See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/8926454

Boys Will Be Boys: Fathersʼ Perspectives on ADHD Symptoms, Diagnosis, and

Drug Treatment

Article  in  Harvard Review of Psychiatry · November 2003

DOI: 10.1080/714044393 · Source: PubMed

CITATIONS READS

90 1,301

1 author:

Ilina Singh
University of Oxford
70 PUBLICATIONS   1,579 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

SNAPBY View project

Global Perspectives on ADHD: Social Dimensions of Diagnosis and Treatment in Sixteen Countries View project

All content following this page was uploaded by Ilina Singh on 27 October 2015.

The user has requested enhancement of the downloaded file.

 ORIGINAL REPORT

Boys Will Be Boys: Fathers’ Perspectives

on ADHD Symptoms, Diagnosis,
and Drug Treatment

Ilina Singh, EdD

Fathers tend to be largely absent from research and clinical settings related to attention-
deficit/hyperactivity disorder (ADHD), as well as from public forums related to ADHD, such as
educational conferences and parent support groups. Because of these absences, little is known about
fathers’ perspectives on ADHD symptoms, diagnosis, and drug treatment. This article presents find-
ings from a qualitative study involving 39 mothers and 22 fathers of boys with ADHD. In-depth
interviews were conducted with participants using a picture-based method that elicited detailed nar-
ratives. Results of this study suggest that fathers’ perspectives on ADHD behaviors, diagnosis, and
drug treatment can be categorized along two dimensions: “reluctant believers” and “tolerant non-
believers.” Across these two dimensions, several related factors are relevant to fathers’ perspectives:
resistance to a medical framework for understanding their sons’ behaviors; identification with the
sons’ symptomatic behaviors; and resistance to drug treatment with stimulants. These factors may
help to explain, in turn, fathers’ absences from clinical evaluations of their sons’ behaviors. The
study affirms the importance of fathers’ perspectives to the clinical evaluation and treatment of boys’
symptomatic behaviors. (HARV REV PSYCHIATRY 2003;11:308–316.)

attention-deficit/hyperactivity disorder, boys/boyhood, family system, fathers/fathering, parents,

medicalization, men’s psychology, psychopathology, psychopharmacology, Ritalin

Attention-deficit/hyperactivity disorder (ADHD) is among
the most well researched childhood psychiatric illnesses,
generating hundreds of articles in clinical and research jour-
From the Centre for Family Research, Faculty of Social and Political
Sciences, University of Cambridge.
Original manuscript received 18 April 2003; revised manuscript
received 13 August 2003, accepted subject to revision 6 September
2003; final manuscript received 19 September 2003.
Reprint requests: Ilina Singh, EdD Centre for Family Research,
Faculty of Social and Political Sciences, University of Cambridge,
Free School Lane, Cambridge CB2 3RF, England. Email: iasingh@
msn.com

c 2003 President and Fellows of Harvard College
DOI: 10.1080/10673220390264221
nals each year. While the current emphasis on discovering
potential neurochemical and genetic correlates of ADHD of-
ten dictates a focus on the individual child or even the in-
dividual child’s brain, child psychiatry and psychology have
traditionally worked from a model of the child-in-context.1
Clinicians are usually well aware of the complicated com-
bination of factors that inhere in ADHD diagnoses. The
disorder has sparked public and intellectual controversy,
however, with regard to the relative weight of individual
(biological) versus contextual (environmental) causes of
symptomatic behaviors. In particular, parents’ contributions
to ADHD symptoms in children and to the escalating use
of methylphenidate (Ritalin) treatment have been actively
debated.2–5
The impact of parenting behaviors on children’s ADHD
behaviors has been investigated in the research litera-
ture using a design initiated in the 1970s by Barkley and
colleagues.6 Following several decades of studies based on
that design, prominent researchers have come to believe
that mothering behaviors are a consequence, not a cause,

