Modelling covariate effects in observer agreement studies: the case of nominal scale agreement

Correction for chance-expected agreement has become an accepted technique in the analysis of observer agreement data and may be particularly useful when the level of agreement achieved in different populations is compared. However, formal methods for making comparisons of chance-corrected agreement or, more generally, for studying the effects of covariates on chance-corrected agreement have not received much attention. For nominal scale agreement data we show how Tanner and Young's model for observer agreement can be applied to this problem. The models discussed can be fitted using existing software and certain model parameters have interpretations in terms of positive and negative agreement odds ratios. The proposed methodology facilitates investigation of issues such as confounding of covariate effects and interaction between covariates in their effect on chance-corrected agreement. The methods outlined therefore allow observer agreement data to be analyzed in a manner strongly analogous to the logistic modelling of the association between disease and suspected risk factors. The methods are illustrated using data on the comparability of primary and proxy respondent reports of the primary respondents participation in physically vigorous leisure time activity.

Adolescent girls. I. Self-reported mood disturbance in a community population

BACKGROUND

This study was undertaken to fill gaps in our knowledge of the rate of mood disorder in teenage girls in transition from school to further education, employment or unemployment.

METHOD

Girls aged 15-20 years (n = 529) whose names were drawn from general practitioner age/sex registers were interviewed at home and completed the Great Ormond Street Mood Questionnaire. Their mothers completed the 28-item General Health Questionnaire (GHQ). Social background variables were obtained.

RESULTS

Of the girls, 20.8% scored over the cut-off point previously established to indicate risk of psychiatric disorder. Scoring over the cut-off point was not associated with age or parental social class. It was associated with parental separation/divorce (P < 0.004), with maternal self-report on the GHQ (P < 0.001), and with parental unemployment (P < 0.04). Lowest self-report scores were obtained by girls who had left school and were in employment (P < 0.01).

CONCLUSIONS

About one in five of girls aged 15-20 are at risk of affective disorder. Self-reported mood disturbance is associated with a wide range of social and familial background variables, but not with age or parental socioeconomic status.

Adolescent girls. II. Background factors in anxiety and depressive states

BACKGROUND

This study investigated the prevalence and background variables associated with anxiety and depressive disorders occurring in a community population of older teenage girls.

METHOD

Girls aged 15-20 years (n = 529) whose names were drawn from general practitioner age/sex registers completed self-report Great Ormond Street Mood Questionnaires. From this sample, 143 girls (69 with high self-report scores and 74 controls) were intensively interviewed. Information was obtained on confiding/supportive relationships, family arguments and rows, quality of marital relationship, and degree of parental control. Psychiatric state was assessed by use of the Clinical Interview Schedule to provide a Total Weighted Score. A modified form of the Bedford Life Events and Difficulties Schedule was applied.

RESULTS

The estimated one-year prevalence rate for psychiatric disorder was 18.9%, and 16.9% for depression and anxiety disorders. Using a logit analysis, it was shown that maternal distress (P < 0.02) and the quality of the mother's marriage (P < 0.02) were independently associated with the presence of depression and anxiety disorders.

CONCLUSIONS

About 17% of girls in a community sample living at home showed a depression or anxiety disorder. Even in late adolescence, the presence of a mood disorder is closely linked to the quality of family relationships within the home.

Lipid peroxidation as a measure of oxygen free radical damage in the very low birthweight infant

(ABSTRACTOxygen free radical mediated tissue injury is implicated as a major factor in the pathogenesis of the long term complications seen in the premature infant, and direct evidence of their role in the development of these long term problems is lacking. A prospective observational study of 78% of very low birthweight infants admitted to a level III neonatal intensive care unit in 1992 was undertaken to determine the relationship between lipid peroxidation products, antioxidant activity, and outcome. Lipid peroxidation (malondialdehyde-thiobarbituric acid, MDA-TBA) and antioxidant activity (vitamin E and glutathione peroxidase activity) were measured in 22 very low birthweight infants in the cord blood and the infant's blood at 24 hours, 48 hours, and 1 week of age and correlated with outcome measures. The normal range for these measures was established in the cord blood samples of 48 consecutive healthy full term infants. The concentration of MDA-TBA at 1 week correlated with the number of days of oxygen treatment and number of days of positive pressure ventilatory support. Controlling for gestational age and antenatal complications simultaneously the MDA-TBA concentration remained significantly associated with the number of days of oxygen treatment and the number of days of positive pressure ventilatory support. Glutathione peroxidase was low in the premature and full term infants consistent with the low concentrations of selenium known to be present in southern New Zealand. There was evidence of a quadratic relationship between vitamin E at 1 week and the total number of days of supplementary oxygen requirement, with both high and low values associated with increased oxygen requirement. This association, however, did not remain after controlling for gestational age and antenatal complications. These results support the role of oxygen free radicals in mediating tissue damage associated with the development of chronic lung disease in the premature infant.

