Drs. Polanczyk and Rohde Reply

To The Editor: We appreciate the thoughtful views of Dr. Amaral. It is of paramount importance to discuss the perceptions of physicians and patients concerning mental health disorders. This is the only way that we can counter the stigma surrounding them. Cultural stigma is an important barrier to recognition and treatment of illnesses, particularly mental disorders, including ADHD. Nevertheless, economic factors seem to be a major impediment to their successful management. In the United States, a survey of more than 100,000 families revealed that uninsured children and children of racial/ethnic minority populations were less likely than others to be receiving medications for ADHD (1) . There is a significant gap between the needs and provisions of mental health services in virtually every country, especially in developing countries (2) . In a Brazilian sample of 100 nonreferred subjects identified with ADHD in schools, only three subjects were currently receiving treatment (3) . The same findings were revealed in a Venezuelan community survey, in which only 4% of children identified with ADHD by researchers were receiving treatment (unpublished study by Montiel-Nava et al. available upon request from the authors).

As Dr.  Amaral points out, it is true that “universal phenomena can be viewed as normal or dysfunctional according to cultural beliefs.” Psychiatric diagnostic criteria are based on conceptual theories, but not only on such theories. Empirical evidence supports the validity of ADHD diagnostic criteria, as well as the validity of several other medical conditions, even if specific cultures legitimize their occurrence as “normal” or “desirable.” For instance, there is a higher prevalence of obesity among individuals of Pacific Island cultures compared with those of European ethnicity (4) . This is probably related to economic factors and a cultural desire for bigger bodies (4) . Nevertheless, the link between obesity and several adverse outcomes is well established, supporting its validity as a medical condition.

It has been demonstrated that the variability of estimates of ADHD prevalence in diverse locations around the world seems to be largely explained by methodological artifacts and not by demographic differences. This indicates that ADHD diagnostic criteria identify a similar frequency of an underlying construct in different locations, independent of local judgments. As previously pointed out, this does not mean that environmental factors are not involved in the etiological process. In fact, emerging evidence indicates that mental disorders are the result of complex interaction between genetic and environmental factors (5) . It is clear that biological and cultural factors must be studied in conjunction, not only for a more comprehensive understanding of scientific phenomena, but also to implement effective treatment plans.