Contemp Fam Ther (2014) 36:260–280

DOI 10.1007/s10591-013-9288-9

ORIGINAL PAPER

‘‘There is Something not Quite Right with Brad…’’: The

Ways in Which Families Construct ADHD Before
Receiving a Diagnosis

Ruth Lewis-Morton • Rudi Dallos • Lynn McClelland •

Rachel Clempson

Published online: 26 September 2013

 Springer Science+Business Media New York 2013

Abstract This study explored how four families who were in the midst of the process of a
potential diagnosis of ‘Attention Deficit Hyperactivity Disorder’ (ADHD) for their child
negotiated competing explanations of the problems. The research drew on a social con-
structionist, systemic and attachment lens to understand; (a) the constellations of meanings
that are constructed by the families to explain the difficulties and (b) how families use
strategies in their talk to account for or contest these constellations of meaning. A discursive
analysis revealed that the families in this study, following initial explorations, adopted a
sequential and cumulative dismissal of psychosocial explanations. Hence, the thrust of the
conversation implicitly added up to the only possibility, the inevitable conclusion that it was
ADHD. The malleability and flexibility in which the families explored these explanations
varied and for some families the process of closure towards ‘illness’ as a dominant expla-
nation sealed alternative conversations more than in others. The findings also revealed a
complexity for the parents in balancing the need to offer discipline versus another response
and this has clinical implications and highlights the need for further research in this area.

Keywords ADHD
Attachment
Systemic
Discursive analysis

Introduction

The DSM-V (APA 2013) provides a classification system to distinguish whether or not a
child or young person ‘has’ Attention Deficit Hyperactivity Disorder (ADHD). However, it
does not provide a contextual basis from which to understand the behaviour displayed or

R. Lewis-Morton (&)
R. Dallos

Plymouth University, Administration Office, 4th Floor, Rolle Building, Drake Circus,
Plymouth PL4 8AA, UK
e-mail: ruth.lewis@plymouth.ac.uk

L. McClelland
R. Clempson
Torbay CAMHS, 187 Newton Road, Torquay, UK

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the reasons why the child or family may be experiencing difficulties. The difficulties
typically involve a mixture of behavioural and emotional problems, with the child being
seen as behaving in highly active and disruptive ways. Such behaviours include struggling
to focus their attention, acting aggressively or impulsively, and striving to calm down and
regulate their feelings. The categorisation of ADHD as a ‘neurodevelopmental disorder’
(NICE 2008) has caused much contention and a number of authors have demonstrated that
social, cultural and relational factors are often dismissed by assuming a purely biological
perspective (Timimi et al. 2004; Asherton et al. 2010).
A number of studies have drawn upon psychological theory in an attempt to formulate
and understand difficulties from a range of perspectives, rather than assuming a diagnosis
of ADHD as a manifestation of a biological ‘impairment’ (Vetere and Cooper 2005;
Marvin 2009; Dallos et al. 2012). Psychosocial models have been used to explain ADHD
and central to this understanding is a recognition that behaviour is learnt and is related to
how emotions are managed in family settings (Nylund 2002). Difficulties children present
with appear to be behavioural but also highly influenced by emotional processes. Hence,
this paper will attend to the emotional and attachment processes that may be contributory
to the formation and maintenance of ADHD.

Family Interactions and Attachment Relationships

Recent approaches have integrated both systemic and attachment perspectives to provide a
framework for contextualising and understanding ADHD (Crittenden and Kulbotten 2007;
Vetere and Cooper 2005; Dallos et al. 2012; Dallos and Smart 2011; Marvin 2009). An
exploration of attachment interactions within the family system facilitates our understanding
of the intricate and complex requirement for co-regulation of arousal between child and
caregiver and the potential behavioural and emotional consequences if this is not established.
According to Crittenden and Kulbotten (2007), ADHD is a manifestation of a combi-
nation of strategies used in order for children to get their attachment needs met. Children
use strategies to raise or lower arousal, signal need to care-givers and elicit feelings and
responses from them accordingly. Contrary to the commonly held view that lack of focus
on school work is a symptom of ADHD, Crittenden and Kulbotten (2007) considered
inattention to be a side-effect of a self-protective strategy namely, hypervigilence/scanning
the environment. The greater the focus on engaging in strategies that promote attachment
needs or survival, the less attention is focused on school work or peer relationships.
A relational model has been suggested in the context of domestic violence where Vetere
and Cooper (2005) suggest that when parents are frightened or frightening they are likely
to find it harder to be mindful of their children and may be ‘volatile or inconsistent in their
caring responses’ (Vetere and Cooper 2005 p. 77). The child’s signs of distress may not be
recognised and the child may be in a contradictory position whereby they seek comfort and
security from their parents and yet they cannot trust their parents’ response. They are
therefore likely to be restricted in their ability to explore and they are unlikely to learn how
to regulate their own emotions in a constructive way. Consequently, the inability to seek
safety may be expressed as constantly moving about and an inability to stay still for long;
this is often thought to be a key feature or symptom of ADHD (Vetere and Cooper 2005).
Marvin (2009) argued that difficulties reside in the relationship between the child and their
parent/care-giver rather than solely within the child. To illustrate the importance of the rela-
tionship, Marvin (2009) referred to the process of the parent supporting the child to regulate
their own emotions. If the child was not supported in their emotional regulation, they would

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find it difficult to understand and regulate intense or difficult feelings. Thus, they would be
more likely to engage in behaviour that the parent may find difficult to manage, such as an
inability to sit still. Dallos and Smart (2011) emphasised the importance of considering
attachment needs in terms of triadic configurations rather than solely dyadic processes. They
also highlighted the complexity of difficulties labelled ADHD and the importance of under-
standing these difficulties as being between people rather than residing within one person. For
example, they refer to triangulation, or being stuck between people, and the emotional cost this
can have on a child. In their study, they allude to very different parenting styles displayed by the
mother and step-father and the extent to which the mother felt that her son needed love and
sympathy, versus the step-father’s view that he needed discipline and containment.
Similarly, Dallos et al. (2012) referred to ADHD as a complex interplay of family
dynamics and attachment strategies. They found that a child’s actions within a family
could be viewed as ‘naughty’ and requiring a disciplinary response or, as an indication of
distress and frustration, requiring an attachment response of emotional containment and
comfort. Their study highlighted a mismatch in the attachment response given to a child in
that at times, the parent responded with discipline whereas a comforting or attachment
response was required. Hill et al. (2011) made reference to ‘domain-specific’ responses or
‘shared interpretative frameworks’ to demonstrate the meaning a family makes of their
difficulties and the attachment response they provide. For all parents, a central task is to
keep their children safe, offer emotional support and also to help prepare them for entry
into the external world. This inevitably involves conflicts in regulating aspects of a child’s
behaviour in terms of offering guidance and discipline but also of offering emotional
warmth and care (Hill et al. 2011). This is a delicate balance to achieve and parents need to
differentiate between when a child is ‘naughty’ as opposed to needing care and affection.

