown. Thus, this study sets out to examine these teachers’ perspectives on the pharmacological treatment of ADHD and their involvement in the decisions of parents of children with ADHD to use it.
Method
Sampling
Thirty-six teachers from the Negev Bedouin community were sampled—34 from Rahat, the largest Bedouin town in Israel; one from Beersheva; and one from a Bedouin town near Rahat. Rahat, where nearly all the participants live, offers general medical services as well as a mental-health clinic. Furthermore, it is a short distance from Beersheva (20 kilometers), where its residents are welcome to make use of advanced medical services, including mental-health facilities.
Rahat has mainstream and special-education schools. Class size in these schools resembles the Israeli average, as does per-pupil educational investment. The Israel Ministry of Education determines pupils’ level of disadvantage, that is, need for special care, on the basis of socioeconomic metrics. Using these criteria, the ministry has found the pupil population in Rahat highly disadvantaged (Weisblei, 2017). If so, pupils who attend schools in Rahat need a larger investment in their education than they actually receive. Furthermore, the schools in Rahat, like those in other Bedouin settlements, still have shortages of equipment and classrooms, and many pupils in the town study in provisional structures that were never intended to serve as schools. Their educational achievements—on matriculation exams, for example—remain far below the Israeli norm and their dropout rate is one of the country’s highest (Weisblei, 2017).
All participants in this study worked in mainstream schools (most in junior high school and a minority in primary schools) and taught a range of subjects. Most were women (Table 1). Each participant had at least 1 year of experience in teaching pupils who were diagnosed with ADHD and in relations with these children’s parents. All had undergraduate teaching degrees, as required by Israeli law, and had children of their own. Diversity among participants was assured to make the interview findings more credible (Patton, 1999). The participants were of different ages and genders and taught different subjects; some had training in special education (Table 1).
Characteristics of Study Participants.
Humanities: languages (Arabic, Hebrew, English), history.
Science: general science, geography, math, computers.
Homeroom (some also teach an additional subject).
Special education (integrated into mainstream teaching).
Purposive sampling was used (Patton, 1999). First, appropriate candidates were identified with the help of the second author, Sharief Dabbah, and a research assistant, both of whom teach in Bedouin schools and mediated the recruitment of additional participants who were knowledgeable in the research topic. Second, a snowball method was employed, a suitable tactic for psychiatric studies in which appropriate participants in a larger community are hard to find (Jastrowski et al., 2007). Thus, eight of the participating teachers had children of their own with ADHD.
Research Procedure and Tools
Thirty-six-hour-long semistructured interviews were conducted. The items explored interviewees’ attitudes toward ADHD and its pharmacological treatment. As we chose to study the use of medication, we focused the research on the interviewees’ attitudes toward use. To elicit this information, interviewees were asked how they perceived the implications of the diagnosis and the pharmacological treatment of a child with ADHD and what methods they would invoke to make sure the treatment would be given. Also examined were the interviewees’ perceptions of parents’ attitudes toward these matters and their own attitudes toward the parents. To get a better understanding of their views, they were also asked about their attitude as parents.
Theory indicates that acculturation may cause individuals to accommodate two different approaches to a given topic, one personal and the other public. For this reason, it was hoped that the participants’ responses as parents would enhance our understanding of the attitudes of parents in the Bedouin community toward their children. Thus, as most of the teachers did not have children with ADHD, their hypothetical attitude toward a child with ADHD was solicited. The minority (eight participants) who did have children with ADHD were asked about them. The interviews were stopped when the researchers believed that saturation had been achieved.
As they analyzed the interviews, the researchers did find differences between the participants’ approach to the pharmacological treatment of ADHD as teachers and their views on this form of treatment as parents. To determine how the participants justified these contradictions, we reinterviewed 10 of them—five women and five men, two of whom had children with ADHD. The complementary-interview technique allowed us to test “the consistency of what people say about the same thing over time” (Patton, 1999, p. 1195, lines 5–6). All 10 interviews proved to be consistent.
Six women were interviewed in their homes with the help of a woman teaching aide who belongs to the Bedouin community. The others were interviewed by, Sharief Dabbah, a teacher who has practical experience with students with ADHD in the Negev Bedouin community. Four women were interviewed in their husbands’ company. Although husbands were present in the room during the interviews, they went about their business, for example, making telephone calls, and did not interfere with the interviews. No differences were observed between these interviews and those from which husbands were absent. The other participants were interviewed discreetly in school so as not to compromise their honor.