308
Harv Rev Psychiatry
Volume 11, Number 6
of children’s behaviors.7 One remarkable feature of many
of these studies is the emphasis on mothers and sons. Even
when research descriptions and abstracts claim to investi-
gate parents and children, study populations often include
no fathers. This emphasis appears to reflect a consistent
gender bias in the ADHD literature. A recent search in the
PSYCHinfo database revealed that of the hundreds of arti-
cles related to families and children with ADHD published
since 1990, only 8% specified the inclusion of fathers and
only 3% specified the inclusion of fathers and girls. The
research emphasis on mothers and sons in the ADHD lit-
erature may reveal a lingering social scientific bias that
posits mother as a potential cause of behavioral problems
and psychiatric symptoms in her young son.8 The absence of
fathers is evident, however, not only in clinical research; in
my experience observing evaluations for ADHD in a hospital
clinic setting, there was ongoing concern among clinicians
about the lack of father presence in initial appointments and
also in follow-up appointments for ADHD referrals. Fathers
are largely absent from the major online support networks
for ADHD, and they are underrepresented in public educa-
tional/support forums for parents of children with ADHD.
For the last 50 years, even advertising campaigns for Ri-
talin and other drug treatments for ADHD have focused on
mothers and sons to the exclusion of fathers and girls (Singh
I, unpublished data).
The observation of father absences in areas related to
children with ADHD suggests two broadly related questions:
First, do fathers matter to the understanding and treat-
ment of children with ADHD? Second, why are fathers so
often absent from ADHD-related environments? Several as-
pects of the first question have been investigated empirically.
One such aspect concerns fathers’ responses to children’s
behavior—which have been shown to differ from mothers’
responses to children’s behavior. For example, maternal de-
pression has consistently been shown to be correlated with
behavioral problems in children, including ADHD.9 Moth-
ers of children with ADHD have higher depression scores
than fathers of ADHD children, whereas fathers of children
with ADHD do not have significantly different depression
ratings than fathers of children without ADHD.10 Although
both fathers and mothers display parenting-role distress
over children’s oppositional or aggressive behaviors, moth-
ers also display distress over the inattentive behaviors of
ADHD, whereas fathers do not.11
Aspects of fathering style may contribute to mothers’
and fathers’ differing experiences of children with ADHD.
Tallmadge and Barkley12 have reported an intriguing find-
ing: boys with ADHD are better behaved for their fathers
than for their mothers. There have been no empirical at-
tempts to replicate this finding. In another unexpected find-
ing, Hinshaw13 has found that a more authoritarian fa-
thering style may be related to more positive behavioral
Singh 309
outcomes in children. When fathers had critical, negative,
or hostile responses to their children’s problem behaviors,
the children demonstrated fewer antisocial behaviors to-
ward their peers than did children whose fathers had more
supportive parenting styles. Interestingly, fathers’ style of
parenting their ADHD children may be related to fathers’
role identification and degree of reported spousal love.14 Re-
searchers found that higher reported spousal love by fathers
was associated with less parenting laxness and less overre-
activity by fathers, while lower reported spousal love was
associated with more parenting laxness and more overre-
activity by fathers. In addition, fathers with above-average
traditional role identification tended to be more lax in their
fathering behaviors.
Research exploring the relationship between parenting
and children’s drug treatment suggests that fathers’ atti-
tudes may play a role in determining treatment outcomes.
In particular, low parenting efficacy in fathers, as well as fa-
thers’ attributions of noncompliance to the ADHD child’s in-
sufficient effort and bad mood, may be associated with worse
treatment outcomes.15 The ADHD child’s being treated with
drugs may also influence parents’ attributions for chil-
dren’s behaviors, particularly parents’ assessment of locus of
control.16,17 The literature on such attributions has tended,
however, either to focus on mothers or to combine mothers’
and fathers’ responses into a “parents” variable. Fathers’ po-
tentially unique perspectives have received little attention.
The few studies of ADHD that include fathers clearly sug-
gest that “mothering” should not be taken to represent “par-
enting” in the literature on ADHD; fathers and fathering
styles do have an impact on their children’s behaviors. More-
over, those behaviors have different implications for moth-
ers’ versus fathers’ psychological well-being.
As for the second question concerning the absence of
fathers in areas concerning their children with ADHD—
why are fathers so often absent from ADHD-related
environments?—Lawrence Diller18 notes that the psychol-
ogist Stephen Hinshaw’s extensive work among families of
children with ADHD has been largely limited to work with
mothers and children. In work related to an ADHD camp
run by Hinshaw and fellow researchers, it proved to be im-
possible to gather a statistically significant group of fathers;
as Diller notes, fathers “weren’t able to participate.”18 While
father absences in this and other ADHD-related venues may
result from various structural phenomena—such as gen-
dered family roles, work and travel schedules, and divorce—
it is also possible that there might be psychological and emo-
tional components to such absences. At present, however,
it is difficult to evaluate or even to identify such compo-
nents without knowing more about fathers’ perspectives on
ADHD.
In this article, results from in-depth interviews with
fathers of boys diagnosed with ADHD provide insights into