Families Constructions of ADHD

Relatively few studies have explored the ways in which families construct and make sense of
difficulties, particularly in relation to a diagnosis of ADHD. Dallos and Hamilton-Brown
(2000) interviewed families during the initial stages of the development of difficulties whilst
their perceptions were still relatively malleable and their difficulties were not fixed on a
particular explanatory model. However, the families’ beliefs still appeared to be shaped and
constrained by prevalent societal discourses of the problems as indicative of an ‘illness’,
possibly ADHD. The social construction of mental health and its social role in society has been
explored by Scheff’s (1974) labelling theory which includes the idea that the initial range of
alternative explanations can show a drift towards ‘closure’ as a label becomes established.
More recently, Gale (2010) has attempted to explore the moment-to-moment construction
of meaning within families by examining the use of discursive analysis (conversational
analysis and discourse analysis) as a social constructionist framework for understanding
clinical discourse. This approach to examining discourse is likely to be beneficial in exploring
how families negotiate meaning at an early stage in problem development as it provides a
close exploration of interactions between family members. It also encourages an exploration
of relational positioning (Davies and Harre 1990), which analyses how a participant may
position him/herself or another in order to resist dominant discourses, be seen favourably or
create alternative subject positions (Gale 2010). These processes are key in understanding
how families talk about difficulties together before a diagnosis.
Dallos et al. (2012) used a similar approach to examining discourse and revealed that
the family in their study both endorsed and contested a biological/medical explanation for
ADHD. The family referred to similarities of appearance between son and father, which

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were construed as implying similarities in their temperament and sparked discussion about
the extent to which he was following in his father’s footsteps. They also contested the
medical discourse through highlighting that inheritance comes from both parents and
maintaining that no simple causal connection could be made between difficulties experi-
enced. There was also a discourse about the son having ‘something odd’ about him that had
required an earlier diagnosis that had led to problems at school, hence, placing the diffi-
culty within the child. Family members adopted different positions to explain his actions
and his step-father and brother also emphasised self-determination and responsibility for
his actions so that the boy could chose to act differently and was not just driven by
biological factors. This study highlighted the ways in which families talk about their
difficulties and how this talk contributes towards the ‘meaning-making’ process and the
construction of ADHD.
There appears to be a significant gap in the literature, namely, the limited research
considering the ways families talk about, negotiate or construct difficulties before having
received ADHD as a medical diagnosis. A few studies have adopted a systemic, attachment
and social constructionist lens to explore the ways in which families talk about and con-
struct ADHD (Dallos et al. 2012; Dallos and Smart 2011), though, it is hypothesised that
prior to receiving a medical diagnosis, families may be more flexible in their approach to
discussing difficulties and use talk to explore a range of potential factors.

Aims of the Study

This study aims to explore the ways in which families create meanings for a range of
problems that might be regarded as constituting ADHD. In particular, the focus was on
how family members engage in conversation before a diagnosis has been given but where
the possibility of a diagnosis is pending. This is a ‘not knowing’ period in which possi-
bilities other than a medical diagnosis are still possible and hence the meaning-making
process is still more malleable.
The aims centred on an exploration of (a) the constellations of meanings that are
constructed by the families to explain the difficulties and (b) how families use strategies in
their talk to account for or contest these constellations of meaning.

Method

Design

A qualitative design was chosen to explore the processes by which children and their
families talk about, construct and make sense of difficulties prior to receiving a diagnosis
of ADHD. Families were invited to participate in order that this period of uncertainty and
meaning-making could be explored. The study employed semi-structured interviews to
engage families in discussions about their difficulties.

Families in this Study

Four families took part in the current study. All names have been anonymised. None of the
children had received a diagnosis of ADHD but had been referred to Child and Adolescent
Mental Health Service (CAMHS) for an assessment.

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1. Adam (aged 9) and Mum (Jill)

2. Callum (aged 7), Mum (Nerys), Dad (Graham) and sisters (Maria and Karen)
3. James (aged 6) and Mum (Kari)
4. Brad (aged 10), Mum (Tilly) and Step-Dad (Owen)
Two families (with female children) agreed to meet with the researcher in the first
instance but later cancelled their appointment and decided not to participate.

Recruitment Process

Families of children/young people (aged 6–18) who had been referred to CAMHS for an
ADHD assessment were invited to take part in this study. The nurse responsible for the
assessment at CAMHS was involved in the recruitment of participants. The recruitment
phase lasted for eight months (between July 2012–February 2013). An extended period of
time was required for the recruitment phase due to the relatively limited time between
referral to CAMHS, the assessment process and diagnosis leaving a restricted time frame
for the family interviews with the researcher.

Procedure

The interview process focused on engaging the family in discussions through the use of a
semi-structured interview lasting for 60 minute. The families were invited to talk about
how they understand their difficulties, how they have managed the difficulties and how
they balance the need for comfort and support with discipline. Although the researcher was
involved in the interview process with the family, a conscious effort was made to
encourage the participants to engage in discussion as a family to allow interpersonal
strategies and processes by which the families engage in talk about difficulties to be
revealed. Following the interview, the family was contacted by telephone within a month
of the meeting and a member of the family was asked to verify key themes arising from the
interview. This enabled a corroboration of the interview themes and an opportunity for the
family member to add any further information if required.