The interviews comprised 20 primary items but, as is customary in semistructured interviews, items were added or subtracted in midcourse as required. They took place in Arabic and were recorded and transcribed verbatim. Sharief Dabbah and the research assistant translated the transcripts into Hebrew for analysis by Amos Fleischmann. Sharief Dabbah and the research assistant are fluent in Arabic (at a mother-tongue level) and Hebrew. The translations were reviewed by an additional senior staff member who is fluent in Hebrew and Arabic; he confirmed their accuracy. Both researchers are well versed in the research topic and in qualitative analysis. Amos Fleischmann has experience in psychiatric research, including research on ADHD (Fleischmann & Fleischmann, 2012; Fleischmann & Kaliski, 2017). Amos Fleischmann has a grown son who has been diagnosed with ADHD. Sharief Dabbah has two young children who have not been evaluated. He is of Arab origin and originally lived in northern Israel but has taught and lived in Rahat for the past 17 years.
As a resident of Rahat and a special-education teacher there, he has acquired friends in various clans and, consequently, made the acquaintance of many teachers in the town’s different schools.
The interview findings were analyzed on the basis of grounded theory (Corbin & Straus, 1990) in a three-stage process (Corbin & Straus, 1990). First, each interview was analyzed paragraph-by-paragraph in open coding to reveal initial themes. Second, axial analysis was performed to categorize the themes. The interviews were compared for similarities and dissimilarities among participants and connections among categories. Finally, selective coding elicited a core category (Corbin & Straus, 1990) of attitudes toward ADHD. This sequence of analyses yielded the following theory.
Although the participants’ views as teachers on the uses of pharmacology corresponded to those of the Israeli education system, they adhered to the Bedouin community’s belief system as parents. Accordingly, their attitudes stem from a conflict between their role as parents and members of the Negev Bedouin community and their role as teachers (L. G. Katz, 1984).
In all three stages of the analysis, the authors treated all interviews separately (“analyst triangulation”—Patton, 1999), compared their findings, and resolved their few disagreements by consensus. A very small number of disagreements were resolved by a third senior researcher who has experience in qualitative research among individuals with ADHD.
Ethics
The college’s Ethics Committee approved the design and protocol of the study. After the participants were advised of the topic and purpose of the interview and were assured that their statements and the research findings would be used for scientific research and teaching purposes only, they signed a form in which they expressed their informed consent to take part. Only then were their particulars recorded. Afterward, they went ahead of their own free will, with no pressure from us. All indicators that might reveal their identities were suppressed.
Findings
Attitudes Toward ADHD
Teachers’ assessment of parents’ attitudes
All participants—young and older, women and men, irrespective of the subjects that they teach—agreed that their pupils’ parents consider an ADHD diagnosis evidence of a severe disorder.
One participant (a 24-year-old woman who has taught 1 year in a junior high school, no children diagnosed with ADHD, and was interviewed at the school) explained this clearly: “Parents take [an ADHD diagnosis] very badly and reject it because they’re afraid of the expression ‘child with a disability,’ like someone who suffers from a terminal illness.” In the participants’ estimation, parents take an even dimmer view of pharmacological treatment of ADHD. Examples are as follows: “A kid takes medicine, especially those calming-down pills, so they consider him abnormal or crazy, who takes pills to calm down . . .” (a 31-year-old woman who has 8 years’ seniority at a junior high school, no children diagnosed with ADHD, interviewed at home). “They’ll always look at a child who’s been given medicine as different or they’ll say unpleasant things, like ‘retarded’ and ‘He can’t sit still unless he’s medicated’” (a 44-year-old woman with 14 years’ experience in teaching at the primary level, one child diagnosed with ADHD, interviewed at the school).
This stigmatization of medicated children by the participants’ society has adverse practical consequences. Several respondents mentioned harm to the marriage prospects of a child with ADHD and even to those of his or her siblings:
A child needs to fit into society without problems and without rumours that he’s getting psychiatric care and that he’s crazy and has some problem . . . And if it’s a girl, it’s a disaster; it ruins her [marriage prospects]. (A 36-year-old man with 9 years’ teaching experience at the junior high school, no child diagnosed with ADHD, interviewed at the school)
Due to these fears, according to the participants, parents of pupils with ADHD deny the very suggestion that their children have ADHD. Instead, they construe ADHD indications in their children as evidence of childishness or faulty character. Examples are as follows: “Parents perceive ADHD as a normal part of their children’s lives and treat their children as ‘naughty’ and not as kids who are ill” (a 35-year-old man with 9 years’ experience in teaching at junior high school, no children diagnosed with ADHD, interviewed at home); “Boys with ADHD in particular are perceived as wayward and fresh; [parents] don’t think of it as something that should be diagnosed” (a 52-year-old woman with 19 years’ teaching experience at junior high, one child diagnosed with ADHD, interviewed at home).