310 Singh
fathers’ perspectives on several related phases of ADHD
diagnosis and treatment: behavioral symptoms, diagnostic
process and outcome, and drug treatment. In particular, data
collection and analysis focused on three interrelated areas:
fathers’ experiences of children’s behaviors; fathers’ belief in
ADHD diagnosis; and fathers’ belief in drug treatment for
ADHD.
METHODS
The grounded theory method of qualitative research and
analysis was used to collect and analyze data for this study.
Grounded theory is used widely in sociology and is in-
creasingly used in psychology and in qualitative medical
research.19 The research question initiating a grounded
theory study is purposely broad and open, identifying the
phenomenon to be studied.20 In this study, the initial re-
search focus was mothers’ and fathers’ experiences with
ADHD diagnosis and methylphenidate treatment. “Theo-
retical sensitivity”—the researcher’s ability to understand
subtleties and nuances in the data—both initiates the re-
search study and guides coding, analysis, and further in-
terviewing strategies.21 In this study, theoretical sensitivity
was initially developed through historical research, exten-
sive literature review, participation in a variety of ADHD-
related forums (including clinical, educational, and Web-
based communities), and teaching in a K–12 school. In-
sight and understanding about the phenomenon in ques-
tion increased through early and continuous immersion in
the data, thereby allowing theoretical concepts, categories,
and relationships to “emerge” from the data.22 In the first
coding phase (“open coding”), a small community of coders
worked together to explore key themes and categories in the
data. This collaborative phase of data analysis and interpre-
tation was instrumental in two ways: the interviewer (that
is, the author) received feedback about the structure and
progress of the interview itself, and the collaborative process
helped to establish the validity of important categories and
codes.
Data Collection and Analysis
In the grounded theory approach, higher-order descrip-
tive and conceptual categories are developed systematically
through several analytical devices, including constantly
comparing data “incidents,” cases, and categories for concep-
tual similarities and differences (method of “constant com-
parison”). Theoretical memorandums further develop the re-
searcher’s theoretical sensitivity; they provide a means for
the researcher to reflect on the data and to enrich emerging
categories with examples from the data. Data collection and
analysis occur simultaneously, with the consequence that
data analysis can inform further data collection.
Harv Rev Psychiatry
November/December 2003
The following were key concepts emerging from early
interviews with fathers and mothers: experiences of chil-
dren’s behaviors, belief in ADHD diagnosis, and belief in
methylphenidate treatment. Analysis suggested two pri-
mary hypotheses: fathers had unique interpretive frame-
works for their sons’ behaviors, and fathers tended to be
skeptical of ADHD diagnosis and methylphenidate treat-
ment. These hypotheses were further tested and developed
through additional sampling and data analysis in a pro-
cess known as “theoretical sampling.” Sampling new data
on theoretical grounds extends the richness and scope of the
emerging theory and diversifies the data set.
The initial sample for this study was drawn from a pedi-
atric neurodevelopmental clinic within a university hospital
in Rhode Island. Twenty-two mothers and 12 fathers of boys
in the clinic were interviewed. Researchers in this study did
not participate in clinical work; the interviewer/principal
investigator observed evaluations and was invited to at-
tend some sessions in which results from children’s eval-
uations were discussed with families. Hypotheses emerging
from the data were discussed in informal conversations with
clinicians, but interview material specific to individuals was
not shared with clinicians. The clinic received a copy of the
study’s final report.
Since the clinic environment might constrain the di-
versity of parents’ experiences and also of their reports,
further sampling in this study reflected an effort to un-
derstand whether key concepts and developing hypotheses
would be relevant in a non-clinic-based sample. An addi-
tional 17 mothers and 10 fathers of boys with ADHD were
interviewed; participants were recruited from educational
conferences for ADHD, online support groups for ADHD,
and local schools. (The text box provides a summary pro-
file of study participants.) The main inclusion criterion for
all interviews was that parents’ sons had been taking med-
ication for a diagnosis of ADHD for at least three months
but not longer than one year. This time frame allowed for
medication effects to be established in children, and allowed
parents to have relatively fresh memories of their parent-
ing experiences prior to diagnosis. Informed consent was ob-
tained from all participants in the study, and institutional
review board approval was obtained for research conducted
within the clinic.
Interviews
Grounded theory invites researchers to develop questions
that take them “away from standard ways of thinking” and
that allow “exploration of other avenues of thought,” pro-
ducing “new insights” into the problem being examined.23
In order to encourage this same level of creativity in those
who participated in this study, open-ended, formal inter-
views were conducted using pictures chosen by participants
Harv Rev Psychiatry
Volume 11, Number 6
Demographic Information on Participants
Participants 39 mothers; 22 fathers
Age of sons From 7 to 12 years (average, 9.5)
Average length of time 5 months
on medication
Additional diagnoses Learning disability, 42%;
Asperger’s syndrome, 7%
Source of child’s Hospital-based clinic, 51%;
ADHD diagnosis pediatrician, 40%; private
clinic, 9%
Socioeconomic status∗ Lower-middle to middle income
Work status (mothers) 22 (56%) working full time
14 (36%) working part time
3 (8%) homemakers
Work status (fathers) 21 (96%) working full time
1 (5%) working part time
Range of job types Construction worker, dentist,
(fathers) electrical engineer, firefighter,
middle manager, plumber, shop
owner
Ethnicity (fathers) White
∗
Assessed using the four-factor Hollingshead index (see
Hollingshead AB. The four-factor index of social status [unpub-
lished manuscript, Yale University, 1978].)
from a standardized set of popular weekly and monthly mag-
azines. The set of magazines included People, Self, Sports
Illustrated, Woman’s Day, and Newsweek. Picture-oriented
interviewing has been used in medical research and in clin-
ical work in order to help participants feel in control of the
interview’s subject matter, to help them talk about difficult
emotions and experiences, and to enrich their verbal nar-
ratives with sensory memories and experiences.24–26 At the
beginning of the interviews, participants were asked to take
30 minutes to leaf through magazines and to collect pic-
tures in response to a broad question: How do you think
and feel about methylphenidate (or other psychostimulant)
treatment? Participants chose up to ten pictures and wrote
down associated ideas and themes. The subsequent inter-
views were organized around the pictures, beginning with
the participant’s explanation of how the picture was rele-
vant to the key question. In initial interviews, research notes
were made of key ideas, emotions, cognitions, phrases, vi-
sual images, metaphors, and story lines. During interviews,
participants were asked to elaborate on these elements—
which enabled the interviewer further to explore the ele-
ments and their importance for participants. As data collec-
tion progressed, interviews became increasingly focused on
exploring representative concepts and emerging hypotheses.
Every effort was made, however, to avoid suggesting partic-
ular topics for the participants to address. In addition, all
participants were asked whether there were important ideas
that they wanted to talk about, but for which they had been
Singh 311
unable to find a picture. Moreover, they were encouraged to
discuss additional thoughts and concerns that had not been
covered during the interviews.
Early interviews with mothers suggested a standard nar-
rative structure to their talk about experiences with stim-
ulant medication. When mothers were given the opportu-
nity to choose the order in which pictures were discussed,
they began with pictures that represented their experiences
of symptomatic behaviors, followed by others that repre-
sented the diagnostic process and diagnosis itself, followed
by still others that represented drug treatment. This narra-
tive structure has been called a “transformation narrative”
and is commonly found in experiences of medical diagnosis
and the ensuing treatment of illness.27
Subsequent interviews with both parents focused on
these three phases of ADHD diagnosis and treatment. It
soon became clear that the transformation-narrative struc-
ture was not always salient for fathers’ experiences. Fathers
tended to begin their interviews with their concerns about
drug treatment of their sons, and worked backward to dis-
cuss diagnosis and their sons’ behaviors. As discussed below,
some fathers were especially resistant to the before/after
framework implied by the transformation narrative. These
fathers did not see medical intervention as appropriate, and
they questioned the efficacy of drug treatment for their sons’
behaviors. Interviews and analysis therefore came to focus
on fathers’ complicated and conflicted feelings about med-
icalization of their sons’ behaviors, and on their attitudes
toward drug treatment for ADHD.
Interviews lasted between one and three hours, and were
audiotaped and transcribed. Many fathers initially felt that
they had little to say about their sons’ ADHD diagnoses and
drug treatment. The fathers’ reactions to the interviews var-
ied. A small number of them resisted the picture-gathering
step and found only a few pictures to represent their re-
sponses to the question. The majority of fathers, however,
found the pictures a helpful way to explore and to verbalize
their thoughts and feelings on the subject.
RESULTS
Fathers’ Experiences of Their Sons’ “Problem” Behaviors
Of the 22 fathers in this study, only 4 (18%) initially agreed
that their sons’ behaviors warranted medical attention.
Most fathers recognized that their sons were not well be-
haved; in particular, fathers noted that their sons did not fol-
low instructions, were falling behind and causing trouble at
school, and were socially awkward or isolated. Fathers’ pro-
posed explanations for these behaviors fell into three over-
lapping categories: indulgent mothering, boys’ lack of moti-
vation, and a “boys will be boys” rationale. An excerpt from
the interview with Ralph (both a composite and pseudonym,