Service Receiver and Carer Involvement

This study has been developed with input and support provided by the DClinPsy Service
Receiver and Carer Consultative Group (SRCCG). The group helped to shape and hone the
ideas of the researcher to produce a project informed by people who have experience
accessing services. A significant focus of this project was to access the voices of children
and young people following a suggestion made by members of the SRCCG who reflected
that children’s voices are often excluded from research.

Ethical Considerations

This study gained ethical approval from the Cornwall and Plymouth NHS Research Ethics
Committee. All participants were provided with relevant information to enable them to
give informed consent prior to participation. All participants involved in this study pro-
vided written consent and were made aware of the procedures and policies to ensure
confidentiality and anonymity of data.

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Method of Analysis

Discursive analysis was employed as it focuses on how language is used to construct

meaning within relationships. This approach is compatible with a systemic framework in
that it focuses both on the process of meaning construction as well as the content of what
meanings are constructed and how these recursively shape each other (Gale 2010). Dis-
cursive analysis incorporates both discourse analysis and conversational analysis (Avdi and
Georgaca 2007; Potter and Wetherall 1987; Wetherall et al. 2001) to enable examination of
interaction with a focus on linguistic features of talk whilst also drawing on how strategies,
accountability and relational positioning are negotiated within families (Gale 2010; Davies
and Harre 1990). Recent publications have demonstrated the benefit of using discursive
analysis within a systemic framework and these papers have been drawn upon in order to
inform the use of this analysis for the current study (Gale 2010; Crix et al. 2012; Dallos
et al. 2012). The discursive analysis was subsequently focused on the key features of
responsibility and accountability.

Process of Analysis

The process by which the data analysis procedure was carried out in this study was as
follows:
1. Interviews conducted and transcribed
2. Repeated reading and re-reading to produce coding—this included highlighting of
relevant conceptualizations, explanations and conversational strategies based on
research questions
3. Identification of discourse themes—this was an inductive process which attempted to
identify constellations of areas of meaning making in each of the families regarding
the difficulties. The analysis then attempted to find shared themes which were common
to the families. An iterative analysis of the text to validate/disconfirm the themes to
produce a final set of discursive themes along with examples of conversational extracts
4. Identification of discursive processes—within each theme and also running across
them was an attempt to identify the strategies relating to how the particular
constellations of meanings, e.g. that ADHD is an ‘illness’ were put forward, supported
and contested by family members
5. Quality assurance and member validation process—validation of themes with other
researchers/supervisor and verification of key research themes with interviewees.

Quality Assurance

Anonymised data transcripts were shared with a fellow researcher and research supervisor
who supported the process by offering a triangulation of the data. A collaborative dis-
cussion of the themes emergent in the data and an iterative process of reading and re-
reading the data enhanced the reliability and validity of the analysis. Bracketing interviews
were used.

Member Validation

Family members were not directly involved in analysis or a formal member validation
process, largely due to the nature of discursive analysis whereby the process is

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interpretative and assumes the participant is unaware of the subconscious process by which
language is constructing meaning (Avdi and Georgaca 2007). However, the researcher
telephoned family members approximately one month following the interview and they
were asked to corroborate key themes arising in the interview and were invited to include
any further information if they felt they wanted to. Each of the family members verified the
key themes and were in agreement with the information and themes captured. This process
enabled families to correct the researcher’s interpretation of information shared and
therefore enhance the quality and reliability of the research process.

Findings

The interviews indicated that in the families, the parents organised their conversations
around a number of constellations of provisional explanations of the problems. A variety of
explanations were considered and formed arenas for contested conversations. The expla-
nations provided by the families have been clustered into key discursive themes and sub-
themes. Within these themes, the families employed a number of discursive strategies.
The strategies tended to coincide with the discursive theme/sub-theme the families were
referring to, for example, whilst talking about family relationships and dynamics, the
strategies employed by the families included a ‘minimisation of problems at home’ and
‘comparison with siblings’. Central to this process was a strategy of supporting an ADHD
explanation by implication in terms of undermining the validity of evidence counter to an
‘illness’ model. The possibility that problems were psychosocial/relational in nature was
curtailed and hence this bolstered the claim that the difficulties must be therefore explained
through an ‘illness’ framework.
Although the strategies were used to support and marshal evidence for the constellations
of meaning constructed by families (discursive themes/sub-themes), the strategies were not
confined or constrained to particular themes and were actually employed at other times
throughout the interview as can be seen in the qualitative extracts (Table 1).
Each discursive theme/sub-theme will be presented with quotes from the interviews to
illustrate how the strategies were employed to support or contest their potential implications.

Psychosocial Explanations

The following themes capture how the accumulation of evidence towards ADHD was
constructed in the families. Each of the families demonstrated different levels of ‘mal-
leability’ in their exploration of difficulties.

Family Dynamics: Minimising Problems at Home

Within the family dynamics sub-theme, there were two key strategies used to provide
evidence in support of an ‘illness’ model. The first was through a minimisation of the
problems at home and as can be seen in the following extracts, this was both corroborated
and contested by family members.
Extract 1. Adam and Mum
R: The next question is for both of you, it’s about any difficulties or things you have
found tough, so I wonder whether both of you could let me know when you noticed things
being tough?

