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Childrens Sense of Self in Relation to Clinical

Processes: Portraits of Pharmaceutical

Transformation

Elizabeth Carpenter-Song

This article presents in-depth accounts of pharmaceutical transformation from the perspective of two

children diagnosed with behavioral and emotional disorders. These portraits provide the basis for an

examination of the complex interrelation between self and clinical processes. Narrative data were col-

lected in the context of a 13-month anthropological study of the lived experiences of children diagnosed

with behavioral and emotional disorders and their families living in the northeastern United States.

Participating families (N520) were from diverse racial/ethnic (African American, Euro-American, and

Latino) and socioeconomic backgrounds. Psychiatric diagnoses and pharmaceuticals present tangible

constraints in the lives of children that call attention to otherwise fluid and ephemeral self processes.

These accounts suggest that psychiatric diagnoses and psychotropic medications present dilemmas for

childrens developing sense of self, revealing limitations to biopsychiatric pharmaceutical promises.

[children, self processes, subjective experience, psychiatric disorder, pharmaceuticals]

I cant handle my own self without

the medicine handlin me.

F12-year-old African American boy

Understanding the impact of illness and clinical treatments on persons is an enduring

interest within social studies of medicine. In this article I examine how psychiatric disorders

and pharmaceutical interventions shape childrens subjective experience. I present the

experience-near accounts of two children diagnosed with behavioral and emotional disor-

ders to illuminate how alterations of self processes, including behavior, emotion, andcognition, through pharmaceutical technologies facilitate transformations in childrens

sense of self.

In a classic formulation of the sick role Parsons (1951) theorized changes individuals un-

dergo as a consequence of illness and medical treatment. This original formulation spawned

decades of subsequent research seeking to delineate behaviors associated with illness

(Mechanic 1962; Suchman 1965; Kasl and Cobb 1966a, 1966b); document variations in how

sick roles are adopted (Twaddle 1969); and examine ethnic, cultural, and class variations in

illness behavior and help seeking (Gordon 1966; Koos 1954; McBroom 1970; Zborowski

Journal of the Society for

Psychological Anthropology

PORTRAITS OF PHARMACEUTICAL TRANSFORMATION 257

ETHOS, Vol. 37, Issue 3, pp. 257281, ISSN 0091-2131 online ISSN 1548-1352. & 2009 by the American AnthropologicalAssociation. All rights reserved. DOI: 10.1111/j.1548-1352.2009.01053.x.


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1952; Zola 1966). From an anthropological perspective, the Parsonian tradition is limited

by its focus on an ideal type.1Although the analysis facilitates examination of intertwined

individual and clinical processes during treatment, it leaves unaddressed the matter of

everyday lived experience.

Recognizing this theoretical and methodological gap, Conrad (1990) has contrasted out-

sider perspectives, including sick role, illness behavior, and sickness career, with insider

perspectives on the experience of illness. The former approach, in Conrads view, tends to

train analysis on institutional encounters, providerpatient interactions, and patienthood.

But, as Conrad observes, individuals with chronic illnesses spend little of their lives as

patients in clinical settings. As a result, he advocates a focus on the subjective experience and

management of illness in the context of peoples everyday lives. Attending to the ways in

which individuals and families navigate through clinical interventions in their lives is onlypossible by engaging with the always distinctive character of local moral worlds that

encompass illness related distress (Kleinman 1988:5, 1995).

In contrast to a beliefs and behaviors theoretical orientation, experiential approaches

center instead on questions of meanings and experiences (Good 1994:5; Good and Good

1981, 1982). This reflects a sea change in culture theory more generally toward lived expe-

rience, individual agency, and intersubjectivity (Jenkins and Barrett 2004:78). Kleinmans

(1988)Illness Narrativesis exemplary in its engagement with personal and cultural meanings

associated with illness and the bodily experience of suffering. Here, the inadequacy of amodel such as Parsonss (1951) is fully revealed. Self and illness cannot be parsed; one does

not don the role of patient and just as easily cast it aside. An orientation to experience en-

gages the immediacy of pain, shame, hope, and fear as constitutive elements in the landscape

of chronic conditions.

The experiential approach that I adopt in this article aligns with recent theoretical concerns

with subjectivity (Jenkins and Barrett 2004) reflecting a growing recognition of the need to

engage simultaneously with inner psychological states as well as institutional, political, and

economic structures of power. In this vein, Good and colleagues argue that, subjectivitydenotes a set of critical issues for anthropologists working in contemporary societies, issues

different than those raised by classic studies of self, or person and emotion (Good et al.

2007:2). Specifically, the conceptual landscape of subjects and subjectivity impels consider-

ation of the dynamics of power in ways that studies of self and personhood do not (cf. Good

et al. 2007; Biehl et al. 2007). A highly elastic category, subjectivity embraces the ensemble

of modes of perception, affect, thought, desire, fear, and so forth that animate acting sub-

jects as well as the cultural and social formations that shape, organize, and provoke those

modes of affect, thought and so on (Ortner 2005:31).

It is this very elasticity that comprises both the principal strength and potential Achilles heel

of subjectivity. Although the fluidity of the term transcends the analytic dangers of ossifying

the individual and culture, the risk is that the term may prove overly inclusive and ambigu-

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ous in its application. Here, Fischers (2007) recent proposal seeking differentregistersof

subjectivity is useful. Fischer suggests viewing subjectivity across four registersFthepoliti-

cal, psychological, linguistic, and biologicalFthat loop back on one another such that [t]his

feedback between the linguistic, personal, sociopolitical, and biological . . . allows nothingto be taken at face value or at first sight (2007:424). Borrowing from Fischers terminology,

I am principally concerned in this article with interactions between psychological subjectivity

and thebiological subject, that is, between ones sense of self and bodily processes, as mediated

through pharmaceutical technologies. Yet I have deliberately chosen to employ the vocab-

ulary ofselfas I find it comparatively more experience-near than subjectivityin the cultural

context of the contemporary United States.

