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Of the more heartbreaking snubs, A Tribe Called Quest and their brilliant swan song, We Got It From Here... Thank You 4 Your Service , was not recognized. Though Vince Staples recently suggested that he deserved noms in the Best Rap Album, Best Electronic Album, Best Alternative Album, and Album of the Year categories, he didn’t get any of those—or any at all. Paramore, one of the few mainstream rock bands worth following nowadays, turned in a fine addition to their impressive catalog with After Laughter , to no avail. And with his production work on Lorde’s Melodrama , Jack Antonoff helped push the sound of pop further than most this year, but he did not receive a nom for Producer of the Year.

Granted, rock music is not exactly at its peak cultural relevance right now, but there were a couple of bands nominated for major rock categories that we’ve barely heard of. So we did some research. According to the Grammys, Texas band Nothing More—essentially a ham-headed cross between Nickelback (minus hooks) and Muse (minus bombast)—are worthy of three nominations, including two for their quasi-political hit “ Go to War .” And filling the white-boy blues hole left by an absent Black Keys this year is the Icelandic group Kaleo, whose zombie-foot-stompin’ track “ Check Shirt Dress Multi Noisy May 2018 Newest 2f1eNRnh
” is up for Best Rock Performance. Now we know!

Why do the War on Drugs get to be nominated in the Rock Album category, but the National are relegated to the (well-stacked) Alternative Album category? Their albums, A Deeper Understanding and Giambattista Valli Woman Striped Silkgeorgette Blouse Black Size 46 Giambattista Valli Discount Real 4W1z9olkx
, have equal amounts of synth weirdness and experimentation with song structures, and the National actually debuted higher on the charts than the War on Drugs. It always feels arbitrary where the Grammys draw this particular line; alternative to what, exactly?

This year’s Best Traditional Pop Vocal Album noms include: Vegas redux Michael Bublé, a Tony Bennett tribute record featuring Lady Gaga and, um, Kevin Spacey, Lilith Fair queen Sarah McLachlan, “Family Guy” and Ted auteur Seth MacFarlane’s fourth (!) standards album, and fucking Bob Dylan. What we would give to see all of them on the same stage, in what would likely be the strangest medley in Grammy history.

“Bodak Yellow” is nominated for two awards, Best Rap Performance and Best Rap Song. The latter is a songwriting award, so the Grammy credits include all songwriters and producers. Though the song’s With Mastercard Online Luke Distressed Wash Skinny Jeans Hypnotise Blue Lee Sale Great Deals Good Service Fashion Style Cheap Price bN3c29
use Cardi B’s real name (Belcalis Almanzar), the name Cardi uses in her Grammy filing is Washpoppin, one of her catchphrases (and Campcollar Striped Cotton Shirt Mr P Clearance Find Great 192ucMzp4
). The Grammys confirmed Washpoppin is Cardi, so now the question shifts from, “Why didn’t the Grammys recognize Cardi B as a songwriter?” to, “Is Cardi B low-key trolling the Grammys?”

FIGURE 4

Prevalence of ADHD over time. US Food and Drug Administration approval year. Conducted in the United States.

Sensitivity Analysis and Potential Bias

Sensitivity analyses were conducted with the 32 studies (contributing 33 prevalence estimates) that were at the lowest risk of bias. The prevalence estimate of ADHD in these studies was slightly higher at 7.8% (95% CI: 6.6 to 9) but not statistically different from the overall pooled prevalence ( .95). Prevalence estimates of low risk of bias studies ranged between 1% and 20%. Heterogeneity remained significant (I = 99.5%), and there were no statistically significant differences between prevalence estimates according to the various DSM editions.

Prevalence estimates were compared with study sample size ( Supplemental Fig 8 ), similar to a funnel plot, to detect publication or methodologic bias. Almost all of the studies with smaller samples (between 100 and 5000 participants) and with prevalence estimates >10% used DSM-IV diagnostic criteria. Of the 75 studies with <1000 participants, 23 studies reported prevalence estimates of >10%. Of these, all but 2 (91%) were studies that used DSM-IV criteria for ADHD diagnosis. Similarly, of the 80 studies with sample sizes between 1001 and 5000, 18 studies reported a prevalence estimate of >10%; of these, 17 (94%) were studies that used DSM-IV criteria. A post hoc χ analysis indicated that studies with prevalence estimates >10% were more likely to be from studies that used the DSM-IV criteria compared with DSM-III or DSM-III-R criteria (χ = 6.99, = .03).

Discussion

We conducted the first meta-analysis investigating if there has been a change in the prevalence of ADHD over time and after publication of new DSM editions. Anecdotally, and using data from physician outpatient registries, the number of children diagnosed with ADHD seems to have increased. However, contrary to our hypothesis, the estimates of prevalence did not statistically significantly increase over time nor were they statistically significantly different between the various DSM editions.