312 Singh
like the other names of subjects in this article) illustrates the
first two categories of explanation.
If he’s interested, he’s motivated. . . . When you ask
him to do something, he just puts you off. “Oh yeah,
I forgot”—that’s what he’s always saying. . . . [His
mother] is soft on him. She babies him. I come down
the hardest. . . . I say, “This is what I expect, and if
you don’t do it, this is what you’re going to get, you
know.” He usually does it for me. He doesn’t get much
of that from his mother.
Another father presented the “boys will be boys” rationale:
I just thought he was—I had ants in my pants. I re-
member always being behind. It’s just the way it was
with me. I did crazy things as a kid. If you had tested
me, you’d probably find I had some form of ADD. So
I said to [my wife], “Don’t worry. He’s fine.” I just
figured [the boy] was the same as me. And I always
pulled it out when I had to. I figured he’d do the same.
Many fathers appeared to understand and even to sympa-
thize with their sons’ behaviors because they felt a strong
identification with those behaviors through memories of
their own boyhoods. Because the fathers had been able to
overcome or outgrow their boyhood excesses, they tended to
feel that their sons would also eventually overcome theirs.
As is clear from the second excerpt above, acceptance of a
medical framework for their sons’ behaviors would likely
lead fathers to have to interpret their own histories and boy-
hoods differently.
It is worth noting that several mothers interviewed sug-
gested that their husbands might have undiagnosed ADHD.
Fathers’ awareness of their wives’ suspicions were some-
times revealed during interviews. For example, one fa-
ther waited until the end of the interview—when the tape
recorder had been turned off—to ask in a casual and jok-
ing manner, “Can you tell—do I have symptoms? My wife is
always saying she thinks I have it.”
Fathers’ Experiences of ADHD Diagnosis and Drug
Treatment for Their Sons
Because fathers were rarely involved in the process through
which their sons had been diagnosed with ADHD, the fa-
thers’ narratives about diagnosis tended to overlap consider-
ably with their perceptions of drug treatment for their sons.
Only 7 of 22 fathers (32%) interviewed said that they had
contributed to the diagnostic process—for example, by fill-
ing out child behavior measures such as the Connors Child
Behavior Checklist, communicating with schools regarding
relevant forms and reports, and accompanying their chil-
dren at clinic or physician appointments. Since all fathers
were interviewed after their sons had begun drug treat-
ment, it was impossible to disaggregate perceptions of di-
Harv Rev Psychiatry
November/December 2003
agnosis from perceptions of drug treatment in this set of
interviews.
Fathers’ perspectives on diagnosis and drug treatment
can be categorized along two dimensions: “reluctant believ-
ers” and “tolerant nonbelievers.” Across these two dimen-
sions, several overlapping factors were relevant to fathers’
perspectives: resistance to a medical framework for under-
standing boys’ behaviors; identification with boys’ symp-
tomatic behaviors; and resistance to drug treatment for be-
havioral problems in boys.
Reluctant Believers
Of 22 fathers, 13 (59%) felt somewhat positively about drug
treatment for their sons. These fathers are categorized as
“reluctant believers” because they saw the positive effects of
drug treatment on their sons’ behaviors, while also contin-
uing to wonder whether their sons’ behaviors actually war-
ranted drug treatment. In general, this group of fathers was
uncomfortable with the idea of medicating sons for ambigu-
ously problematic behaviors, and they were skeptical as to
whether it was the drug that was making the difference in
the boys’ behaviors, or whether there were other plausible
explanations.
A prominent feature of reluctant-believer fathers was the
extent to which they saw drug treatment as a material rep-
resentation of their sons’ inherent difference from other boys
their age. Their narratives about drug treatment often high-
lighted their concerns about their sons’ inherent weakness,
interspersed with reflections about their own boyhoods and
genetic culpability. In the following excerpt from an inter-
view, we hear Rowan speaking about the picture that he
had chosen to represent his feelings about his son Patrick’s
drug treatment. In the picture a young man stands in the
foreground against a cityscape of several skyscrapers and
tall buildings, which are all white. He wears casual clothes,
all black, and gazes off into the distance with a pensive ex-
pression on his face. His arms are folded around him. The
young man was photographed in such a way that he appears
close to the viewer, almost in profile, with the buildings far
in the background. There is a large distance between the
young man and the skyscrapers, but there are no other peo-
ple in the picture. The effect is of a person alone in an empty,
impersonal landscape.
Rowan responded to this picture as follows:
This represents the medication, the Ritalin, kind of
the isolation, a feeling, a separate feeling, you know,
different, isolated. I know how he feels—I think it’s
my feelings toward how Patrick feels about himself,
being taken out of the classroom, you know, people
knowing or thinking about the Ritalin. . . . I felt bad
that he had something he was going to have to live
with for the rest of his life, that he wasn’t going to
Harv Rev Psychiatry