Human immunodeficiency virus type 1 protease inhibitors: evaluation of resistance engendered by amino acid substitutions in the enzyme's substrate binding site

The human immunodeficiency virus type 1 (HIV-1) protease is a homodimeric aspartyl endopeptidase that is required for virus replication. A number of specific, active-site inhibitors for this enzyme have been described. Many of the inhibitors exhibit significant differences in activity against the HIV-1 and HIV type 2 (HIV-2) enzymes. An initial study was conducted to ascertain the HIV-1 protease's potential to lose sensitivity to several test inhibitors while retaining full enzymatic activity. The substrate binding sites of the HIV-1 and HIV-2 enzymes are almost fully conserved, except for four amino acid residues at positions 32, 47, 76, and 82. Accordingly, recombinant mutant type 1 proteases were constructed that contained the cognate type 2 residue at each of these four positions. The substitution at position 32 resulted in a significant adverse effect on inhibitor potency. However, this substitution also mediated a noted increase in the Km of the substrate. Individual substitutions at the remaining three positions, as well as a combination of all four substitutions, had very little effect on enzyme activity or inhibitor susceptibility. Hence, the four studied active site residues are insufficient to be responsible for differences in inhibitor sensitivity between the HIV-1 and HIV-2 proteases and are unlikely to contribute to the generation of inhibitor-resistant mutant HIV-1 protease.

Multiple organ dysfunction: pathophysiology and therapeutic modalities

This article focuses on the physiologic systemic inflammatory immune response system that occurs normally to any event resulting in cellular injury. A review of the mediators of the inflammatory immune response system is presented along with the pathophysiologic description of the development of multiple organ dysfunction syndrome and the complex interrelationships between inflammatory mediators and the host cell. Endotoxin is reviewed as a suspicious precursor in the development of the multiorgan cascade and the response of key mediators in the complement system, tumor necrosis factor, interleukin 1, and oxygen radicals. A review of the literature is presented in an effort to describe new therapeutic modalities specifically developed in an effort to alter mediator-induced inflammatory immune responses at the cellular level.

Primary versus proxy respondents: comparability of questionnaire data on alcohol consumption

Questionnaire data on alcohol consumption obtained from primary respondents participating in a community-based case-control study of coronary heart disease were compared with similar data obtained from their next of kin. The primary respondents were men and women aged 25-64 years who were a representative sample of myocardial infarction cases (n = 58) and controls (n = 456) from the case-control study. The study was conducted in Auckland, New Zealand between 1986 and 1988. When alcohol drinking frequency was collapsed into five categories, exact agreement between primary respondents and next of kin was 64% for cases and 62% for controls. Agreement within one category (plus or minus) was 89% for both cases and controls. Tests of marginal homogeneity showed no evidence that next of kin systematically over- or underestimated the primary respondents' self-reported drinking frequency. With respect to the amount of alcohol drunk, mean differences between primary respondents and next of kin were small (mean difference: 2.25 g per day for cases; -0.77 g per day for controls), although there was considerable variability between individual pairs in the level of agreement. The findings suggest that studies which use proxy sources of data to assess alcohol drinking are unlikely to produce biased estimates of alcohol consumption at the aggregate level, particularly with regard to frequency measures.