With respect to the self as an etic category, psychological anthropologists have dispelled

notions of a universal, unitary, stable construct and have instead emphasized cross-culturalvariability (Geertz 1983; Kirkpatrick 1983, 1985; Levy and Rosaldo 1983; Lutz 1988; Myers

1986; Rosaldo 1980; Shweder and Bourne 1984). Scholars working at the juncture of

narrative and self have argued that narrative processes constitute an essential resource in

the struggle to bring experience to conscious awareness (Ochs and Capps 1996:21) and a

fundamental human way of giving meaning to experience (Garro and Mattingly 2000:1;

Mattingly et al. 2008). This body of scholarship advocates a view of fragmented, multiple

selves that are connected in part through webs of personal narrative (Ochs and Capps 1996),

thereby emphasizing self processes as malleable and open to change across time and space.

However, the stress on the multiplicity and subjunctive (Good 1994) character of self

processes potentially clouds the concept and Hallowells classic formulation of the self in its

behavioral environment may offer a conceptual mooring. Hallowells concept of self

is grounded in self-awareness, in what he views as the fundamental human capacity for

discriminating between self and other as an object in a world of objects (1955:75). This

reflexive self-awareness is shaped in part by culturally specific parameters that together

provide the fundamental means of orienting oneself in the world. Scholars have observed

that Hallowells conception of self marks it as both universal and culturally specific as it links

perceptual processes with social constraints and cultural meanings (Csordas 1994:6;Garro 2003). This view privileges first-person, experiential perspectives over cultural

models of self and personhood such that the scholarly imperative becomes examining how

cultural models of the self are taken up as a matter of everyday lived experience in specific

cultural contexts (Hollan 1992; Garro 2003).

The contemporary shift toward exploring biological bases for psychiatry and pharmaceuti-

cal intervention has resulted in new cultural models of the self in relation to mental health

problems. In particular, the transnational marketing and delivery of pharmaceuticals opens

spaces to reimagine certain ways of thinking, feeling, and acting as constituting neurologicalproblems with biochemical solutions. In this vein, Rose (2003) notes the emergence of

neurochemical selves and psychopharmacological societies. This cultural imaginary is a

realm of wonder drugs that promises better living through chemistry (Jenkins 2005),



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rupturing assumptive existential worlds by necessitating that subjects make explicit other-

wise tacit, ephemeral self processes and engage vigilantly in monitoring subjective

experience. We live in a culture in which self-formation has become more and more of a

conscious mission, instead of something pre-given (Svenaeus 2007:163). Psychotropicmedications are increasingly a part of this project of self-formation insofar as being on

drugs for life is becoming a normal condition in the United States (Dumit 2002).

Cultural studies of medications have attended well to the global marketing and consumption

of Western pharmaceuticals (Petryna et al. 2006) and have emphasized how pharmaceutical

companies shape global psychiatric practice by continually creating new markets for their

products through the commodification of health (Applbaum 2006; Vuckovic and Nichter

1997). Yet, as Jenkins (2005) notes, there remains a substantial disconnect between cultural

studies of medications and the subjective experience of medications. In the research thatforms the basis for this article, I have opted to bracket concerns with the globalization of

pharmaceuticals in favor of attending to the meanings and experiences of psychiatric disor-

ders and treatments for individuals and families in the context of daily life. As such, I

position this article as a contribution to an emergent anthropology of pharmaceuticals

and, in particular, to a growing body of scholarship concerned with the lived experiences of

psychotropic medications (Biehl 2005; Jenkins and Carpenter-Song 2005).

I examine pharmaceutically mediated self transformation through the experiences of two

children who were diagnosed with, and medicated for, behavioral and emotional disorders,including bipolar spectrum disorders and/or attention-deficit hyperactivity disorder

(ADHD). Children and adolescents in the United States are coming of age in a cultural

context marked by the historically and culturally unprecedented consumption of pharma-

ceuticals (Jenkins 2007). Within the United States, rates of diagnosis and pharmacological

treatment for a range of psychiatric disorders in youth have skyrocketed.2 According to

national estimates, 913 percent of children and adolescents in the United States are

diagnosed with serious emotional and behavioral disturbances (U.S. Department of Health

and Human Services 1999) and nearly five percent of U.S. children ages 417 were pre-

scribed medication for behavioral and emotional difficulties during 200506 (Simpson et al.2008). Yet childrens perspectives on psychiatric illness and pharmaceuticals have rarely

been considered. Daley and Weisner (2003) observe that youths explanatory models of

cognitive and social impairment have received scant attention and Floersch (2003) argues

that scholars have not examined how youth make sense of treatment with psychotropic

medications. Such observations reflect a more general neglect of attention to youth within

the medical social sciences (Davis et al. 2000; Fabrega and Miller 1995; Mayall 1998).