Volume 11, Number 6
be just brilliant without medication. . . . And I don’t
know. I don’t really know how much I believe that he
really needs the medication. Sometimes I think he’s
going to be fine and that he really doesn’t need it.
Rowan’s explication provides a good illustration of the three
overlapping factors in fathers’ perspectives on diagnosis and
treatment. While he accepted that Patrick “may not be bril-
liant without medication,” he did not completely accept a
medical framework for understanding his son’s behaviors,
and he wondered whether Patrick actually needed medica-
tion. Rowan also identified with his son; he projected feel-
ings of separateness and isolation onto Patrick from his own
memories of boyhood; and later in the interview, as the fol-
lowing excerpt illustrates, he clearly identified with Patrick’s
symptomatic behaviors.
You know I did it. I did those crazy things as a kid.
If I was diagnosed, I probably would have had some
form of ADHD. Yeah, I’m sure I would. . . . I think I’m
too geared up, too high strung or something. I don’t
know. I guess I look at it as some sort of failing in me.
I probably contributed to his heredity.
All reluctant-believer fathers mentioned their own boy-
hood histories and genetic ties to their sons’ behaviors at
some point during the interview. Their memories of them-
selves as boys were conflicted; the somewhat idealized mem-
ories of fun and mischief were colored by a concern that these
boyhood behaviors might betray the presence of pathology.
In the process of identifying with their sons’ disorders, fa-
thers tended to see their own behaviors in more pathologi-
cal terms, focusing on weakness and failure. At these times
during the interviews, it was difficult to tell whether fa-
thers were talking about themselves or their sons as they
described symptomatic behaviors. For example, after dis-
cussing the previous picture, Rowan turned to the following
one, along with its associated observations. In it, an older
man, somewhat heavyset, is standing, facing the viewer. The
man wears a flannel shirt and jeans. The man cradles a life-
size, naked, white crash dummy in the manner that one
might hold an older child, with one arm beneath the knees
and the other across the upper back. The picture is in black
and white. Crash dummies surround the man. The crash
dummies have the usual blank expression; the man looks
directly at the viewer with an expectant, hopeful, almost
vulnerable expression on his face.
Rowan: I guess this picture is how I sometimes
see Patrick—weak, maybe, because he
has the disorder and he takes Ritalin.
Interviewer: Can you tell me, the dummy represents
Patrick, right?
Rowan: Yeah.
Interviewer: Who is holding Patrick in this picture?
Rowan: I guess I am.
Singh 313
Interviewer: How does it feel to be the father holding
this boy?
Rowan: Heavy, it feels heavy, although he looks
pretty light, doesn’t he?
Interviewer: You mean the boy is heavy?
Rowan: Yes, he feels heavy, but maybe the fa-
ther is weak.
Reluctant-believer fathers tended to appear most accept-
ing of drug treatment for their sons when their sons’ athletic
or social success was at stake. Fathers’ resistance to medi-
cation and their concern about their sons’ “difference” were
clearly in conflict with their desire to have their sons per-
form well during athletic events. One father admitted that
he would give his son a dose of medication before games: “I
guess I see a difference in how he plays. He’s less impulsive,
doesn’t do wild stuff as much.” Watching their sons play,
reluctant-believer fathers felt embarrassed over their sons’
lack of control on the field, and struggled with their sense of
disappointment in these boys. As one father explained:
I get frustrated when he’s daydreaming on the
field. . . . I’m like, “You’re missing the whole game!” I’d
probably be proud if he was the best baseball player,
and he’s not going to be. So I have to think about
what the best is that he can do, and I have to live
with that.
Fathers’ desire to see their sons perform well in athletic
events can be seen as another aspect of fathers’ identification
with their sons’ behaviors. Athletic prowess is important to
the social status of boys and men. Many fathers in this group
admitted that they had had a desire as boys to be good ath-
letes, and several said that their lack of ability had been a
disappointment to their own fathers. In this sense, fathers’
struggles over the medicalization of their sons’ behaviors can
be understood as having psychological dimensions that are
rooted in family history as well as in contemporary events.
Tolerant Nonbelievers
Of 22 fathers, 6 (27%) could be categorized as “tolerant non-
believers” in ADHD diagnosis and drug treatment for their
sons. (The remaining 3 fathers could not be clearly cate-
gorized as “reluctant believers” or “tolerant nonbelievers.”
Following grounded theory, cases that do not fit are consid-
ered to require further analysis in order to determine the
likely conditions underlying the observed variation.) These 6
tolerant-nonbeliever fathers were not exactly negative about
drug treatment. They just did not believe that it was do-
ing very much for their sons or that the ADHD diagnosis
was a valid explanatory framework for their sons’ behav-
iors. Despite their extreme skepticism about diagnosis and
drug treatment, however, these fathers were, on the sur-
face, tolerant of both. They did not prevent the diagnos-
tic process from going forward, and they did not interfere