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Table 1 Summary of the key discursive themes and strategies employed by families
Discursive themes Sub-themes Strategies

Psycho-social a. Family Sequential and cumulative dismissal of ‘other’ possibilities

explanations dynamics through a minimisation of problems at home and making
comparisons with siblings thus undermining the validity of
evidence counter to an illness model
b. The school Through adopting a ‘lovely’ teacher discourse it reduces the
context probability that the problems are related to school and therefore
bolsters the claim that the difficulties are more likely related to
an ‘illness’ model
c. Child’s Contesting the parents’ dismissal of relational difficulties
voice
Discipline versus e. Self- Negotiation of child’s self-responsibility for ‘naughty’ behaviour
other response responsibility versus lack of responsibility due to an ‘illness’ explanation
Biological/genetic f. Genetic Biology and genes as an unequivocal explanation to resolve the
explanations inheritance dilemmas arising from psycho-social explanations

A: umm
M: Can you remember which teacher you were with when you started to get a little bit
A: hmm Mrs Harrister
M: no I think it was before then
A: na it was Mrs Harrister
M: na because remember you had some tests before then with Mrs Cochrane, do you
remember?
A: ohhh Mrs Cockroach
M: yes haha
A: haha
M: she’s a lovely teacher hehe
A: (ahhh)
M: s::o at home, it’s been (.5) it’s not difficult at home, behaviour wise and that he’s a
good boy (.8) it’s just that he’s very hyperactive, so as long as you know how to deal
with that errm and you know he’s got boundaries so you know it’s okay but obviously at
school and that with his concentration and focus um (.5) that he just can’t handle it at all
(.5) um so it was with Mrs Cochrane wasn’t it and you were getting behind a little bit
weren’t you with your reading and things like that…
This discussion about difficulties is immediately positioned around school as Adam and
his mother negotiate which teacher he was with when the difficulties were first noticed. A
number of strategies are used in order to minimise the possibility that the difficulties are
related to problems at home. Adam’s mother positions herself as being a ‘good’ and
‘competent’ mother by highlighting her ability to deal with hyperactivity by saying ‘as
long as you know how to deal with that’. She also implies that the difficulty resides within
Adam and she emphasises the extent of the problem by saying ‘he just can’t handle it at
all’. Their discussion proceeded with reference to discipline.
M: Mrs Cochrane was really good with him and she thought that (.5) she shouted at him
but it wasn’t working so we thought of a different solution to not shout at him ‘cause it
just won’t help
R: what happens when people shout?

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A: I get really really stressed ((not making eye contact))

R: yea yea
M: it’s not just you darlin’ that’s everybody, especially if you don’t understand that
you’ve done something wrong what’s going on
R: ye::ah
M: um
R: so so these are difficulties noticed in school what about any difficulties at home?
A: uhh when Simon shouts at me
R: when Simon shouts
A: ((nods))
A discipline discourse is introduced at the start of this extract by Adam’s mother who
confirms that a solution is to ‘not shout at him ‘cause it just won’t help’, by implication this
suggests that something else must be going on and this is not just ‘naughty’ behaviour. This
is emphasised when she appears to draw upon an ‘illness’ model in explanation for Adam’s
feelings of stress, ‘you don’t understand that you’ve done something wrong’. This positions
the problem within Adam whilst also acknowledging he has no responsibility for it, hence
suggesting it must be medical or ‘illness’ related as there appears to be no other expla-
nation. The construction of the ‘problem’ evolves in the second part of this extract and
shifts from a problem at school to a potential difficulty at home. Adam introduces the
notion that difficulties may be relational in nature and connected to his relationship with
his step-dad, in doing this he contests his mother’s dismissal of other possibilities and
introduces a relational perspective.
In the following extract Brad’s mother and step-dad use language to demonstrate a
relatively flexible approach in their discussion of difficulties. Brad’s mother begins by
minimising the difficulties at home and suggesting difficulties began at nursery.
Extract 2. Brad, Mum and Step-Dad
M: u::mm well when we’ve discussed it, we’ve discussed Brad’s development a lot
recently and the only thing that Brad wa::s, right up until about the age of 3, was really,
really, extremely well behaved like this angel child hahaha
SD: hahahaha
M: like an exceptionally good toddler
R: so very well behaved
M: yea::h (0.5) and then [ he kinda went to nursery school and it all changed \ ha ha
bless him
R: so something changed around that time?
M: yeah I mean he just started
SD: well we got together when he was 3 didn’t we?
M: yeah we got together when he was 3 so we thought it was the change in
circumstances and things that maybe affected him but yeah he just started doing silly
things like he weed on the floor and silly things that he just wouldn’t have done in the
past
SD: yeah
Brad’s mother uses language to construct an image of Brad as ‘really, really, extremely
well behaved… like this angel child’. She indicates that the problem didn’t exist prior to
school and then ‘it all changed…bless him’. The use of ‘bless him’ may indicate that the
problem was within him or was imposed upon him without it being within his control or
responsibility. Through implication, Brad’s mother’s suggestion that all was well before

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nursery and it having changed when he started nursery strongly suggests that the problem
began at school rather than home. However, step-dad contests the original suggestion made
by Brad’s mother and proposes a potentially different explanation and moves the focus to a
more relational perspective, ‘well we got together when he was 3 didn’t we?’. Brad’s
mother appears to accept this change in discourse and explores the ‘change in circum-
stances’ or divorce as a potential consideration for the change in behaviour they observed.
Within both of these families, the mother has, in her talk, accumulated evidence to
demonstrate that prior to starting school there were no problems at home. This highlights
the requirement, as a mother, to avert blame or accountability and this is central to their
negotiation of difficulties more broadly and likewise this informs decisions about how to
respond to the behaviour observed. Adam’s mother highlighted that they first noticed
problems at school and Brad’s mother describes him as an ‘angel child’ before nursery.
Adam contests this in the first extract and step-dad in the second and this highlights the
malleability of their exploration at this relatively early stage of negotiation of difficulties.

Family Dynamics: Comparison with Siblings

The attempt to eliminate family, relational and attachment factors as relevant to the
problems was also achieved through the strategy of making comparisons with siblings.
This consisted of the proposition that since the siblings shared the same environment there
was no reason why one should show ADHD type problems and the other not unless one
had some fundamental organic, biologically based illness. The following extracts illustrate
how this was achieved within the families.
Extract 3. Brad, Mum and Step-Dad
M: I suppose with my other kids, Callum and Matthew, I had them young but I put
everything into it and I thought these are really lovely kids you know and always invited
to birthday parties, getting on great at school, they’re really popular and everybody
loves them and they’re really nice kids [ and then Brad came along and changed that
mould \ and I thought where have I gone wrong, I must have done something, so that’s
what you think something has happened here, what have I done.
R: yeah.. just wondering how you are both doing?
SD: yeah
M: uh I feel a bit emotional actually (0.5) but I’m fine (1.0) if I go just ignore me (0.5)
haha ((became tearful))
During this extract, the mother positions Brad’s siblings as ‘lovely kids’ and ‘everybody
loves them’ this serves a function in that it highlights that there must be something fun-
damentally different about Brad who ‘changed the mould’. It also offers a support or buffer
for Brad’s mother as she explores a relational perspective and considers ‘where have I gone
wrong’. The malleability of Brad’s family’s exploration and ability to consider relational
perspectives becomes apparent during this extract.
Adam’s mother also explores a potential psychosocial explanation during the sub-
sequent extract.
Extract 4. Adam and Mum
M: I’m not sure to be honest because (.) when you have two children you look at them
both and they’re completely, totally, totally different and I think about the fact that [ he
was only two when Keith and I split up and Colin was eight and did that have an
impact \ ? But then I think about them having been looked after by their grandparents