The stigma is so strong that parents would rather see their children expelled from school than medicated:
Truth to tell, it happens lots in our school: parents are called in again and again, but if the kid isn’t good at studies either, then his father spares himself the aggravation and sends him out to work. There you don’t need diagnosis and pills. There he’ll become a good boy. (A 36-year-old man with 9 years’ experience in junior high school, no children diagnosed with ADHD, interviewed at the school)
Participants’ attitudes toward ADHD
The participants took a dour view of ADHD. Few differentiated between ADHD and more serious disorders such as psychosis and cognitive deficiency. They manifested this in derogatory expressions that they used to describe pupils with ADHD, several of which recurred in many interviews: “abnormal,” “crazy,” “criminal,” “good-for-nothing,” “delinquent,” “disturbed,” “ill,” “problematic,” “retarded,” “undisciplined,” “uninhibited,” “unstable,” and “violent.”
Participants’ ambivalence toward pharmacological treatment
The participants were ambivalent about pharmacological treatment, convinced that it improves children’s classroom behavior and learning but sure that it stigmatizes the children badly. When asked about methylphenidate use in their role as teachers, they commended it, calling it, for example, “a medication like any other,” “a normal medication,” “a wonder drug,” and a substance that elicits “joie de vivre.”
When asked about their attitude toward medicating their own children in their role as parents, however, disdain surfaced. Now they described pharmacological treatment as, for example: “a medication with negative implications,” “bad for health,” “a dangerous chemical,” “a dangerous drug,” and “a drug with severe side effects,” the users of which “urinate on themselves,” “will become violent criminals,” and “will develop mental illness.” They regarded the very use of medication as proof of the user’s deviance. One participant said, “I think [a child with ADHD] is abnormal if he takes these pills regularly because it means there’s a problem, it makes him not an ordinary kid, not normal” (a 40-year-old man with 10 years’ experience in junior high school, no children diagnosed with ADHD, interviewed at the school).
Still, most participants said that they would urge their pupils’ parents to seek ADHD evaluation and use medication in the event of a positive diagnosis. They also admitted that they would attempt to convince reluctant parents (in some cases by pressure) of the importance of medicating. Their dislike of ADHD evaluation and pharmacological treatment, however, surfaced when they were asked about their own children or their hypothetical attitude as parents. Here no difference was found between participants whose children had been diagnosed with ADHD (the minority) and the others.
Most participants (20) flatly rejected the use of medication for their children. Others (12) strongly demurred but agreed to consider it as a last resort. Only four said that they would allow their children to take pharmacological treatment if necessary. Fourteen of the 20 participants who vehemently opposed pharmacological treatment for their children said that they would recommend it for their pupils, and all 12 participants who hesitated about giving it to their own children said that they would recommend it as teachers. The following example emphasizes the differences between the participants’ attitudes as teachers and as parents:
Ritalin allows [pupils with ADHD] to sit quietly and not disrupt. What it really does is give the teachers a quiet day. As I told you, the student in my class, the day he gets Ritalin is a quiet day, but when he doesn’t take it, God help us. [So] I talk them into it by using the books. I tell [a parent] that it’s [pharmacological treatment] for the kid’s own good. (A 38-year-old man with 11 years’ experience in junior high school, no children diagnosed with ADHD, interviewed at his home)
This participant then stated that if he fails to convince a parent, he hands the matter to the counselor. When asked about his own child, however, he vehemently opposed the use of pharmacological treatment:
First, if I had a kid with ADHD, heaven forbid, I wouldn’t agree to give him Ritalin. I’d try to deal with it some other way. As I told you, in our community it’s a problem for a kid to take pills regularly. It says that he has a problem or that he’s crazy or mentally ill.
Asked to explain the dissonance, participants said that their main concern when dealing with pupils is the utility of the medication for their teaching. When their own children are at stake, however, they give primacy to concerns about them and their honor. Below a participant whose son was diagnosed with ADHD explains the contradiction:
I really hadn’t given any thought to it. But if I think about it more, I’ll feel that I have emotions about my kid. So, I’ll do it due to emotion. I also have this fear that they’ll say my son is taking pills or, worse, lost his mind or some such. With a pupil in school I don’t have this emotion. I just work and do what I should to let the class flow properly and it’ll make him sit quietly without bothering me and the other children. (A 37-year-old participant with 12 years’ experience in junior high school, one child diagnosed with ADHD, interviewed at the school).
