CLINICAL PERSPECTIVES
ADHD in Brazil: The DSM-IV Criteria
in a Culturally Different Population
LUIS AUGUSTO ROHDE, M.D., SC.D.
The diagnosis of attention-deficit/hyperactivity disorder (ADHD)
has been recognized in different countries and cultures
(Baumgaertel et al., 1995; Reid, 1995; Rohde et al., 1999).
Inasmuch as the DSM has become widely used in clinical and
research settings as a classification system for mental disorders
(Baumgaertel et al., 1995), the validity of its ADHD criteria
should be evaluated in cultures from different countries. This
is even more important if one considers that cultural factors
may modulate the clinical manifestation of disruptive behav-
ior disorders (Livingston, 1999; Reid, 1995).
Since the historical controversy about the reasons for the
difference found in the prevalence of syndromes of attention
deficit and overactivity between the United States and England,
several studies of ADHD have been conducted in developed
countries in Europe, using DSM-IV criteria. In Germany,
Baumgaertel et al. (1995), partially applying the DSM-IV
ADHD criteria to an elementary school sample, found that
the prevalence of ADHD (17.8%) was much higher than the
usual prevalence rates encountered in the United States (3%–6%).
However, the scarcity of studies using DSM-IV criteria to exam-
ine relevant aspects of ADHD in cultures from developing coun-
tries is surprising. This is important even for the United States,
where approximately one third of public school children are from
culturally different backgrounds, with children of Hispanic descent
from the developing countries of Central and Latin America con-
stituting the largest minority group (Reid, 1995). As proposed
by Reid (1995, p. 539):
To attain valid cross-cultural assessment of ADHD, we must address
the fundamental question of equivalence, namely: Do the scores [diag-
nosis] on a given scale [by a given criteria] mean the same thing across
different cultural groups? If not, the validity of the assessment is ques-
tionable.
Accepted March 6, 2002.
Dr. Rohde is Professor of Child and Adolescent Psychiatry at Federal University
of Rio Grande do Sul and Coordinator of the ADHD outpatient clinic at Hospital
de Clínicas de Porto Alegre, Brazil.
This work was partially supported by a research fund from the Hospital de
Clínicas de Porto Alegre.
Correspondence to Dr. Rohde, Serviço de Psiquiatria da Infância e Adolescência,
Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre,
Rio Grande do Sul, Brazil 90035-003; e-mail: lrohde@zaz.com.br.
0890-8567/02/4109–1131䉷2002 by the American Academy of Child and
Adolescent Psychiatry.
DOI: 10.1097/01.CHI.0000026602.17655.e7
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2
Associate Editor: Michael S. Jellinek, M.D.
Therefore, carefully applying DSM-IV criteria for ADHD
to evaluate children and adolescents from a developing coun-
try with a diverse culture might result in two different out-
comes:
1. Clinical and research findings may be completely different
from those found in developed countries, indicating that
either an important variability (e.g., different phenotype or
genetic variability) in the disorder may exist among cultures
or that a classification system (DSM ) created in one cul-
ture is not suitable to evaluate the disorder in another one.
2. Clinical and research findings may be similar to those found
in developed countries, suggesting that the classification
system is suitable for use in a different culture. If this is the
case, the cross-cultural or external validity of DSM-IV cri-
teria for ADHD will be higher.
We would like to share some research and clinical data found
in Brazilian children and adolescents when DSM-IV criteria
for ADHD were used. In addition, some cross-cultural issues
related to the process of evaluating ADHD with DSM-IV cri-
teria are emphasized.