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growing up and they have both had that and also that Keith and I have always got on
even you know before I met Simon we were on our own for five years weren’t we? But we
always got on even when we were both single and we’ve always taken it in turns to look
after the boys and everything and there is nothing different between them so I am not
quite sure really and I can’t say I know
R: it is sometimes really difficult to know
M: and we’ve talked about medication haven’t we Adam and it’s been suggested and
we’ve decided to make that decision together when we’re faced with it and we’ve
thought about anything else that could help because it would only be a last resort really
but it would only be for at school because at home we’re alright aren’t we?
Adam’s mother begins this extract by highlighting the difference between her two sons.
She alludes to the separation from her husband and poses a question about whether it has
had an impact on Adam. This demonstrates a flexibility in her exploration, though she
quickly averts blame by emphasising that both siblings had been looked after by grand-
parents and her and Keith had always got on. She appears to draw upon an ‘illness’ model
during the second part of this extract and emphasises that if Adam was to take medication
it would be for school only. This serves as confirmation that things are okay at home and
hence weakens the evidence in support of a psychosocial explanation whilst strengthening
the ‘illness’ explanation.

School Context: ‘Lovely’ Teacher Discourse

The excerpt below further exemplifies how dismissal of alternatives operated through
framing the school context as positive and supportive. In the passage below, the teacher is
described by the mother as a ‘lovely/good’ teacher which appears to add to the mounting
evidence to support or justify ADHD as an ‘illness’ since the school context was positive
and there was little that could have caused such problems in the child.
Extract 5. Adam & Mum
M: u::m he enjoys school as in socialising and meeting your friends you miss them don’t
you when you’re not at school but work wise you really struggle don’t you?
A: I get really stressed with it and just don’t do it
M: yeah it’s hard isn’t it and that was even [ way way back \ when you had Mrs Soot
a::nd
A: yeah she was nice
M: she was a lovely teacher wasn’t she and that was in yea::r
A: year one
M: that was in
A: year 1, year 2, year 3, year 4
M: that’s where you are now you’ve struggled a bit haven’t you
A: ((nods))
In this extract, Adam emphasises the extent to which he feels stressed and his mother
confirms that this happened ‘even way way back when you had Mrs Soot’, this constructs
the problem as being long-standing and emphasises that even with ‘lovely’ teachers the
problem exists. By implication, this extract of talk bolsters the claim that the problem
exists despite the teacher being ‘lovely’, hence, there must be something fundamentally
‘wrong’ with Adam.

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Callum’s parents also engage in a similar process whereby they acknowledge how good
the teachers have been.
Extract 6. Callum & Family (K = sister)
M:…and pointed him out straight away and that was tha::t, it all started from school
R: from school
D: yeah
M: he was in year 1
D: it was fortuitous because the (.5) when he was a little one the teacher was very good,
Mrs Good she was called actually…
M: it was not Mrs Good, he’s got Mrs Good now
K: yeah
M: Ms Legg
D: Ms Legg, oh yes that’s right yes, oh Gosh, my memory frame is terrible
M: hahaha
D: Ms Legg, she was very very good and um, uh I think Callum and Ms Legg were, they
had sort of a:: very good communication together and they got on very well together
M: he’s been very lucky because he has had [D: excellent teachers yeah] yeah and he
has a teacher now called Mrs Good [D: yeah she’s very good] yeah
During this extract, Callum’s family position the teachers as ‘very very good’ this
removes any potential blame from the school context and adds to the accumulation of
evidence in support of an ‘illness’ model by suppressing other potential avenues of
exploration.

Child’s Voice

The children, at times, contest their parents’ explanations of the problems. In the following
extract, Adam contests his Mother’s position and explores a relational explanation, dem-
onstrating his dissatisfaction with his relationship with his Step-father.
Extract 7. Adam and Mum
M: …and then we have to calm everything down and we try not to shout at you but
sometimes it’s hard isn’t it?
A: (.) um next time Mum can you tell Simon [Step-father] to stop saying shut up to me
M: I know but sometimes it is difficult isn’t it
A: well he kept he kept on saying shut up to me so I said shut up to him and then he
started having a go at me
M: I know I know (.5) we’ve just got to try and keep everything calm(.5) It sounds like
you don’t get on very well with Simon
A: shakes head
M: do you not?
A: I don’t Mum
M: really?
A: NO I don’t at all
M: Oh right
A: hmm
M: oh hahah that is news to me! Oh right then (2.0)
R: so maybe coming here today?
M: it’s a reve^lation (.) do you really not get on with Simon?

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A: I don’t
M: (2.0) ahh (2.0) okay, are you sure you don’t?
A: I’m SURE
During this extract, Adam’s mother attempts to position herself as a ‘good’ parent by
talking about her ability to ‘calm everything down’. However, Adam contests this position
as he refers to difficulties that appear to reside within family relationships. Adam’s mother
finds it difficult to accept that Adam may not get along with Simon, she uses phrases such
as ‘do you not?’ and ‘that is news to me!’ to indicate this. Overall, this extract highlights
the ways in which language is used to uphold a position of ‘good’ mother and how difficult
it is for the mother to accept when this position is threatened by her son who implies that
there are relational difficulties. Systemically, it illustrates the complexities of negotiating
the role of mother and providing care and guidance for a child whilst also developing a
meaningful relationship with a new partner.