Secrecy as a Strategy
Many participants rejected the idea of pressuring parents to allow medication. “It insults them and dishonours them and might get you into trouble with them,” one participant warned.
There’s a teacher who works with me who puts a lot of pressure on parents to bring their daughter in for evaluation and they don’t agree . . . If we go about it that way, we’ll put ourselves in a rut that’ll be hard to get out of. (A 31-year-old man with 10 years’ experience at the primary level, no children diagnosed with ADHD, interviewed at the school)
Another participant thought that pressuring parents to allow medication would boomerang: “Sometimes all this pressure to agree to evaluation gives parents the wrong idea. For example, they think their son has some enormous problem and then they really dig in their heels” (a 28-year-old woman with 6 years’ teaching experience at junior high school, no children diagnosed with ADHD, interviewed at the school). If so, pressure exacerbates parents’ disapproval of medication by convincing them that their children have a problem that they must conceal even more vigorously.
Most participants stated that secrecy must be assured because disclosure of the use of medication is parents’ “greatest fear.” Examples are as follows:
[Parents] keep it close to the chest . . . because they’re afraid that people will find out and think he’s retarded, especially if he’s taking pills. They try to say that he’s naughty, that he’ll settle down once he grows up . . . They don’t know much about diagnosis and you have to promise that it’ll be kept quiet. (A 31-year-old man with 10 years’ experience at the primary level, no children with ADHD, interviewed at the school)
Another participant (age 41, man, 15 years’ experience at junior high school, no children diagnosed with ADHD, interviewed at home) explained:
What I can do is call in [the parent] and explain that it’s for the child’s good and what might happen otherwise. If persuasion doesn’t work, I’ll visit them at home and tell them about Ritalin and the diagnosis and promise them that it can be kept secret, without anyone in the neighbourhood or in class knowing.
A third participant (age 42, female, 10 years’ experience in primary special education, one child diagnosed with ADHD, interviewed at the school), reported hearing from the mother of a boy with ADHD that she had consulted with her sister, with whom she meets often, to help her decide whether to medicate. It was only during this consultation that she discovered that her sister’s daughter had been taking medication and had two young children who had not been evaluated for several years. Thus, secrecy “works”: some children are medicated but people around them are unaware of it. One participant summed up the phenomenon: “I know lots of families whose children were evaluated and have ADHD but most of the families keep it under wraps. So, nobody knows”(a 41-year-old woman with 14 years’ experience in junior high school, no children diagnosed with ADHD, interviewed at the school).
Discussion
Attitude Toward ADHD
According to the participants, parents in the Negev Bedouin community consider an ADHD diagnosis a dishonor to the diagnosed child and his or her family. Medication stigmatizes, they say, because it proves that the child deserved the diagnosis. Therefore, when these parents notice typical ADHD behavior in their own children, they describe it as mischievous, puerile, and unschooled, but not as evidence of ADHD.
Studies on indigenous peoples’ attitudes find parental behavior of the kind identified in this study (Loh et al., 2016; Oldani, 2009). Aboriginal parents in Western Australia, for example, accept their children as normal even when professionals interpret the youngsters’ behavior as typical of people with ADHD. Thus, they allow them to misbehave at family activities and refrain from defining them as with ADHD and medicating them with Ritalin (Loh et al., 2016). A Canadian study yielded similar findings: A mother of indigenous origin excused her children’s maladjusted behavior as occasioned by poor character due to unsuccessful education. Thus, she regards the school as wrong when it sees her children as suffering from a biological disorder (Oldani, 2009).
The question of the origin of ADHD—biology or socio-environmental influence linked to faulty education—is of concern to parents in Western societies (Bussing & Mehta, 2013; Gray Brunton, McVittie, Ellison, & Willock, 2014; Mueller et al., 2012). Many studies, most performed in countries of Western cultural orientation, report a generally positive view of the theory of biological origin. Parents who share this outlook favor diagnosis and pharmacological treatment of the disorder (Bussing & Mehta, 2013; Mueller et al., 2012). Evidently, such an attitude serves them because it absolves the child of blame for his or her behavior (Jastrowski et al., 2007). Parents of children with ADHD, too, are stigmatized for ostensibly poor parenting. Therefore, a diagnosis that explains the child’s uncontrolled behavior also argues against parental fault (Bussing & Mehta, 2013; Mueller et al., 2012).