Research Data
Several studies conducted in our ADHD outpatient program
and at schools in Brazil have suggested interesting findings: (1)
a prevalence of DSM-IV ADHD close to 6% and a high comor-
bidity with other disruptive behavior disorders (conduct or
oppositional behavior disorders) (47.8%) in a sample of young
adolescents (Rohde et al., 1999); (2) a bidimensional factor con-
struct (inattention and hyperactivity/impulsivity) for DSM-IV
ADHD symptoms (Rohde et al., 2001); (3) the adequacy of
the threshold of six symptoms of inattention and/or hyperac-
tivity/impulsivity (DSM-IV criterion A for ADHD) (Rohde
et al., 1998); (4) the lack of clinical usefulness for the criterion
of age at onset of impairment (DSM-IV criterion B for ADHD)
(Rohde et al., 2000); (5) a high prevalence of ADHD accord-
ing to DSM-IV criteria in parents of children with ADHD (31%
of families with at least one parent with past or past/present
diagnosis of ADHD) (Roman et al., 2001); and (6) in a ran-
domized double-blind clinical trial, a significantly higher pro-
portion of children with ADHD that improved 50% or more
with methylphenidate than with placebo (53% versus 6%)
(Szobot et al., unpublished, 2002).
1131
ROHDE

Clinical Data nostic criteria are used and similar diagnostic procedures are
performed. However, our experience with ADHD in Brazil has
The diagnosis of ADHD with or without comorbidity is
indicated that clinicians should pay special attention to cross-
achieved in our clinic through a three-stage process: (1) eval-
cultural issues when they are evaluating ADHD in culturally
uation with a semistructured interview (Schedule for Affective
different populations.
Disorders and Schizophrenia for School-Age Children-
Epidemiologic Version [K-SADS-E]) modified to assess DSM- Normative Equivalence
IV criteria and administered to the parents by trained assistants;
(2) discussion of each diagnosis derived through the K-SADS- It is well established that there are significant cultural dif-
E in a clinical committee; and (3) clinical evaluation of ADHD ferences in the demands of environment (e.g., at home and at
and comorbid conditions using DSM-IV criteria by child and school). Also, the expectation and tolerance for certain behav-
adolescent psychiatrists who have previously received the results iors vary in different cultural groups (Livingston, 1999). Thus
of the K-SADS-E. Information about the symptoms in the standards for normal and deviant behaviors are culturally deter-
school environment is obtained through the use of the Attention mined (Reid, 1995).
Problems scale of the Child Behavior Checklist-Teacher’s Report This is a key issue in the process of evaluating ADHD in cul-
Form. When a diagnostic disagreement occurs in the three- turally different populations. Although DSM-IV criteria for
stage process, priority is given to diagnoses derived from clin- ADHD are operationally defined, some degree of subjectivity
ical interviews (ADHD Molecular Genetics Network, 2000). remains. The request that symptoms must occur frequently to
The clinical characteristics of children and adolescents with be considered positive and that their intensities need to be mal-
ADHD who were evaluated in the outpatient clinic at the Child adaptive and inconsistent with children’s or adolescents’ devel-
and Adolescent Psychiatric Division of our University Hospital opmental level are clearly subjective and culturally influenced.
from 1998–2000 are presented in Table 1. It is important to For instance, children and adolescents from Latin cultures tend
stress that the male-female ratio, the preponderance of the com- to show emotional distress more frequently through behavior
bined type, and the pattern of comorbid disorders were all sim- symptoms and tend to be more talkative and active than chil-
ilar to findings reported from child and adolescent psychiatric dren from Anglo-Saxon cultures. In other words, how may clin-
outpatient services in university centers in the United States icians be able to define a behavior as frequent and maladaptive,
(American Academy of Child and Adolescent Psychiatry, 1997). if they are not aware of the patterns normally found in a cul-
These research and clinical findings seem to suggest that a turally different group? Our clinical experience working with
variety of aspects related to ADHD in a developing country children and adolescents from disadvantaged backgrounds has
like Brazil are not substantially different from those found in demonstrated that a clinical judgment tuned with cultural aspects
developed countries like the United States, when the same diag- can be achieved only if the interviewer is from the same culture
of the family that is being evaluated or if he or she is strongly
TABLE 1 familiar with that culture.