Discipline Versus Other Response

All of the families, particularly the mothers, emphasised the complexity of striking a
balance between offering discipline versus some other response to their child. This relates
to a central concern of discursive analysis which is how people require each other to
account for, and take responsibility for their actions. The following extracts illustrate how
the issues of responsibility were negotiated in the families.

Self-Responsibility: ‘Illness’ Versus ‘Naughtiness’

Extract 8. James and Mum

R: I mean, how do you, as a Mum, balance the need to comfort and support with the need
to offer discipline…
M: with James?
R: yeah
M: OH that is the most hardest thing ever (.5) that is so hard and I think about that every
day yeah I don’t want him to be I want him to know right from wrong, [ I can’t be
wrapping him up in cotton wool and say \ aw it’s because of aw he doesn’t like me
shouting you know and so you know I am not (.4) I am a human being you know I am not
a robot sometimes I do shout [R: yeah] and I have to go into another room and sit down
and just I have got to and he could be screaming or doing whatever and I think I just
have to totally shut off ‘cause I think I am going to go mad in a minute (.5) that is the
hardest thing out of all of it especially when you are with people who don’t know
R: hm
J: ((background noise whilst playing with toys))
M: and you’re out in the supermarket or in public and people are looking at me you
know and I get very protective of my son because they are looking at my son as if he is
really naughty you know and I am trying my hardest to do my best and it’s like (.4) you
know what do you want him to have a big sign on his head? (1.0) You know and they
say [ oh he doesn’t look like he’s got \ well what do you expect him to look like? Like
he has two heads?
James’ mother immediately positions herself as being in a ‘hard’ role. She moves from
seeing James’ behaviour as ‘naughty’ and needing discipline to know ‘right from wrong’ to
a position where James could be ‘screaming or doing whatever’. This emphasises the

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complexity of the problem as well as demonstrating how hard it is for her to negotiate
whether James has responsibility for the behaviour displayed. This negotiation is central to
the role of a parent in determining accountability for behaviour and hence the response
required, for example, discipline versus an attachment response. James’ mother alludes to
the fine balance between ‘naughtiness’ and ‘illness’ in her reference to other people in
public who may say ‘oh he doesn’t look like he’s got’ and she appears to recognise this as a
challenge to an ‘illness’ based model but confirms that James does not have self-respon-
sibility for his behaviour. Residing in this position appears to alleviate blame from the
mother and from James. James’ mother presents the complexities of this negotiation
(‘naughtiness’ versus ‘illness’) whilst also highlighting the critical role of wider societal
discourse in making assumptions about children’s behaviour.
Brad’s parents also highlight the complexities of identifying the reason for Brad’s
behaviour and responding in a way that meets his discipline and attachment needs.
Extract 9. Brad and family
M: ye::ah well see for us now we’ve just done a behavioural management course which
has given us a major back up because I think before this we were kind of [ running
around like head-less chickens \ not really knowing what to do ‘cause (SD: yeah yeah)
if he was really really upset and I would think OH MY GOD you are really
upset although he would be angry and smashing his room up and you would actually
think you are re::ally upset and I would try to cuddle him and he would be like push me
away and call me (.5) and then you kind of think oh, fine then, you know if that’s (.5) I’ll
leave you to it but it’s but then one of us would go up and stop him smashing his room up
you know (.5) sorry what were you going to say
SD: yeah I think you know like what you’ve said we would try different ways of
disciplining him with rewards and things like that you know but now with this
M: I think we didn’t know what we were doing because the things we did with the other
children and even with Maisie it didn’t work (.5) and with Brad it wouldn’t work and you
would keep coming up against each other all the time and as horrible as it sounds, it’s
really hard when a child’s being like he is (.5) I’m guna go again, I’m sorry ((became
tearful))
This extract highlights how emotionally demanding the parental role is. Brad’s mother
describes running around like ‘headless chickens’ suggesting that before the behavioural
management course they did not know what to do. She then moves to an understanding that
although Brad may be displaying anger and ‘smashing his room up’, he could actually be
‘really really upset’. Brad’s mother negotiates the extent to which Brad should be held
accountable for his actions and this fine balance informs her response to him. She refers to
her attempts to comfort and soothe Brad by trying to ‘cuddle him’ though his pushing away
appears to halt her attempt to comfort and both parents move into a discipline domain by
suggesting they then ‘stop him smashing up his room’ or ‘try different ways of disciplining
him with rewards and things like that’. Brad’s mother emphasises the problem by high-
lighting that, with their other children, their parenting worked, but with Brad ‘you would
keep coming up against each other all the time’. This potentially suggests a domain
mismatch whereby Brad may be operating from a position of emotional dyregulation and
requiring an attachment response, though when his mother offers this it is rejected and a
disciplined response is then offered which is unlikely to meet Brad’s attachment needs.
The following extract refers to a potential conflict within the family regarding the extent
to which family members view Callum’s behaviour as being related to ‘illness’ versus

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‘naughtiness’. Callum’s mother refers to strategies learnt at a behavioural management