For children, the pursuit of mental health services and the taking of medications occur from

the structurally disadvantaged social position of youth. Although there has been a shifttoward advocating for patient-centered care and the sharing of clinical decisions in mental

health services generally, such paradigms appear to hold little relevance for how children

themselves engage with mental health care. Decisions to seek treatment, which providers to

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see, what forms of intervention will be utilized, and when (and if) to terminate services are

under the purview of adultsFparents, teachers, mental health professionalsFin the life-

worlds of children. These patterns mirror decades of scholarship examining nonpsychiatric

pediatric medical encounters that find children are rendered silent or passive in the contextof interactions with clinicians (Silverman 1981; Strong 1979; West 1984).

A central thrust of the recent resurgence of interest in children and childhoods within

anthropology is an emphasis on childrens agency (Bluebond-Langner and Korbin 2007).

Western cultural assumptions that children are unable to engage meaningfully with and

become active participants in matters of health and illness have been shown to be erroneous.

Children exhibit detailed knowledge of their medical conditions often in spite of adult

efforts to conceal such knowledge from them (Bluebond-Langner 1978), develop complex

explanatory models of disability (Daley and Weisner 2003) and mental health (Armstronget al. 2000), employ creative coping strategies for the daily management of chronic condi-

tions (Dell Clark 2003), and can make informed judgments in decisions concerning the

course of treatment (Alderson 1993; Miller et al. 2004). Matters of health and illness are

neither beyond the interest nor the comprehension of children.

Following from these studies, the present analysis begins from the stance that youth are

active stakeholders in their health, a position that aligns with an emphasis on the active

engagement of subjects in cultural construction that is characteristic of experiential

approaches. Thus, the recent medicalization of childrens behavioral and emotional distressdemands knowledge of childrens own perspectives and offers the possibility of tying

psychological anthropologys long-standing interest in self processes and medical

anthropologys concern with illness experience together with an interest in childrens

everyday lived experience. Understanding how psychiatric disorders and psychotropic

medications mediate self processes is an increasingly important arena for investigation and

contributes to scholarship concerned with the interrelation between self and chronic illness

or disability (Ablon 1984; Charmaz 1983; Edgerton 1993; Estroff 1989; Estroff et al. 1991;

Jenkins and Carpenter-Song 2005; Kleinman 1988; Lester 1997; Murphy 1990).

Description of the Study and Ethnographic Setting

The two children considered in depth in this article were participants in a 13-month

anthropological study of the lived experiences of behavioral and emotional disorders among

children and families. These children and families lived in a midsize metropolitan area of the

northeastern United States. At the time of data collection in 200506, the city was ranked as

the poorest large city in the nation and had the most children living in poverty (U.S. Census

Bureau 2006). Although the study sample as a whole ranged from low to high income, thetwo children in this article were alike in coming from low-income backgrounds. The racial

ethnic diversity of the larger study sample is reflected in the children in this article, who self-

identified as African American and Euro-American, respectively.3 Participating families



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were recruited from two sites: (1) a community mental health center serving a predomi-

nantly African American and lower-income population, or (2) a research university hospital

setting serving a largely Euro-American and middle-income population.4

Of the children in the study,5 19 were diagnosed with bipolar spectrum disorders and/or

attention-deficit hyperactivity disorder (ADHD).6 Diagnoses were made as part of another

research study titled, Improving the Assessment of Juvenile Bipolar Spectrum Disorder,

(5R01 MH066647, PI: E. Youngstrom) and were assessed using the K-SADS-PL Plus, an

adapted version of the Schedule for Affective Disorders and Schizophrenia for School-Age

Children-Present and Lifetime version (K-SADS-PL; Kaufman et al. 1997) conducted with

youth and parent or guardian. Most of the children (n5 15) in the study were taking one or

more psychotropic medications, including stimulants (n5 14), antidepressants (n5 3), anti-

convulsants (n5 3), atypical antipsychotics (n5 7),7

and an antihypertensive drug used forbehavioral problems (n5 2).8

Meanings and experiences of mental health treatment were explored through convergent

methods of ethnographic interviewing and participant observation. The Subjective Experience

of Illness and Medications in Youth (SEIMY) interview was administered to all parents and

children in the study. The SEIMY is a semistructured interview adapted from the Subjective

Experience of Medications Interview (SEMI) used in a study of adults diagnosed with schizo-

phrenia-related disorders (NIMH R01 MH-60232; PI: J. H. Jenkins). Interviews took place in

participants homes and were conducted over multiple sessions. The interviews were audio-taped for verbatim transcription and analysis. The length of the interviews varied and the

number of research contacts with individual families ranged from two to twelve, reflecting

variations in interactive and communicative styles of families. In total, 102 home visits were

made to complete SEIMY interviews. A subset of eight families from the overall sample par-

ticipated in more intensive participant observation across home, community, and clinical

contexts. All research protocols were reviewed and approved by the Institutional Review Board

of the university and participants gave their informed consent (adults) or assent (children) to be

involved in the research. In keeping with this protocol, all names used herein are pseudonyms.

Narrative data were analyzed with the aid of Atlas.ti, a qualitative coding software program

(using Atlas.ti, ver. 5.0). Using a hermeneutic approach, transcripts were reviewed for con-

cepts of interest, producing a combination of researcher-driven and inductively derived

analytic categories. Broad themes such as explanatory model, power/control over prob-

lem, and medication experiences were gradually made more specific through iterative

review of the narratives for emergent details and subtleties.