314 Singh
with their sons’ use of medication. Both mothers and fathers
reported, however, that some fathers were not told that their
sons were scheduled for an ADHD evaluation until after the
boys had been diagnosed. Mothers who withheld this infor-
mation from fathers tended to be worried that fathers would
not allow the evaluation to proceed.
Fathers in the tolerant-nonbeliever group were clearly re-
sistant not only to a medical framework for understanding
their sons’ behaviors, but to drug treatment. The most im-
portant factor in their analysis of their sons’ symptomatic
behaviors was a close identification with those very behav-
iors. These fathers held fast to the alternative explanatory
narrative for those behaviors—which has been character-
ized above as “boys will be boys.” Fathers’ identification
with these behaviors was not overtly characterized by the
sense of shame and guilt found in the reluctant-believer
group.
Tolerant-nonbeliever fathers tended to be part of a family
structure in which parents’ gender roles were more rigidly
defined and mothers were viewed as largely responsible for
decisions relating to the children. Most of the fathers in this
group could not say how long their sons had been taking
medication for ADHD, or how the daily dosing worked. Only
one father had attended an ADHD-related medical appoint-
ment. All fathers in this group agreed to be interviewed only
after strong encouragement from their wives. Some of these
fathers mentioned several times before and during the inter-
view that they did not know much about their sons’ diagnosis
and medication.
In view of the above differences in parental roles, one
explanation for these fathers’ tolerance of ADHD diagnosis
and drug treatment for their sons might be that they had
delegated responsibility for such issues to their wives. As
Bob said:
I agreed to this medication because I respect the opin-
ion of my wife. She spends much more time with
Joseph than I do, so she was seeing things that she
thought might be helped with the medication. But I
don’t really think he needs it. It is true that he’s more
wound up; he has trouble paying attention at school.
But my wife comes from a family of all girls, and she
doesn’t have the experience with boys that I do. You
know, boys will be boys. . . . My boys are all boy—they
like sports and running around. My tolerance level
for Joseph is a lot stronger than my wife’s.
Fathers like Bob were apparently able to compartmentalize
their own interpretation of their sons’ behaviors and to es-
tablish an objective distance from the pathologizing message
of medication. Bob was even able to characterize Joseph’s
impulsive behaviors during athletic events as part of being
“all boy.” Although Bob mentioned later in the interview that
Joseph was “ridiculously bad” at sports, Bob had no desire to
medicate his son for games. In general, though invested in
Harv Rev Psychiatry
November/December 2003
their sons’ athletic ability, tolerant-nonbeliever fathers did
not demonstrate an increased interest in medicating their
sons for participation in sports.
If an awareness of the more negative aspects of their iden-
tification with their sons’ behaviors came through in inter-
views with this group of fathers, it could be found in their
jokes. For example, Bob broke abruptly out of our conversa-
tion to ask: “Hey, did she [his wife] tell you I had ADHD?
[Laughs] [Pause] Just kidding.” Fathers’ jokes revealed that
they did know something about ADHD. They knew that the
medical narrative of explanation included a story of a ge-
netic link between father and son. And they knew that their
wives might suspect them of having ADHD. Whereas fathers
in the reluctant-believer group were able to express their
concerns about medicalization of their sons’ behaviors and
possible genetic ties more directly, fathers in the tolerant-
nonbeliever group seemed to find it more difficult to voice
their personal anxieties and vulnerabilities in relation to a
medical-genetic formulation of their sons’ behaviors.
DISCUSSION
Father Absences in the Clinic
The results of this study point to the importance of fathers’
perspectives on ADHD symptoms, diagnosis, and drug treat-
ment in the clinical setting. In particular, when fathers’
input is not encouraged in the clinic, fathers’ explanatory
narratives for their sons’ behaviors are overlooked by the
process of medical diagnosis and drug treatment of their
sons’ behaviors. As a consequence, possibly alternative per-
spectives on boys’ “problem” behaviors are not seriously at-
tended to as part of clinical evaluations, and the clinical pic-
tures of children referred for ADHD evaluations are more
likely to be incomplete.
In any effort to bring fathers into the process of ADHD
diagnosis and treatment, it must be remembered that med-
icalization potentially contradicts fathers’ understanding of
their sons and of their own boyhoods. Participation in the
medical process thus brings with it the risk of confrontation
between the father’s authority and medical authority, and
also the risk of exposing vulnerabilities rooted in fathers’
personal histories, genes, and self-understandings. Fathers’
reluctance to participate in their sons’ medical process might
therefore be part of a defensive stance that allows fathers’
own explanatory narratives of their sons’ behaviors to re-
main authoritative within the family. Such a stance, how-
ever, may undercut what medical professionals, mothers,
and sons have achieved, or are attempting to achieve, in
the way of diagnosis and treatment.
In view of increasing concerns about rising rates of ADHD
diagnosis and of treatment with stimulant medications—
and especially in view of sometimes superficial diagnostic
Harv Rev Psychiatry
Volume 11, Number 6