The analysis of ordinal agreement data: beyond weighted kappa

The weighted kappa statistic has been used as an agreement index for ordinal data. Using data on the comparability of primary and proxy respondent reports of alcohol drinking frequency we show that the value of weighted kappa can be sensitive to the choice of weights. The distinction between association and agreement is clarified and it is shown that in some respects weighted kappa behaves more like a measure of association than an index of agreement. In particular, it is demonstrated that the weighted kappa statistic is not always sensitive to differences in the observed proportion in exact agreement and that high values of weighted kappa can be observed even when the level of agreement is low. We illustrate the use of statistical models in the analysis of epidemiologic agreement data and conclude that modelling ordinal agreement data produces insights which cannot be obtained through the use of weighted kappa statistics.

Giardiasis in Canterbury: the first nine months reported cases

AIM

To obtain epidemiological information about giardiasis in Canterbury.

METHOD

From October 1990 general practitioners were requested to report laboratory confirmed cases. The first 100 cases were sent a questionnaire and also asked to provide the details of two persons to be controls.

RESULTS

In the first nine months 109 cases were reported. Eighty four cases completed questionnaires and 51 were matched with controls. The overall reported attack rate was 4.0 per 10,000 population per year. The rate was highest for preschool children and young adults and in rural areas. There was a significant risk associated with having contact with sewage or travelling overseas and a marginal risk for drinking water outside Christchurch.

CONCLUSION

The results indicated that giardiasis was relatively common in Canterbury and confirmed that the major mechanisms of infection were probably the same as those previously identified overseas, namely person to person spread via faecal-oral transmission and the drinking of inadequately filtered water.

Young spinal cord injured patients in nursing homes: rehospitalization issues and outcomes

Most spinal cord injured (SCI) patients are discharged to their homes and families after they complete their initial rehabilitation program. Nursing homes, however, were the discharge destinations for 3.9% of all SCI patients nationally. When a nursing home is the only discharge option for a young SCI adult, certain economic, medical and psychosocial incongruencies make this placement potentially stressful for both the nursing home staff and the young patient. This study of the rehospitalization of 12 SCI patients under the age of 50 who were discharged to nursing homes explores the issues of cost, care and outcome during their first year following nursing home admission. Nine of the 12 patients were rehospitalized a total of 21 times, mainly for urinary tract infections and decubiti. Charges for 18 of these 21 rehospitalizations amounted to over $423,110 for 599 days of care. Four of these 9 patients died before the end of the first year. Although this is a retrospective study of the medical records and follow up data for a small key group of SCI patients, it calls attention to the need for continued investigation into the outcomes of a minimally visible population that lacks advocacy for change.

Biochemical Diagnosis of Pheochromocytoma by Simultaneous Measurement of Urinary Excretion of Epinephrine and Norepinephrine

The utility of specific assay of urinary catechols in pheochromocytoma diagnosis was examined by reviewing our data on the investigation of pheochromocytoma in a population of 2476 patients investigated over a six-year period. We used specific gas-chromatographic/mass-spectrometric (GC/MS) analysis for the simultaneous measurement of norepinephrine, dopamine, and the neuronal metabolites 3,4-dihydroxyphenylglycol (DHPG) and 3,4-dihydroxyphenylacetic acid (DOPAC) in all samples; the last two years of data collection (from 1101 patients) also included the specific GC/MS assay of epinephrine. The importance of assaying epinephrine as well as norepinephrine was shown by these latter data. During this latter period, 19 of 1101 patients were found to have pheochromocytoma; of these, nine had tumors that exclusively secreted norepinephrine, six had tumors that exclusively secreted epinephrine, and four exhibited excess production of both norepinephrine and epinephrine. Neither dopamine nor DOPAC was useful in the diagnosis of pheochromocytoma. A substantial proportion of patients may have uniquely epinephrine-secreting pheochromocytomas, previously considered a rarity. Thus we recommend that the biochemical testing for pheochromocytoma include the specific measurement of both norepinephrine and epinephrine.