Portraits of Pharmaceutical Transformations

To illuminate how psychiatric diagnoses and psychotropic medications mediate childrens

senses of self, I turn now to the experiences of Latasha Lewis, a 13-year-old African

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American girl, and Brent Martin, an 11-year-old Euro-American boy. In a future article I

intend to examine childrens understandings of behavioral and emotional problems more

broadly across the participating families. For most children in the larger study, mental

health concerns remain muted in their lives.9

In fact, only five children in the study useddiagnostic labels in their interviews. The present analysis examines two children for whom

psychiatric diagnoses and mental health interventions were more fully thematized in every-

day experience. I have chosen to use ethnographic portraits as a means to preserve the

wholeness of the childrens experiences. Other analytic strategies may offer the advantage of

a more comprehensive view across participants, but are limited by the tendency to shatter

the data and disembody narrative passages from the person and their lived-in contexts of

daily life (cf. Conrad 1990). Furthermore, thick description of subjects aligns with the

experiential theoretical and methodological orientation adopted as the basis for this article.

Latasha and Brent both gave extensive accounts of subjective transformations produced, in

large part, by their respective psychotropic medications. Attending to these accounts of sub-

jective experience brings to the fore radically different orientations toward psychotropic

medicationFLatashas being quite negative and Brents overwhelmingly positive. Looked at

more closely, however, both accounts at times reveal conflicting perspectives. Although sub-

stantially different in tone, these accounts each speak to a deep-seated ambivalence regarding

the practice of ingesting pills everyday to remain focused, keep quiet, or stay out of trouble.

Latasha Lewis

Latasha Lewis lived with her mother, Michelle, and four siblings in a predominantly African

American neighborhood on the outskirts of the city. The family had moved to this neigh-

borhood from another part of the city two years earlier when Michelle purchased a home

here. During my visits the house bustled with people as extended family members, neigh-

borhood children, and friends would drop by unannounced to hang out and catch up on the

latest gossip. Michelle appeared to enjoy her house as a hub for family and friends, perhaps

especially because it kept her own children close to home in a neighborhood notorious fordrug activity and violence. Even so, Michelle had been unable to fully protect against the

incursion of drugs and violence into her family. Her eldest daughter regularly used alcohol

and drugs and was badly scarred from a fight in which a neighbor had slashed her cheeks

with a razor blade. Latasha preferred their previous neighborhood because it was a quiet

place and . . . like if you live out here you gotta watch your back . . . like its not bad in [our

previous neighborhood], but down here its bad.

Michelle worked two jobs and although the familys income was modest, the children were

treated to stylish clothes, cell phones, and eating out at local fast food restaurants. With asmile, Latasha observed, Yeah, were spoiled. For Latasha, her cell phone was her lifeline

to friends and I frequently found her hunched over the tiny screen with her thumbs busily

tapping out text messages. At home, after she finished her chores of tidying the kitchen or



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cleaning the bathrooms, Latasha enjoyed watching music videos with her sisters, showing

off new dance steps, playing video games with her younger brother, and writing poems in

her journal. She was active in the school choir and dreamed of becoming a pop singer. Like

several other girls in the study, she characterized herself as a tomboy, explaining to me that,I dont really do all that girly stuff, before proudly flexing her well-defined bicep muscle.

She loved to run and would often dash into the house flushed and out of breath from playing

with friends outside.

When I arrived at the Lewiss house one February afternoon, Latashas mood appeared in

sync with the dreary weather outside. I sat with Latasha and her mother at the cramped

kitchen table as Michelle tried to get her daughter to explain why she was upset. Latasha

remained slumped in her chair, her eyes downcast. She was currently on punishment at

home because she had gotten in trouble for talkin and being disrespectful at school. Atthis point, Michelle asked her daughter, What part of this has to do with your illness? to

which Latasha replied, Nothin. Michelle used this as an opening to educate and reinforce

Latashas knowledge of her diagnoses:

Michelle: What are you diagnosed with?

Latasha: What, like my medicine?

Michelle: No, what is your illness called?

Latasha: Bipolar and attention deficit.

Michelle: Scuse me?

Latasha: Bipolar and attention deficit.

Michelle: Attention deficit disorder with what? [pause] Hyperactivity. Can you say that?

Latasha: Hyperactivity.

Michelle: Can you say that one word, attention, can you say the whole thing?

Latasha: Attention deficit with hy-hyperactivity.

[ . . . ]

Michelle: What do you think bipolar is?

Latasha: Um, a lot of energy.

Michelle: What is attention deficit?

Latasha: I dont really know what attention deficit is, but all I know is that bipolar ishyper, like provide me wit energy.

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talk a lot. By contrast, the medications make me not run around and talk off at the mouth.

Latasha only identified behavioral effects of her medications and, despite her diagnosis of a

bipolar spectrum disorder, never described affective changes resulting from her medications.

Latashas descriptions of the bodily effects of her medications align with the intended con-

sequences of psychostimulants, namely to improve focus and inhibit motor (over)activity.

But, in Latashas case, such consequences are not experienced as welcome phenomenologi-

cal changes. Explaining to her mother why she disliked taking her medications, she

described a cognitive transformation: Its like I dont be thinkin about nothing. Another

time, she elaborated on how the stimulant medication makes her too quiet:

I dont wanna eat or I just dont wanna be bothered. I just sit there and play with my

hands. I dont do anything. . . . I dont get to play or nuttin. I just sit there. . . . Okay, sayeverybodys playin and they just ask me like, Do you wanna play? And I just say,No, and then they come back another time and ask me again and I just say, No . . .Ill just sit there.