Our pooled estimate of 7.1% for all studies exceeds the 5.3% estimate reported by Polanczyk et al, but the difference may be explained by the language restriction in that sample and by the increased number of studies included in our review. We included 83 studies published since the review of Polanczyk et al was published, and we had no language restriction for included studies. Willcutt also conducted meta-analyses for prevalence estimates of ADHD. The author categorized the prevalence estimates according to informant, with the lowest prevalence estimate reported for clinicians (5.9% “best estimate”) and the highest for teachers using measurements that assessed symptoms only (13.3%). Our estimate is within this range.

Although pooled estimates were not statistically significantly different between DSM editions, prevalence estimates were smaller when studies used the DSM-III-R criteria for diagnosis of ADHD. It is possible that the inclusion of subtypes in both DSM-III and DSM-IV criteria allow for a broader group of children to be diagnosed with the disorder that our study has not had the power to detect. When different DSM criteria were considered simultaneously in a univariable and multivariable analysis, studies using the criteria of DSM-III-R had significantly lower ADHD prevalence than studies using either DSM-III or DSM-IV criteria.

The only other study characteristic that contributed to the variation in prevalence estimates was region. Estimates of ADHD prevalence were greater in the Middle East compared with North America in univariable analyses; multivariable analysis studies conducted with participants from Europe had lower prevalence estimates of ADHD compared with North America. Unexpectedly, sample size, sampling frame, informant, and measurement did not account for differences in prevalence estimates.

Our study has several strengths. It is the first to quantify changes to ADHD prevalence estimates over time. The included studies span 36 years and report on prevalence estimates of ADHD for >1 million children. We included all languages, and most regions of the world were represented. We used the most conservative estimates of prevalence by analyzing data in a manner that reflected best practice (eg, full criteria rather than partial criteria). This study is also the first to rate risk of bias of prevalence studies for ADHD.

The major limitation of our review is the sampling frames of the primary studies. Few studies used a whole population approach with random selection. Most were from single towns or regions, thereby limiting generalizability. The majority did not discuss the potential of nonresponse bias. We also did not contact authors to find unpublished studies; given the range of prevalence estimates over the 3 DSM editions, however, we do not consider this omission likely to have affected our outcomes.

To ensure that the study data were as homogeneous as possible, we extracted prevalence estimates from each by using the study’s most conservative diagnosis. This method may also be a limitation of our review. There are no agreed standards regarding accuracy or reliability of different informants, and studies vary in their informant source. Using the most conservative estimates based on informant and full criteria rather than partial criteria may have affected prevalence. Finally, only 55 studies reported clinician involvement in the diagnosis of ADHD, and studies using these informants decreased over time; the impact of this outcome is unclear.

There is significant community and professional concern that ADHD is overdiagnosed. Some researchers have argued that to determine if overdiagnosis of ADHD has occurred, a comparison of actual diagnoses with the prevalence estimate of a large-scale, well-conducted, national representative study would be suitable. We contend that our estimates provide a suitable benchmark. Over time and editions of the DSM, the high-quality estimates of prevalence are relatively consistent. If diagnoses from national or state population surveys exceed our estimate, then prima facie overdiagnosis of ADHD may be occurring for some children. If fewer, then underdiagnosis may be occurring.

Prevalence estimates matter because they have an anchoring effect. If a condition is considered rare, a clinician does not often consider it as a primary diagnosis. Conversely, if deemed common, the condition is often considered one of the most likely diagnoses. ADHD is a well-known, “common” childhood diagnosis, and publications of high estimates receive widespread media coverage. We have established a benchmark prevalence estimate for ADHD by systematically extracting the most robust and conservative estimates from 36 years of published research.

There was a wide variation in prevalence estimates between studies, and few factors in our meta-regression explain this variation. It is possible that how the diagnostic criteria were applied may explain some of the variation. For example, although 2 studies may consider the extent to which ADHD symptoms clinically affect an individual, the subjective interpretation of “clinically significant” can vary. This qualification was added to DSM-IV criteria and has been criticized for its subjectivity. It has been changed in the to symptoms must “interfere with, or reduce the quality of” functioning. How this change affects the prevalence of ADHD is unknown.

Conclusions

Given the range of prevalence estimates in published studies and that these estimates matter to professionals and the public alike, it is clear that how the criteria of the DSM are applied must be standard and systematic. Media reports of high rates of diagnosis may cause suspicion regarding the diagnosis overall and can lead to stigma for those diagnosed with the condition. Extensive media coverage of prevalence estimates that exceed expectations subject the diagnosis of ADHD to ridicule and incredulity, and harms those with severe problems the most. An accurate diagnosis is arguably the single most important thing a clinician can do for a patient, and our estimates may help to better establish population-based benchmarks for clinicians to consider.

Footnotes

Dr Thomas, Ms Sanders, Dr Doust, and Dr Glasziou conceptualized and designed the study; Dr Thomas led the review process, drafted the initial manuscript, and with Ms Sanders reviewed all articles and extracted data; and Dr Beller and Dr Thomas analyzed and interpreted the data. All authors made substantial contributions to revising the manuscript and approved the final manuscript as submitted.

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