Biochemical diagnosis of pheochromocytoma by simultaneous measurement of urinary excretion of epinephrine and norepinephrine

The utility of specific assay of urinary catechols in pheochromocytoma diagnosis was examined by reviewing our data on the investigation of pheochromocytoma in a population of 2476 patients investigated over a six-year period. We used specific gas-chromatographic/mass-spectrometric (GC/MS) analysis for the simultaneous measurement of norepinephrine, dopamine, and the neuronal metabolites 3,4-dihydroxyphenylglycol (DHPG) and 3,4-dihydroxyphenylacetic acid (DOPAC) in all samples; the last two years of data collection (from 1101 patients) also included the specific GC/MS assay of epinephrine. The importance of assaying epinephrine as well as norepinephrine was shown by these latter data. During this latter period, 19 of 1101 patients were found to have pheochromocytoma; of these, nine had tumors that exclusively secreted norepinephrine, six had tumors that exclusively secreted epinephrine, and four exhibited excess production of both norepinephrine and epinephrine. Neither dopamine nor DOPAC was useful in the diagnosis of pheochromocytoma. A substantial proportion of patients may have uniquely epinephrine-secreting pheochromocytomas, previously considered a rarity. Thus we recommend that the biochemical testing for pheochromocytoma include the specific measurement of both norepinephrine and epinephrine.

Rhizobium tropici, a novel species nodulating Phaseolus vulgaris L. beans and Leucaena sp. trees

A new Rhizobium species that nodulates Phaseolus vulgaris L. and Leucaena spp. is proposed on the basis of the results of multilocus enzyme electrophoresis, DNA-DNA hybridization, an analysis of ribosomal DNA organization, a sequence analysis of 16S rDNA, and an analysis of phenotypic characteristics. This taxon, Rhizobium tropici sp. nov., was previously named Rhizobium leguminosarum biovar phaseoli (type II strains) and was recognized by its host range (which includes Leucaena spp.) and nif gene organization. In contrast to R. leguminosarum biovar phaseoli, R. tropici strains tolerate high temperatures and high levels of acidity in culture and are symbiotically more stable. We identified two subgroups within R. tropici and describe them in this paper.

School reintegration: a rehabilitation goal for spinal cord injured adolescents

This article describes how the Education for All Handicapped Children Act of 1975, Public Law 94-142, assists in achieving the rehabilitation goal of school reintegration for spinal cord injured (SCI) adolescents. It also describes how subordinate goals are achieved during the inpatient rehabilitation phase. Comments from a survey of 13 SCI adolescents who returned to school demonstrate the need to prepare SCI adolescents for the services to which they are entitled, to acquaint them with ways of resolving possible problems they may encounter, and, when they return for follow-up care, to encourage them to continue in school.

The link between fluid intake and weight gain in psychosis

Diurnal weight gain was found to be abnormal among 44 of 77 institutionalized chronically psychotic patients. All patients were weighed and urine samples obtained weekly for 3 weeks at 7 A.M. and 4 P.M. Diurnal weight gain was normalized as a percentage by subtracting the 7 A.M. weight from the 4 P.M. weight, multiplying the difference by 100, and then dividing the result by the 7 A.M. weight. Normalized diurnal weight gain (NDWG) was 2.504 +/- 1.266% for the 44 study patients with abnormal findings, .631 +/- .405% for the 16 acutely psychotic controls, and .511 +/- .351% for 29 normals. Urine excretion was related (r = .476, p = .001) to NDWG in the subgroup of study patients with abnormal NDWG, consistent with the observation that their fluid intake exceeded fluid excretion in the afternoon.

From ICU to rehabilitation: a checklist to ease the transition for the spinal cord injured

Spinal cord injuries are devastating. The injured person faces many unknowns including surgical procedures, hospitalization and rehabilitation. Frequently, the transition from acute care to rehabilitation is frightening. In the intensive care unit (ICU), the patient receives one-to-one nursing care and develops trust, but then may feel abandoned when faced with rehabilitation. In order to facilitate readiness for rehabilitation, coordinators of the Southeastern Michigan Spinal Cord Injury System proposed a checklist of activities designed to meet individual patient and family needs. Coordinators assess the patient within 24 hours of admission to the spinal ICU. The physiatrist is notified of the admission and recommends initial therapies as appropriate. The patient is followed through the acute phase and preparations are made for rehabilitation. A checklist format has been developed to coordinate the transfer. This article describes the checklist and its use at our institution.

Previous pet ownership and Paget's disease

The relationship between pet ownership and Paget's disease (PD) of bone was investigated in 112 patients with PD who were matched with a similar number of community-based controls. There was a significantly increased frequency of dog ownership by patients with PD aged less than 60 years. Multivariate logistic regression analysis revealed that there was a significant age-related increase in risk of PD associated with past or present ownership of either dogs or cats, with younger patients having the greatest risk. These results suggest that slow virus infection of osteoclasts by paramyxoviruses acquired from pets may contribute to the development of Paget's disease in the younger patient.