By her account, the medication has reduced her energy to such a degree that Im just like a

statue. I just sit there and dont do nothing. By diminishing her playful energy, the

medications radically alter the way in which Latasha engages with the world. As she stated

forthrightly, I dont do nothin like I usually do. I dont act like myself. In short, the

medications have made her feel like a different person:

Yes, it has happened to me. I just feel like a different person. Like one day I took themedicine and I just didnt feel like myself . . . I take my medicine and I just change to a

whole nother person, I just quiet all the time.

Elaborating on the difference between the two Latashas at my request, she explained that

The other person is like Im runnin around and playin and jumpin around and all that.

Latashas experience of feeling like a different person because of taking psychotropic

medications challenges the assertions of her normality. The medications present a dilemma,

demanding that she negotiate competing discourses: at once insisting that she is like ev-

erybody else while at the same time feeling fundamentally not like herself. In what could

be interpreted as an attempt to assert and reclaim herself, about two months into the study

Latasha stopped taking risperidone altogether and resorted to hiding pills in the sofa cush-

ions because she felt it was slowing her down too much. Her strong sense of personal

agency was also evident when she called into question the necessity of taking medications:

Sometimes I think that I can do it without taking my medicine. Most of the time I canjust do it without takin my medicine because most of the time I dont take my medicine

I just do it by myself.

The negotiation of the triadic constellation of self-illness-medications is made doubly difficult

if we expand the analysis to consider the social field of taking medication. Although her peers

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may not treat her differently on account of having problems or issues with her behavior,

she feared that others might make fun of me if they found out about her medication:

Latasha: . . . people dont really mess wit me about it. They might mess with me aboutbein on medications, but they dont mess wit me about none of that.

Ethnographer: What do they say about the medication?

Latasha: That I take pills and that I used to take Ritalin.

Similarly, at one point she explained what she disliked the most about taking psychotropic

medications in connection with her psychiatric diagnoses:

Latasha: . . . the most thing that I dont like about it is I gotta take medication for it.Because everybody gonna act like, just sayin things to me.

Ethnographer: About the meds?

Latasha: Uh huh. [nods yes]

Ethnographer: What do they say about it?

Latasha: Like Im on pills and I take medication and they make fun of me.

Ethnographer: How does that make you feel?

Latasha: Sad.

Not surprisingly, Latasha was cautious about to whom she revealed that she took medication.

Brent Martin

Brent Martin lived with his mother, Cassie, in a modest house on a suburban street of sim-

ilarly modest homes. They shared a home with Cassies partner, Christine, and Christinesgrandmother. The houses in the Martins neighborhood were all built equidistant from the

road, overlaying symmetry and order to an otherwise rundown tableau of pothole-pocked

streets, overgrown lawns, and peeling paint. Just a year earlier, Cassie Martin had moved

with her son and partner to this city from the northwestern United States after inheriting

the house from her grandfather. When I would arrive for a visit my presence was always

announced by the insistent squawking of the familys pet cockatoo. Although the house was,

in Cassies words, dated and, in Brents words, crappy, the atmosphere inside was com-

fortable and welcoming. The Wall of BrentFan assemblage of blue ribbons, certificates

of achievement, and school photosF

formed the visual focus of the living room.

Brent enjoyed spending time with his family members, especially his grandmother because,

as he explained, the older they are the less time youre going to have em. He spent the



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hours outside of school doing homework, helping with yard work, playing with friends, and

watching sports on television. He readily characterized himself as a jock. His family

members were all avid sports fans and, when money allowed, they enjoyed attending base-

ball games at the local stadium. To pay for such treats the family earned money from oddsand ends jobs like collecting scrap metal on the weekends. Family finances had been tight

ever since Cassie developed a chronic illness rendering her unable to work. In the wake of

her disability, the family had been forced to rely on a monthly governmental assistance

income of a few hundred dollars.

I was surprised to learn that Brent was 11 years old as he could have easily passed for 13 or

14. Physical size was not the sole contributor to this impression. Brent appeared at ease with

himself and his deliberate manner of speaking and vast vocabulary all lent him an air of

social control and sophistication that was unrivaled among the other boys in the study. Hedescribed himself as a people person, elaborating that I like to hang out with friends.

I was not surprised to hear of the numerous academic awards he had received or of his

popularity among his peers. Academically, Brent had always performed well and he told me

that, second semester this year was the first time I ever got a B. Social interactions

appeared to come easily for Brent and, with pride, he told me that although he had only

recently moved to the area he had already befriended half of the school.

As we spent more time together it was difficult to reconcile this calm, well spoken, thoughtful

boy with the inattentiveness and hyperactivity taken to be hallmark signs of Brents diagnosisof ADHD. Yet when we first met, Brent was grounded and he indicated that getting in

trouble was not uncommon: I usually dont go a week without being grounded. He readily

acknowledged being bad at times and having difficulty controlling my actions. Unlike

the concealment and silence surrounding matters of diagnosis and treatment that I com-

monly observed among other families in the study, the Martins openly incorporated mental

health concerns as a dimension of everyday discourse. Brent spoke matter-of-factly about his

diagnosis of ADHD, and like Latasha, was one of few children in the study to refer to prob-

lems using a diagnostic label. For Brent, ADHD was just meant to happen and he casually

stated that, This is just how I am. Although ADHD-related behaviors such as being hy-per may cause him to get in trouble at school and to get grounded frequently at home, such

behavior was not discursively positioned as contrary to Brents sense of himself. Instead, he

appeared to recognize multiple possibilities in himselfFfor good and bad.