course for parents of children with or suspected to have ADHD.
Extract 10. Callum and family
M: It depends what the actual item is which is the problem and then yes we would have
to (1.0) come down with it (.5) with Callum (2.0) trying to get the girls to [ actually
understand \ that you don’t jump down his throat on every item that (.5) important
items yes:: you do the counting and that’s 1 it carries on that’s 2 carries on that’s 3, five
minutes out yeah? And um (2.0) that’s fine but it’s getting them to actually understand
that (.5) you know if he’s been naughty doing something but if he is picking his nose, you
ignore the picking his nose and do the things which you feel is the most awful thing
K: Hhhh
M: and needs sorting out and we just have to slowly work that out you know but both of
them find that very difficult don’t you?
D: well it’s completely different way than you’ve had all your life
K: no
M: ((looks at Karen))
K: well I don’t
M: OK well you explain then how you feel
K: well when he’s naughty I tell him off
M: but we don’t you know
K: OH CALLUM (.5) you stink!
M: hahahha (2.0) um they won’t do the 1,2,3
K: UM I did do it
M: did you?
K: yeah yesterday (.5) Callum was being really naughty
M: it was probably when I wasn’t here and Graham was at work
K: yeah
M: hmm that’s good well done
K: NO [ ‘cause he carried on doing it\
M: well then did you tell him five minutes out?
K: no (.5) I kept warning him
C: uh:: she only got up until 2
K: yeah but you got millions of warnings before that
M: you see that’s that’s the wrong way of doing it that’s why it didn’t work (1.0)
Callum’s mother begins this extract with an acknowledgement that discipline does need
to be used by saying ‘we would have to come down with it’, though she balances this
statement by saying she tries to get Callum’s sisters to understand that you ‘don’t jump
down his throat on every item’. She directs her talk towards her daughters and emphasises
the complexity of achieving the ‘correct’ approach. Karen states that ‘when he is naughty I
tell him off’, though her mother replies to this by saying ‘but we don’t you know’. Callum’s
mother engages in a discussion about negotiating accountability, which appears to inform
whether or not the behaviour is viewed as ‘naughty’ or related to ‘illness’ and hence
informs the response given. The mother appears to dispute Callum’s position of being a
‘naughty’ boy as suggested by his sisters and instead appears to suggest this is not
deliberate ‘naughty’ behaviour but something which requires a specific, measured
behavioural response. Callum’s mother continues to hold this position and when Karen
suggests that Callum was being ‘really naughty’, the mother confirms that this was when ‘I
wasn’t here and Graham [Dad] was at work’. This not only indicates that Callum is not

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naughty for his parents but also, as demonstrated by her subsequent response, it indicates
that Karen’s disciplinary approach is ‘the wrong way of doing it that’s why it didn’t work’.
This bolsters the claim that it is not deliberate ‘naughty’ behaviour and therefore typical
disciplinary approaches will not work. However, responses learnt from a behavioural
management course for children with ADHD will work which, by implication, confirms
this must be ADHD.

Biological/Genetic Explanations

The strategies used by families to accumulate and marshal evidence in support of a bio-
logical/genetic origin was achieved by rejecting other possible explanations. These dis-
cussions appeared to act as a resolving of the psychosocial dilemmas, for example, it was a
strategy by which to confirm that although the psychosocial explanations had been
explored, the biological/genetic explanations sealed these conversations by offering a
resolution overall.

Genetic Inheritance: ‘Resolving the Psychosocial Dilemmas’

The two extracts presented below demonstrate an explicit attempt to make connections
with a genetic basis for the difficulties. This has been achieved by referring to other family
members who appear to have had similar difficulties as well recognising the impact of
genetics in other areas, such as appearance.
Extract 11. Callum & family
M: I mean the environment doesn’t seem to affect any of us because it doesn’t seem to
(.8) what is it (.5) nature or nurture
R: so you’re saying you think nature or genes has most influence over nurture?
M: yeah so it’s really weird and the other weirdest thing is that u::m your father’s
brother ((looks at Karen)) is the spitting image aren’t they of you and Maria
During this extract, Callum’s mother states that ‘the environment doesn’t seem to affect
any of us’, this immediately suggests that genes or nature is the key influence within their
family, thus implying that the difficulties experienced or ADHD are related to genetic
factors primarily. The mother refers to family members as being the ‘spitting image’ of
each other, hence strengthening her argument in support of genetic factors.
The subsequent passage illustrates an example of the mother’s attempt to position
herself as having had similar difficulties as Callum. This supports the assumption that the
difficulties are genetic in nature.
M: I had the concentration problem
D: and like Maria (.8) she can’t do some of the exams and stuff whereas I love exams
R: right
M: I need blinkers, total quietness more than anything else, I’ve definitely got signs of it
u::m I had to go to an extra special school and certain afternoons when I got to middle
school [ because they said I had u::h um dyslexic\
K: yeah but you still ha::ve anyway
M: but then there is loads of different other things ‘cause, I was premature, they always
put everything down to that (.5) I was a month premature and they always put everything
down to that but I don’t know, I don’t know if I had the ADHD because literally there’s
lots of things there [D: well it wasn’t thought of then was it] and I honestly still get

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terrible problems with the noise and I am trying to read and it’s like in a foreign
language when there is distractions
During this exchange, Callum’s mother moves through a variety of different positions,
initially she claims to have ‘had the concentration problem’, she follows this by saying she
may have had dyslexia, she explores the possibility of these difficulties being connected to
being premature and she appears to sum up her exploration by claiming to not know
whether she had ‘ADHD’ or not. This movement between different hypotheses might
suggest that the mother is unsure how to position herself in relation to ADHD. She seems
desperate to make sense of where it may have come from and provides evidence to
demonstrate her struggles. Dad appears to provide potential justification as to why Cal-
lum’s mother didn’t receive a diagnosis by saying ‘well it wasn’t thought of then’ which
may bolster the claim that Callum has inherited ADHD.
In the extract below, Adam’s mother also entertains the idea of a genetic inheritance of
‘ADHD’.
Extract 12. Adam & Mum
M: …and um we thought first of all ‘cause Daddy’s dyslexic isn’t he? (.5) um and Daddy
always struggled at school didn’t he so we thought we had better better get you checked
really so he had some tests when he was in year two and um (.5) they weren’t conclusive
they couldn’t decide could they whether there was anything more going on or not really
because he was too you^ng um
The mother makes links with Adam’s biological father and invites Adam to join with
her in a discussion about it, ‘Daddy’s dyslexic isn’t he?’ and ‘Daddy always struggled at
school’. This passage introduces the possibility of a genetic discourse, which may serve to
alleviate blame from the mother and bolster the claim that the problem exists. She also
introduces the notion that the teacher who was ‘really good’ with Adam has tried discipline
but it does not work. This statement may serve to demonstrate further that the problem is
likely to be biologically based hence the strategies and discipline not working.