procedures and inadequate follow-up of children on
medication—fathers’ alternative perspectives on their sons’
behaviors should serve as an additional and important cau-
tionary note for clinicians considering diagnoses of ADHD.
As fathers’ perspectives are brought into the clinical process,
however, every effort should be made to resist seeing fathers’
alternative explanatory narratives of boys’ behaviors as sim-
ply another piece of evidence to support a genetic theory of
ADHD. While genes may tell part of the story of ADHD, fa-
thers’ memories of boyhood remind us that environmental
factors play a large role in determining how behaviors are
perceived, measured, and labeled.
Fathers’ Silences at Home
Once their sons had begun taking medication, both
reluctant-believer and tolerant-nonbeliever fathers infre-
quently discussed their alternative perspectives with their
wives. Fathers in both groups remarked that they had not
discussed with family members or friends their own feelings
of personal vulnerability in relation to their sons’ ADHD
diagnosis and drug treatment. Fathers’ perspectives were
therefore often absent in the clinic and largely unspoken at
home.
The psychological and emotional components that poten-
tially underlie and explain fathers’ absences in the clinic
and silences at home become clearer when fathers’ perspec-
tives are viewed in a domestic context. Mothers and fathers
in this study tended to differ significantly in their expe-
riences of sons’ symptomatic behaviors, ADHD diagnosis,
and drug treatment.28 Mothers, for example, had no expe-
rience of close identification with their sons’ behaviors, and
they tended to dismiss their husbands’ “boys will be boys”
explanatory narrative. While many mothers continued to
worry about the decision to medicate their sons, all mothers
in this study believed in the medical explanation for their
sons’ behaviors. In fact, fathers’ alternative understanding
of the reasons for boys’ problematic behaviors—which in-
cluded indulgent mothering in many cases—was deeply dis-
tressing to mothers and sometimes created problems in the
marriage.
There are, potentially, important psychological implica-
tions to fathers’ unspoken concerns about medicalization.
Fathers’ feelings of personal failure and weakness, disap-
pointment in their sons and in themselves, and tacit knowl-
edge of their wives’ suspicions regarding their husbands’
own potential pathology are likely to have an impact on
fathers’ self-esteem, the marital relationship, and the re-
lationship between father and son. As Maccoby29 and others
have shown, group status and authority are important as-
pects of boys’ and men’s socialization processes, and make a
difference to self-perceptions and self-esteem. It is not sur-
prising that fathers generally reported that they did not dis-
Singh 315
cuss their sons’ diagnoses and drug treatment with friends
or family outside the home. This reluctance to reveal their
sons’ difficulties to others meant that fathers did not usually
have the opportunity—even outside the home—to unburden
themselves of their concerns.
It is important to note, however, that there may also be
positive aspects to fathers’ silences. Research on fathering
consistently shows that the quality of the marital relation-
ship is a strong predictor of fathers’ emotional well-being,
their involvement in child care, and the quality of their rela-
tionships with their children.30 It may be that fathers seek to
preserve their marital relationships by burying their skep-
ticism about diagnosis and medication—particularly after
they see the benefit for their wives of medicalizing their sons’
behaviors. It may even be that in thus maintaining marital
harmony, fathers’ silences also protect their relationships to,
and interactions with, their sons.
Limitations
A primary objective in this paper was to allow fathers’ own
narratives to inform an understanding of fathers’ perspec-
tives on symptomatic behaviors, ADHD diagnosis, and drug
treatment in sons. It is hoped that this study, grounded in
a psychosocial method and theoretical approach, can make
a contribution to clinical thinking and practice. Several lim-
itations to the study should be noted. Qualitative studies
are not designed either to produce specific, generalizable
findings or to exactly replicate other research findings.31 In-
depth interview studies investigate individual experiences,
and these experiences are contextualized in the group of par-
ticipants as a whole; in this way an understanding of inter-
nal reliability and validity is achieved. While an effort was
made to include a diversity of perspectives in this study,
participants were relatively homogeneous with respect to
ethnicity, socioeconomic status, and geographic location. In
addition, all participants in this study were interviewed only
after their sons had begun treatment. It is possible that real-
time accounts of symptomatic behaviors and diagnostic pro-
cedures would differ from the retrospective perspectives pro-
vided in this study. Much might be gained from a pre- and
postdiagnosis study design that combined interviews with
direct observation of family dynamics.
There is also a question of whether a larger sample may
have disclosed further diversity in the viewpoints and at-
titudes identified in this particular study, and whether it
may also have changed our understanding of the categories
that emerged. For example, how does one explain the ap-
parent association between lack of desire to participate in
the study and the category of tolerant-nonbeliever fathers?
Further sampling might provide insight into this category
or enable us to move beyond it to a fuller understanding
(e.g., if such sampling disclosed that there were tolerant