Demographic and Diagnostic Characteristics
of ADHD Patients (N = 285) Detection of False-Positive Cases
Age (years) 9.9 (3.2)
Sex (males) 237 (83.2)
A substantial proportion of children in Brazil and other South
Estimated IQ 92 (16) American countries are exposed to dysfunctional families and to
DSM-IV ADHD types inadequate educational systems. In addition, many youths in
Predominantly hyperactive 32 (11.2) these countries live in very poor environments, where even an
Predominantly inattentive 75 (26.3) adequate food supply is not available. Since inattention and hyper-
Combined 178 (62.5)
Main comorbid conditions a
activity can be the end point of a variety of conditions and prob-
Oppositional defiant disorder 111 (39.1) lems, the chance of diagnosing false-positive cases (phenocopies
Conduct disorder 44 (15.4) of the disorder) is high in these populations. For instance, it is
Anxiety disorder 62 (21.8) well known that malnourished children are at risk for attention
Depressive disorders 39 (13.7) deficits. Our clinical experience strongly suggests that, although
Bipolar disorders 20 (7)
Enuresis 17 (6)
it is important in any case, a careful evaluation according to com-
Tic disorders 10 (3.5) prehensive parameters (American Academy of Child and Adolescent
Psychiatry, 1997) should be mandatory in developing countries.
Note: DSM-IV ADHD = attention-deficit/hyperactivity disorder To avoid overdiagnosing in these cultures, clinicians should be
according to DSM-IV criteria; mean and standard deviations (in
parentheses) are reported for continuous variables; n and percent-
cautious in diagnosing ADHD when the symptoms are observed
ages (in parentheses) are reported for categorical variables. in a strict temporal or spatial relation to common psychosocial
a
Multiple comorbid conditions may be present. stressors. Also, because mental health services are scarce in devel-

1132 J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2

oping countries, making treatment available only for the most
severe cases, parents tend to overemphasize the severity of ADHD
symptoms in their children to guarantee access to treatment.
Otherwise, they will be part of long waiting lists. Therefore, the
investigation of the pervasiveness of symptoms through the use
of multi-informants is fundamental to the evaluation process.
Although it is always difficult to integrate information from dif-
ferent sources (e.g., parents and teachers) in the evaluation of
ADHD, our strategy of assessment, besides separated interviews
with parents and children, also includes information about the
symptoms from the teacher or educational advisor who knows
the student best. ADHD is confirmed only when some impair-
ment from the symptoms is reported by parents and teachers. For
children who are not attending school, information is gathered
from at least two family members. Interviews based on quick
checklists with only one parent are erroneous in this population,
excessively inflating prevalence rates with false-positive cases and
making it difficult to manage the true-positive cases before being
overwhelmed by false-positive cases.
Conceptualization of the Disorder
In Latin cultures, current concepts of behavior disorders
link them with bad manners and poor abilities of parents to
educate their children. Because most of the child mental health
professionals in Brazil are psychoanalytically oriented, even
psychiatrists and psychologists who work with children tend
to only understand ADHD symptoms as the product of inter-
nal or interpersonal conflicts. Thus the evaluation of ADHD
frequently needs to begin with an open and clear discussion of
the modern neurobiological aspects of the disorder. In our out-
patient clinic, we invite all families of children with ADHD
to weekly meetings with our team about ADHD issues (e.g.,
modern concepts about ADHD, etiology, management of
ADHD symptoms) and we provide frequent lectures about
ADHD in parents’ and teachers’ school associations.
Conclusion
Mental health professionals from developing countries have
always been reluctant to apply diagnostic criteria generated in
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 9 , S E P T E M B E R 2 0 0 2
DSM-IV CRITERIA FOR ADHD IN BRAZIL
developed countries to the evaluation of ADHD, arguing that
important cross-cultural differences prevent their use. Although
our samples are not representative of the whole Brazilian chil-
dren’s population, our clinical and research data preliminarily
suggest that DSM-IV criteria for ADHD may be suitable for a
developing country like Brazil. However, to perform evaluations
that are culturally tuned, clinicians should be familiar both with
standards for normal and deviant behaviors and with the con-
ceptualization of the disorder in the child’s culture. More stud-
ies of ADHD in different cultures are needed to formulate a
more definitive answer for the question of “equivalence.”
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