Discussion

Key Findings

The main explorations in this study included (a) the constellations of meanings that are
constructed by the families to explain the difficulties and (b) how families use strategies in
their talk to account for, or contest these constellations of meaning. The findings also
illustrate a central concern of accountability in the families to demonstrate their position as
competent parents and to highlight that although there may have been difficulties these
have been managed and no longer pose a problem. Therefore, by implication, it was
suggested that the difficulties observed must reside within the child rather than being
related to a more systemic explanation. This process was not overt, though central to this
was a sequential and cumulative dismissal of other possibilities hence, the strategies
identified may subsequently lead towards the explanation that there is only one remaining
possibility, the conclusion that it was ADHD. The malleability and flexibility in which the
families explored these explanations varied and for some families the process of a potential
closure towards an individual or ‘ADHD’ based explanation sealed alternative conversa-
tions more than in others. The strategies used by family members to illustrate this were

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both corroborated and contested by other family members. Finally, the recourse to an
explanation whereby the problems reside within the child may serve as a function to
resolve the tensions and emotions triggered by the exploration of the relational and psy-
chosocial explanations.

Explorations Prior to a Diagnosis

All of the families in the study were investigative in their style and explored a range of
potential explanations. It appeared that Brad’s family, more so than the other families in
the study, were able to talk about relational and psychosocial explanations, though they
also appeared to resolve dilemmas by promoting the child as the focus of the problem. The
malleability of the families’ explorations at an early stage in problem development sup-
ports previous findings (Dallos and Hamilton-Brown 2000), which have highlighted the
role of prevalent medical or societal discourses of distress in closing down alternative
explanations. This raises important clinical implications regarding the enablement of
family explorations and attempting to avoid a drift towards ‘closure’ or ‘pathologising’ at a
critical period of problem development (Scheff 1974).

Balancing Discipline and Attachment Needs

The findings complement the family domains approach in highlighting the dilemmas in
accountability that parents face (Hill et al. 2011; Gale 2010). The central concern within
the families was to negotiate the responsibility and accountability held by the child and
themselves as parents, this is compatible with a discursive analysis approach. Given that
the parents struggle to understand the problems in psychosocial and relational terms it is
therefore not clear what balance of discipline and affection is most appropriate. The
parents in this study highlight the complexities of achieving this balance. Given uncer-
tainty regarding this balance, it is possible to see that parents may become ‘frozen’ in
responding and fail to meet the child’s attachment needs or to provide adequate guidance
and control. The ‘illness’ model therefore is very seductive with its promise of a quick fix
through medication. However, a broader issue is not simply whether the ‘illness’ model is
correct or not but, most importantly, the role of attachment and discipline responses needs
to remain on the agenda for parents. However, we have also seen, consistent with previous
studies (Dallos et al. 2012; Dallos and Hamilton-Brown 2000) that the ‘illness’ discourse
helps to resolve the potential conflictual tensions that family dynamics, problems at school
and parenting evoke for families.

Systemic Issues

One of the key intentions of this study was to enable children’s voices to be heard along
with their families. However, the findings revealed that this is a complex process in
research and in the conversational space of the families. For example, Adam contested his
mother’s explanations that all was well at home. With regards to his statement that he did
not get on with his step-father, we can see a triadic process in which the mother felt caught
in the middle. She needed to balance the relationship between her son and her partner and a
family dynamics explanation would mean confronting these relational difficulties. This
confrontation of relational difficulties could involve a risk for the mother in that she may
alienate her partner by voicing concern about his role with her son or alternatively dismiss

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her son’s concerns and risk affecting their relationship. It seems understandable that a
solution to this triadic dilemma is to support an ‘illness’ model, though the temptation to
accept this framework for understanding can silence children’s voices. This may also
connect with why some of the children appeared not to want to take part in the interviews,
perhaps feeling that they might be exposed to blame, framed as ‘ill’, but perhaps above all,
as in Adam’s example, not listened to and their views discounted. More broadly, this
highlights a parallel process whereby children’s voices may not be well heard within
clinical services and it raises questions about the impact of a medical discourse of ADHD
within our society more generally.

Clinical Implications

This study raises important clinical observations.

1. At the early stages of families’ negotiation of the problems, there was an active
exploration of a range of possibilities. This is likely to be due to a relatively limited
input from medical professionals and hence, a less fixed framework from which to
understand the difficulties. Clinically, it is important to recognise that families come to
services having been exposed to discourses about ADHD or mental health within
society. As a clinician, it is important to both validate a family’s experience whilst also
encouraging an exploration of a range of factors not purely based upon the medical
model.
2. Parents have salient concerns about their ability to manage and respond to their child’s
behaviour with a disciplined versus a comforting response. The families appeared to
emphasise the complexity of recognising their child’s communication and responding
in a manner that would diffuse or resolve the difficulties. Although the families
reported benefit in attending the behavioural management course there is also
potentially a requirement for an attachment-based understanding of the struggles the
parents are faced with in managing emotional dysregulation in their children. An
awareness of how and when to offer an attachment response versus discipline is an
important aspect of managing difficulties.

Further Research

It would be interesting and clinically relevant to extend the current study by meeting with
families before a diagnosis as well as following a decision about whether or not the child
receives a diagnosis of ADHD in order to observe how the explanations explored and the
strategies used by families may be different at these different stages. There is still further
scope to explore the ways in which families negotiate the balance in offering a discipline
versus an attachment response and whether families who accept relational explanations
feel more or less able to respond to their child’s attachment needs. Further explorations
such as this could help to inform clinical services and further support families at the early
stages of difficulties.

Conclusion

Very few studies, if any, have adopted a social constructionist, systemic and attachment
perspective in order to explore the ways in which families talk about and construct ADHD

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before a diagnosis. In this study, families were accumulating evidence to construct ADHD,
though they were exploratory in their approach and did not appear to have subjugated all
explanations besides an ‘illness’ model. The study illustrates the importance of meeting
with families at an early stage and validating their experiences but also enabling an
exploration of a range of factors. The process of exploration may be less evident following
an actual diagnosis whereby contemplation of other factors or a need to justify a medical
understanding becomes unnecessary. The study also highlighted the need for further
support for families who experience difficulties, with a specific focus on interpreting and
understanding attachment-based needs and offering a balance of comfort and support with
discipline and guidance.

Acknowledgments The authors appreciate the helpful and insightful comments of Jacqui Stedmon, Arlene
Vetere and the anonymous reviewers.

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