316 Singh
nonbelievers who were nonetheless eager to participate in
the study, or if it became apparent that the categorization
of some fathers as tolerant nonbelievers was itself merely
a function of these fathers’ inability to refuse their wives’
requests that they participate in this study).
Findings from this study must therefore be seen as
preliminary. As an initial investigation into an under-
researched area, however, the study raises important ques-
tions about the implications of father absences in ar-
eas related to ADHD, and suggests directions for further
research.
The author thanks Martin Richards and three anonymous review-
ers for helpful comments on a previous draft of this paper, and ex-
tends special thanks to the families who agreed to participate in
this study.
REFERENCES
1. Bronfenbrenner U. The ecology of cognitive development: re-
search models and fugitive findings. In: Wozniak RH, Fischer
KW, eds. Acting and thinking in specific environments. Hills-
dale, NJ: Erlbaum, 1993:3–44.
2. Breggin PR. Talking back to Ritalin. Monroe, ME: Common
Courage Press, 1998.
3. DeGrandpre RJ. Ritalin nation. New York: Norton, 1999.
4. Hancock L. Mother’s little helper. Newsweek 1996 (18
March):51–6.
5. International Narcotics Control Board. Use of methylphenidate
for the treatment of attention deficit disorder. In: Report of the
International Narcotics Control Board for 1995. UN Doc. No.
E/INCB/1995/1:§II.B.4. [http://www.incb.org/e/ar/1995/menu.
htm]
6. Cunningham CE, Barkley RA. The interactions of normal and
hyperactive children with their mothers in free play and struc-
tured tasks. Child Dev 1979;50:217–24.
7. Barkley RA. The effects of methylphenidate on the interactions
of preschool ADHD children with their mothers. J Am Academy
Child Adolesc Psychiatry 1988;27:336–41.
8. Singh I. Bad boys, good mothers and the ‘miracle’ of Ritalin.
Science in Context 2002;15:577–603.
9. Cunningham CE, Benness BB, Siegel LS. Family functioning,
time allocation, and parental depression in the families of nor-
mal and ADDH children. J Clin Child Psychol 1988;17:169–77.
10. Brown RT, Pancini JN. Perceived family functioning, marital
status, and depression in parents of boys with attention deficit
disorder. J Learn Disabil 1989;22:581–7.
11. Podolski C-L, Nigg JT. Parent stress and coping in relation to
child ADHD severity and associated child disruptive behavior
problems. J Clin Child Psychol 2001;30:503–13.
12. Tallmadge JM, Barkley RA. The interactions of hyperactive and
normal boys with their fathers and mothers. J Abnorm Child
Psychol 1983;11:565–80.
View publication stats
Harv Rev Psychiatry
November/December 2003
13. Hinshaw SP, Zupan BA, Simmel C, Nigg JT, Melnick SM. Peer
status in boys with and without attention-deficit hyperactivity
disorder: predictions from overt and covert antisocial behavior,
social isolation, and authoritative parenting beliefs. Child Dev
1997;64:880–96.
14. Arnold EH, O’Leary S, Edwards G. Father involvement and
self-reported parenting of children with attention deficit-
hyperactivity disorder. J Abnorm Child Psychol 1997;22:247–
65.
15. Hoza B, Owens JS, Pelham WE, Swanson JM, Conners CK,
Hinshaw SP, et al. Parent cognitions as predictors of child treat-
ment response in attention-deficit/hyperactivity disorder. J Ab-
norm Child Psychol 2000;28:569–83.
16. Johnston C, Leung DW. Effects of medication, behavioral and
combined treatments on parents’ and children’s attributions for
the behavior of children with attention-deficit hyperactivity dis-
order. J Consult Clin Psychol 2001;69:67–76.
17. Johnston C, Fine S, Weiss M, Weiss J, Weiss G, Freeman WS.
Effects of stimulant medication treatment on mothers’ and
children’s attributions for the behavior of children with at-
tention deficit hyperactivity disorder. J Abnorm Child Psychol
2000;28:371–82.
18. Diller LH. Running on Ritalin. New York: Bantam, 1998.
19. Henwood KL, Pidgeon N. Grounded theory in psychological re-
search. In: Camic PM, Rhodes JE, Yardley L, eds. Qualitative
research in psychology: expanding perspectives in methodology
and design. Washington, DC: American Psychological Associa-
tion, 2003:131–57.
20. Strauss A, Corbin J. Basics of qualitative research: grounded
theory procedures and techniques. London: Sage, 1990.
21. Glaser BG. Theoretical sensitivity: advances in the methodology
of grounded theory. Mill Valley, CA: Sociology, 1978.
22. Strauss A, Corbin J. Basics of qualitative research. 2nd ed.
London: Sage, 1998.
23. Strauss A, Corbin J. Basics of qualitative research. London:
Sage, 1990.
24. Clark CD. Childhood imagination in the face of chronic ill-
ness. In: de Rivera J, Sarbin TR, eds. Believed-in imaginings.
Washington, DC: American Psychological Association, 1998:87–
100.
25. Gerace H. Using family photographs to explore life cycle
changes. Nurs Healthc 1989;10:245–9.
26. Weiser J. Phototherapy techniques. San Francisco: Jossey-Bass,
1993.
27. Mattingly C. Healing dramas and clinical plots: the narra-
tive structure of experience. Cambridge: Cambridge University
Press, 1998.
28. Singh I. Doing their jobs: mothering with Ritalin in a culture of
mother-blame. Soc Sci Med (in press).
29. Maccoby EE. The two sexes: growing up apart, coming together.
Cambridge: Harvard University/Belknap Press, 1998.
30. Parke RD. Fatherhood. Cambridge: Harvard University Press,
1996.
31. Creswell JW. Research design: qualitative and quantitative ap-
proaches. Thousand Oaks, CA: Sage, 1994.