Clashing Roles: Teacher Versus Parent
The findings illuminate a difference between the participants’ outlook as parents and their views as teachers. When the possibility of medicating their own children was raised, the participants expressed an attitude that resembled the one they described among parents of children whom they taught. Namely, most strongly opposed medication. When they interacted with parents of children who had been diagnosed with ADHD, however, they recommended medication vigorously, sometimes via pressure.
In recent years, more and more young members of the Negev Bedouin community, including women, have been enrolling in Israeli academic institutions. By so doing, they risk a collision between their traditional values and those of Israel’s Western-oriented society (Kalagy, 2017). The Bedouin teachers who participated in our study received their training in Israeli academic institutions that view the treatment of ADHD, including pharmacological treatment, from a Western perspective. For this reason, they were susceptible to acculturation (Berry, 1997; Kalagy, 2017). People who undergo acculturation may act along two lines, one reflecting the adoption or rejection of the majority culture and the other mirroring the adoption or rejection of their original culture. Accordingly, they may embrace the values of one of the two societies to which they belong (the old and the new), totally reject the values of one or the other, reject those of both, or adopt values that they acquire from both (Berry, 1997). They may even take on values that they acquire from one society, usually the dominant one, in public (e.g., at work) and values from their origin society in private (family and home) (Arends-Tóth & van de Vijver, 2004).
Our participants appear to have fallen into these patterns. As teachers, they are committed to the conventional wisdom of the Israeli medical and educational establishment to which they belong. Thus, they perceive ADHD as a psychiatric disorder that, ipso facto, entails the use of medication to improve functioning. Thus, their interest leans toward medication because it may enhance the relevant pupils’ functioning in class. As parents and as members of the Negev Bedouin community, however, they are worried about the stigma that attaches itself to psychiatric disorders, one that may even impair the marriage prospects of their offspring, and oppose the use of pharmacological treatment for their own children on these grounds. Differences in teachers’ attitudes between their role as teachers and their role as parents may originate in different circumstances and, of course, are not specifically typical of teachers of Bedouin origin (L. G. Katz, 1984). It has been theorized that teachers concern themselves with their ability to teach and serve the interests of the system that employs them, whereas parents assign the highest importance to aspects that detract from their children’s welfare (L. G. Katz, 1984).
Importance of Community, Family, and Secrecy
The perception of a psychiatric disorder as so severe as to cause stigmatization is a corollary of a social attitude that varies among societies (Jones et al., 1984; Liang et al., 2016; Rosen, 2006). In Arab (Al-Krenawi & Jackson, 2015) and Muslim societies (Ciftci, 2012), individuals are closely bound to their families and communities. Support from the family may help a person with a psychiatric illness to surmount his or her difficulties (Ciftci). The problem with this is that the very existence of strong ties to family and community may cause individuals to fear these institutions’ remarks about them and, for this reason, avoid or withhold psychiatric treatment (Ciftci). Our participants fully understood the stigma attached to the use of medication and manifested it in their attitude toward medicating their children. Just the same, as teachers they thought it necessary to convince parents of ADHD children in their classes to medicate.
Wishing to refrain from dishonoring their clients and families, our participants promised not to reveal the giving of pharmacological treatment to children diagnosed with ADHD. However, once both the diagnosis and the treatment are kept under wraps, it is thought that only highly abnormal individuals have the disorder and need to be treated for it. The fear of stigma prolongs the cycle of secrecy and, in turn, resistance to evaluation and pharmacological treatment.
Apparently, however, continued exposure of the Bedouin population to Israeli society and Western cultural values, as described in the past (Aburabia-Queder, 2011; Grodofsky & Soffer, 2011; Kalagy, 2017; Raz et al., 2003), may also induce a change of mind among this population toward ADHD diagnosis and treatment. Indeed, studies show that parents of children with ADHD from population groups that stigmatize the disorder may be more willing to treat it with medication after being exposed to Western culture and undergoing the acculturation that follows (Araujo et al., 2017; Liang et al., 2016). As more and more people treat ADHD with medication, the use of this method will become impossible to conceal. The public of Bedouin parents may then realize that those diagnosed with ADHD are not materially different from ordinary pupils and certainly do not deserve epithets such as “mentally ill” or “crazy.” Such a process may heal the schism in educators’ attitudes between their view as parents and that as professionals. The destigmatization of ADHD may allow educators to lead more easily an open discussion in which parents of children with ADHD, including those who are teachers, will participate. Perhaps, too, parents will be exposed without fear to the advantages and drawbacks of pharmacological treatment.