Psychotropic medicationsFin this case, psychostimulantsFfigured prominently in Brents

account of his everyday experience. Brent was first diagnosed with ADHD at age 4 and was

initially prescribed methylphenidate (Ritalin). Over the years, Brents medications had been

switched in response to negative side effects as well as outgrowing the dosage. Nearly

all of the available medications indicated for ADHD had, at one time or another, beenprescribed for him. He was currently taking methylphenidate HCl (Concerta), an extended-

release form of methylphenidate that is marketed as a once-daily medication. In Brents

case, however, he took two daily doses of 36 milligrams that his pediatrician had informed

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him constituted the maximum allowable dosage. Brent took his second dose at school,

which was unproblematic except for the fact that his trip to the school nurse cost him

precious minutes of time at lunch.

Overall, Brents account of the subjective experience of taking psychostimulants was over-

whelmingly positive. He described having trouble concentrating and being very hyper

without the medication: I would literally be bouncing off the walls. The medication

helps me control my actions and since taking it Im the smartest person in the entire fifth

grade at my school. I won an award for it. Brent was adamant that he needed the medica-

tion: without my pills I cant do anything about my behavior, at least anything right. In an

interesting entanglement of personal agency and pharmaceutical effects, he credited the

medication with helping him to be more accountable for his actions:

Before I took it, Id get upset because I always kept getting in trouble but now I knowthat when I go get in trouble, I know its my fault that I couldnt control my actions.

Despite having a well developed sense of having ADHD, the disorder did not render him

different from his peers. Like Latasha, a strong and recurrent theme throughout Brents

account was that others see him as normal and not any different. He explained that

others dont really know about the problem and they dont see anything wrong with me.

Yet there is a crucial difference in their respective accounts. Whereas Latashas discourse of

normality stems from her strategy of downplaying the disorder, concealing her medications,

and recasting her symptoms as desired aspects of her personality, medication plays the

primary role in enabling Brent to be a normal kid. To that end, Brent credited the medi-

cation with helping me feel like Im normal, so that I just fit in with all the other kids.

Rather than calling attention to a problem, Brent gives voice to the power of medications to

erase or render imperceptible his behavioral problems. When asked what he would tell

others about the medication, Brent responded assuredly:

youll feel like a normal person. Youll feel like theres nothing wrong with you becausewhen you take it there really is nothing wrong with you.

Overall, Brent felt better since taking the medication because Im with the crowd:

when I take this medicine and Im better, Im not bad so youre not singled out as one ofthe bad people at school.

Being with the crowd not only helped to keep him out of trouble with teachers but also

was crucial for maintaining relationships with his peers as he observed that no one really

wants to be friends with the bad kids. Moreover, he believed that the medication was

responsible for making him:

more motivated to do what I wanna do because without it I feel because Im so bad Icant reach my goals, but with it I feel normal enough or smarter that I can achieve mygoals.



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Overall, Brent felt that he was getting better, which he described as relieving. However,

his sense of improvement and the effects of the medication are short lived:

Ethnographer: Do you think youre getting better?

Brent: Thats what it feels like when I take the medication, but when it wears off, no.

In spite of his incredibly positive endorsement of medication, Brent nevertheless identified

substantial drawbacks. Ideally, he would prefer not take medication at all and disliked

always havin to take em. He was especially concerned that he was building a tolerance to

the medication:

because all my life Ive been on a narcotic that now because it gets worse and worseI need more and more and more and thats the maximum dosage [current dose], so Ithink that its like strong and powerful but its just barely holdin on.

He also worried about the long-term:

Sometimes Im scared that Im gonna have to take it my whole life . . . I dont wannawake up when Im 35 and have to take a pill. I mean, to me thats just sad that a 35-year-old adult cant control his actions.

However, he seemed resigned to this fate, observing reluctantly that I probably cant

function without it.

In addition to his personal concerns of becoming dependent on the medication, Brent also

placed the negative aspect of taking medication in a broader social context. He painted a

vivid picture of the challenges of navigating his peer social world:

Youre either the cool kids, the kids that no one wants to be friends with, or theannoying kids so in order to be one of the cool kids you have to do other stuff

. . . otherwise youll be one of those annoying kids that keeps buggin, Can I play? Can Iplay? Can I play? . . . You have to know when to do stuff. Like you have to know

when to hit someone but I dont. I havent participated in that yet. You have to knowwhen to say something. You cant say something at the wrong time. Um, you just have toknow, you have to know when, where, how, and what to say to keep your reputationgood.

Brent had so far been successful at maintaining his cool position in the school

pecking order but he was keenly aware of the fragility of this social status. Against this

backdrop, Brent vigilantly guarded knowledge of his diagnoses and that he takes medica-tions, revealing this information only to his two closest friends (one of whom was also

diagnosed with ADHD). The social danger of this information is made clear in the exchange

below:

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both prescribed stimulant medications and Michelle empathized with her daughters strug-

gles with reduced appetite, a common side effect of these medications. At one point, she

implored Latasha, We gotta help each other. Even if we dont feel like eating, weve gotta

help each other to eat. Similarly, Brents mother, Cassie, emphasized the intersubjectivequality of medication practices in her family. At one point, she explained to me that the

entire family takes their pills together:

You know we all take medicine cause we need it so hes just one of us and hes totally finewith it. Hes, he thinks its kind of cool he gets to set up his medicine weekly like we docause he has um the morning pill, weekends he has the afternoon pill, and then he has

vitamins too. Hes totally, hes totally digs it. Its not a problem.