Summary and Conclusion
Our participants, embracing the approach of the Western-oriented Israeli education system, displayed a commitment to the use of pharmacological treatment in their role as teachers. For this reason, several indicated in their interviews that parents were being subjected to pressure to medicate their children. Pressure to medicate is applied with the encouragement, if not the prodding, of education systems in many countries (Hinshaw et al., 2011). Where the pharmacological treatment of ADHD is concerned, however, the use of pressure breaches morality and medical ethics and has been roundly criticized (Chandler, 2013; Comstock, 2011). It also transgresses explicit rules about the Israel Ministry of Education (Hasisi, 2013). Thus, parents’ right to use medication without pressure should be honored. It follows that parents who belong to a disempowered community, such as the Negev Bedouin in Israel, must not be exposed to unfair pressure. Moreover, such pressure is ineffective.
The findings presented above also show that the strategy of forcing parents in the Negev Bedouin community to use pharmacological treatment may have the opposite result of that intended. Some parents in this community would rather see their children accused of faulty character than saddled with a profile of abnormality that stains them and their families with the shame of psychiatric illness.
The current study describes a mechanism that may account, in part, for the scanty use of pharmacology among the Negev Bedouin population and, perhaps, among similar groups elsewhere. The meager use of medication for the treatment of ADHD may have dire implications for youngsters’ functioning and prospects of remaining in school, as has been suggested in respect of other indigenous communities (Manonita, D’Arcy, Holman, & Preen, 2015; Oldani, 2009).
Therefore, a candid discussion about the meaning of an ADHD diagnosis and pharmacological treatment in the Negev Bedouin community is needed. To give any discussion of practical educational and therapeutic significance a chance of success, the Negev Bedouin community should be allowed to lead the debate by itself and the establishment should make a supreme effort to refrain from imposing its policies (Mizel, 2009a, 2009b). Such a discussion should take considerate account of the sensitivities and the special social structure of the population group at issue (Al-Krenawi & Jackson, 2015). In any discourse on the possibility of using pharmacological treatment among pupils with ADHD who belong to this population group, parents, teachers, clergy, and doctors who belong to the community should be co-opted into the process at the stage where a possible action plan is discussed. This stage should yield recommendations for a program of action on the treatment of pupils with ADHD, in which pharmacology would figure importantly. In the aftermath of this discourse, parents may be advised that in Negev Bedouin society, too, there are children who have achieved prodigiously due to the use of medication. Such an approach may alleviate fears of the stigma that diagnosis and treatment arouse. A fair discussion would also advise parents of the risks attending to the use of pharmacology, their full right to oppose it, and the alternatives available. Namely, it is important to assure parents that their views will determine the outcome and will be respected. If such an approach is taken, parents may be more willing to seek assistance when their children need it and may feel it less necessary to conceal their youngsters’ use of medications.
When the Israeli establishment expresses its support of the pharmacological treatment of ADHD, it must realize that the use of such medication in the Negev Bedouin community is feasible only with the consent of members of the community. Therefore, teachers should be trained to take a sensitive and considerate approach toward the difficulties that parents encounter in regard to such use. They should be advised that the overall prerogative in accepting pharmacological treatment belongs to parents and should be exposed, through appropriate counseling, to nonpharmacological methods of dealing with pupils who have ADHD. Teachers need to realize that these are the only feasible methods to apply when parents do not assent to pharmacological care.
Future quantitative and qualitative research may complement the current study by examining the attitudes of parents from the Bedouin community toward pharmacological treatment of ADHD and the role of acculturation in Israeli society on these parents’ attitudes toward ADHD evaluation and pharmacological treatment of the disorder. Such research may look into teachers’ thinking from a complementary point of view and, in turn, improve the examination of teacher–parent relations in respect of ways of treating children with ADHD in the Bedouin community. Future research may also compare Bedouin parents’ attitudes with those of parents in other communities in Israel, for example, Arab and Bedouin communities in northern Israel. Such communities are more exposed to Israeli society than are the Negev Bedouin, some members living in mixed-population cities such as Jaffa, Haifa, and Acre. Such a comparison may yield a better understanding of the effects of acculturation on attitudes toward ADHD.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