Like Latasha, Brent was growing up in a family in which chronic illness and matters of

mental health were a part of the ebb and flow of daily life. His mothers days were structuredaround physical therapy sessions and appointments with various doctors. Brent was also

privy to the fact that his mothers partner, Christine, was diagnosed with bipolar disorder

and ADHD. Brent and Christine frequently butted heads and Cassie understood this

dynamic in relation to their psychiatric disorders: Its really hard for two ADHD people to

get along.

Although the families orientations to chronic illness and pharmaceutical interventions

provide a backdrop against which Latasha and Brent are developing understandings of

mental health problems and treatment, both children offer perspectives that differ fromadult orientations to these problems. Latasha most obviously strays from her mothers

staunch acceptance of a medical model by offering alternative, nonpathological interpreta-

tions of her own experience. Although Brent does appear to accept medicalized

perspectives, he nevertheless illuminates deeply troubling personal and social aspects of

taking medications that call into question his mothers assertions that he totally digs

medications and that its not a problem. Especially in contexts in which engagement with

mental health services is wholly adult-driven, the stances taken by Latasha and Brent offer

further empirical support for childrens agency in general (Bluebond-Langner and Korbin

2007; James and Prout 1996) and in matters of health and illness specifically (Bluebond-Langner 1978; Dell Clark 2003). Childrens accounts offer crucial knowledge of the lived

experience of psychiatric disorders and mental health treatments. Attending closely to chil-

drens experience we become privy to the complex ways in which children are working to

develop understandings of their diagnoses and treatments and actively situating themselves

at the dynamic nexus of self-illness-pharmaceuticals.

Psychiatry and the Project of Self Transformation

Diagnoses and pharmaceuticals present tangible constraints in the lives of children that callattention to otherwise fluid and ephemeral self processes, a point supported by van der

Geest and Whyte (1989) who argue that the power and popularity of Western pharmaceu-

ticals is attributable to their concreteness. Medicines, put simply, are thingsFaccessible,

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convenient, ready-to-use substances that facilitate the concretization of illness and treatment

by linking shifting, ambiguous sensations to physical problems with a physical remedy:

By applying a thing, we transform the state of dysphoria into something concrete, intosome thing to which the patient and others can address their efforts. Medicines thus fitlogically into biomedicine and most other medical traditions. Practicing medicine, afterall, is the art of making dis-ease concrete. [van der Geest et al. 1996:154]

In a related vein and specific to psychopharmaceuticals, Rose argues that the ascendance of

neurological discourses has shifted the sense of self from psychological being toward

somatic individuality:

To be a somatic individual, in this sense, is to code ones hopes and fears in terms ofthis biomedical body, and to try to reform, cure or improve oneself by acting on that

body. At one end of the spectrum this involved reshaping the visible body, through diet,exercise, and tattooing. At the other end, it involves understanding troubles and desiresin terms of the interior organic functioning of the body, and seeking to reshapethatFusually by pharmacological interventions. [2003:54]

By concretizing otherwise ambiguous experiences and inscribing distress on the body, biolog-

ical psychiatry and pharmaceuticals offer the promise of taming uncertainty. The brain is

configured as the site and source of pathology. Especially in the context of ADHD and

pediatric bipolar disorder, psychodiagnostic entities that remain fundamentally ambiguous and

highly contested, scientific explanations and interventions are all the more alluring as an appeal

to both certainty and legitimacy. Yet at the level of lived experience, such pharmaceuticalpromises fall away as the daily ingestion of psychotropic medications becomes fraught with

ambivalence and worry. As the portraits of pharmaceutical transformation suggest, rather

than allaying anxieties by inscribing boundaries on problems, psychiatric diagnoses and psy-

chotropic medications appear to present dilemmas for childrens developing sense of self: What

does it mean if I need to take medication everyday to be normal? Why does a medication that

is supposed to make me feel better instead make me feel like a different person? If I need to

take medications for a disease that is not my fault, why do people still make fun of me?

Biological psychiatry holds out the possibility of self transformation through pharmaceuticaltechnologies; by altering behavior, cognition, and emotion psychopharmaceuticals drive to the

very heart of what it means to act, think, and feel in the world. The nexus of self, illness, and

psychopharmaceuticals is a site replete with possibility: for some, medications may enhance or

facilitate the emergence of a truer or better self; others fear that medications may dull di-

mensions deemed fundamental to self and style of engagement with the world. Latashas

experience illuminates the crucial point that pharmaceutical self transformations are not always

in the direction of improvement or self-enhancement whereas Brents experience shows that

even when medication-induced phenomenological changes are welcomed,10 full transforma-

tion may remain elusive.

Latashas account of her pharmaceutical transformation points to how the bodily effects of

medication may profoundly implicate ones sense of self. Pharmaceuticals produced a subjec-



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tive sense of not me by slowing her down, tempering her otherwise high energy that con-

stituted a fundamental dimension of her sense of herself. In Brents case, his pharmaceutical

transformation might, at first blush, seem unambiguously positive. For Brent, medication ap-

pears to open the door to an awareness of an improved self. But running through his account isalso an anxious awareness of the fragility of this balance between good kid and bad kid, normal

and abnormal. Brent is vividly aware of the impermanence of this better me, which exists

only so long as the chemicals remain at the proper concentration in his bloodstream. More-

over, below the pharmaceutical poster child veneer is a deep worry over what the future

holds. His imagined need to take medication as an adult strikes him as just sad and runs

counter to his expectations for adulthood. For these children, taking psychotropic medications

entails deep personal risk, altering their sense of self and posing a challenge to feeling normal

or to their expectations for the future.

Beyond personal sacrifices, the experiences of Latasha and Brent strongly suggest that

children must tread cautiously through their social fields. Rather than mitigating stigma,

medicalized models of problems and pharmaceutical treatments appear to hold substantial

social danger in the peer worlds of children. Latasha and Brent fear being ostracized on

account of having problems and, especially, because they take pills. As a result, both

remain on guard and must be cautious about to whom it may be safe to reveal such infor-

mation about themselves. Childrens perspectives thus expand notions of risk in relation to

diagnosis and treatment of behavioral and emotional disorders. It is clear that risks are not

limited to troublesome pharmaceutical side effects or to the danger of misdiagnosis. More-over, expanding the analysis to include the social worlds of children is a crucial means of

illustrating situational and relational qualities of self formation.

On a more sanguine note, it is also the case that the challenges presented by psychiatric

diagnoses and pharmaceutical treatment may present opportunities for children to actively

assert a sense of who I am or to envision possibilities for who I (dont) want to be.

Latasha is resilient in the face of substantial challenges, employing strategies of normaliza-

tion and resistance to counter pathologizing discourses and unwelcome effects of

medications. Her refusal to take medication takes on significance beyond non-complianceand may be read as a means of preserving her sense of self. Brents assertions of his normality

and equality to others may also be understood as a creative discourse of resistance to limi-

tations imposed by diagnoses. Rather than lowering expectations for himself on account of

ADHD, Brent speaks with pride of his ability to exceed and to be the smartest kid in fifth

grade. Such forms of resistance exemplify the effort and reflexivity that Csordas (1994)

deems fundamental as characteristics of the self.

The triadic relationship of self-diagnosis-medications is dynamic, producing multiple selves

through complex personal negotiations. Although Latasha appears to strongly rejectpathological readings of her experience, it is nevertheless the case that she also readily

invokes clinical language and diagnostic labels. Recalling Estroff and colleagues (1991)

articulation of I have versus I am illness statements, Latasha occupies both positions:

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2. As recently as the mid-1990s, bipolar disorder was one of the least frequent diagnoses among children hospi-

talized with psychiatric conditions; by 2004, it was the most common diagnosis in this population (Blader and

Carlson 2007). The number of children diagnosed with ADHD also increased dramatically in the 1990s. The

number of office-based visits documenting a diagnosis of ADHD increased from 947,208 in 1990, to 2,357,833 in1995 for U.S. children ages 5 to 18 (Robinson et al. 1999). There have been substantial increases in pharmaceutical

interventions for these types of disorders. Results of a 10-year study of community treatment data on nearly 900,000

youth in two U.S. health care systems found that total psychotropic medication prevalence for youths increased

two- to three-fold and included most classes of medication (Zito et al. 2003). Office visits resulting in a psychotropic

prescription increased from 3.4 percent in 199495 to 8.3 percent in 200001; by 2001, one out of 10 office visits by

adolescent males resulted in a prescription for a psychotropic medication (Thomas et al. 2006). The number of

office-based visits by youth that included antipsychotic treatment in the United States is estimated to have increased

from 201,000 in 1993 to 1,224,000 in 2002 (Olfson et al. 2006).

3. The 20 families with whom I worked included families that self-identified as African American (n5

9), Euro-American (n5 10), and Latino (n5 1) backgrounds.

4. Among the families in the study, more African Americans came from lower-income and working class back-

grounds and more Euro-Americans had middle to high incomes. However, there was socioeconomic heterogeneity

within the sample, with low to upper-middle income Euro-Americans and low-to-middle income African Amer-

icans recruited to the study.

5. ADHD diagnoses included hyperactive/impulsive, combined, or inattentive type. Bipolar spectrum disorders

included strictDSMIVdiagnoses of bipolar I, bipolar II, cyclothymia, or bipolar NOS where the youth either

shows one too few symptoms but adequate durationFconsistent with Lewinsohn et al. (1995), or an adequate

number of symptoms but with briefer episode durationF

consistent with Findling et al. (2001) or Leibenluft et al.

(2003).

6. Because of an error in the diagnostic database used for recruitment, one child who had been classified as ADHD

at the time of recruitment was, on more recent examination, diagnosed only with Oppositional Defiant Disorder

(ODD).

7. An atypical antipsychotic medication was introduced in the course of the study to four children.

8. When I first met them, five children in the study were only receiving nonpharmacological mental health treat-

ment, eight children were only receiving pharmacological treatment, and seven had a multitiered approach to

treatment incorporating therapy and medications. Four children had been in therapy in the past and, in the

course of the study, therapy was added to the treatment regimen of one child.

9. In some families, parents actively sought to conceal knowledge regarding diagnoses and treatments from chil-

dren by, for example, calling psychotropic medications vitamins or referring to therapists as teachers. My

ability to work with one family was contingent upon multiple assurances that I would not reveal their sons diagnosis

to him. For others, a diagnosis or the daily practice of taking pills was simply not the basis for reflection, as 11-year-

old Matthew stated, I dont really think about it, with a casual shrug of his shoulders. And for children in some

families, the struggles of daily lifeFparents out of work or taking care of younger siblingsFfar overshadowed the

salience of formal mental health concerns.

10. Kramer (1997) has perhaps most famously written about the transformative powers of psychotropic medica-

tions in his bestsellingListening to Prozac in which he examines the phenomenon of patients feeling better than

well as a result of taking fluoxetine.

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