The validity of Maori mortality statistics

Data from an Auckland coronary heart disease register have been used to assess the validity of Maori mortality statistics produced by the National Health Statistics Centre. During the period 1983-4, 804 people aged 35-64 years and resident in the Auckland statistical region, were identified by both the register and death registration data as having died of coronary heart disease. The coronary heart disease register failed to classify the ethnicity of thirteen of these people. Of the remaining 791 cases, the register classified 80 as Maori while only 44 were classified as Maori in the national death registration data; over the period 1983-4 Maori mortality due to coronary heart disease in the Auckland statistical region was understated by 82% (80-44/44). Although some of this discrepancy may be due to differences in classification of ethnicity, the major reason for the understatement is missing information on the death registration form. Simple changes in the documentation of ethnicity could markedly reduce the degree of underreporting.

Diurnal weight gain in chronic psychosis

We found diurnal weight gain to be abnormal among 93 chronically psychotic patients, most of whom had schizophrenia. They were weighed at 7 a.m. and 4 p.m. weekly for 3 weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and dividing the result by the 7 a.m. weight. NDWG was 1.7 +/- 1.0 percent for the study sample, 0.6 +/- 0.4 percent for 16 acutely psychotic controls, and 0.5 +/- 0.4 percent for 29 normals. More than 60 percent of the study sample had abnormal NDWG values. NDWG related to antipsychotic drug dose (r = 0.290, p = 0.005) with variability in drug dose accounting for 8 percent of the variability in NDWG. This report provides yet another piece of evidence that disordered water balance is common in chronic psychiatric patients. The etiology is unknown, but it may relate to subtle brain abnormalities in the regulation of fluid intake and excretion.

Validation of coronary heart disease death certificate diagnoses

Data from a coronary heart disease register in Auckland have been used to validate routine death certificate data produced by the National Health Statistics Centre. The register used current World Health Organisation criteria for definite or possible coronary heart disease and identified all suspected events in people aged less than 65 years for the years 1983 and 1984. During this period 768 coronary heart disease cases were included in the register and in the same population 772 death certificates were coded 410-414 (coronary heart disease), according to the ninth revision of the International Classification of Diseases, by the National Health Statistics Centre. Ninety one percent of deaths meeting the register's criteria for definite or possible coronary heart disease were coded 410-414 in the official data. Conversely of all death certificates coded 410-414, 93% were registered as due to coronary heart disease. The validity of subcategories was considerably lower; only 49% of deaths coded 410 (acute myocardial infarction) were categorised as definite myocardial infarction by the register. These findings suggest that the broad official statistics for the category coronary heart disease mortality (codes 410-414) are accurate to within approximately 10% in New Zealand; the validity of the subcategory myocardial infarction (code 410) is considerably lower.

A double-blind, placebo-controlled comparison of the efficacy of standard and individually titrated doses of theophylline in patients with chronic asthma

Forty adult patients with chronic asthma completed a 3-month double-blind crossover study to compare the effect of sustained-release theophylline given both as a fixed 300 mg twice daily dose (standard) and an individually titrated dose (titrated) with placebo. Theophylline was given in addition to other usual therapy, inhaled bronchodilators, inhaled steroids and, in 12 patients, oral steroids. The 3-month period was preceded by a run-in phase to determine the dose of theophylline which each subject required to achieve peak serum levels of 12-20 mg/litre and trough levels of 8-12 mg/litre. Doses ranged from 300 mg to 700 mg twice daily. Twenty-one patients needed more than the standard dose to achieve satisfactory serum levels. Patients recorded daily peak flow rates and symptom scores and were seen at monthly intervals to measure lung function, check serum theophylline levels and change treatments, which were given in random order. FEV1 was significantly higher for the whole group after standard (2.11 litres) and titrated (2.15 litres) theophylline therapy than after placebo (1.89 litres), as was FVC, but in the large subgroup whose titrated dose was greater than the standard dose, the FEV1 only improved with the titrated dose. Peak flow measurements at home showed the same pattern. Patients taking oral steroids appeared to derive less benefit from theophylline than others. It is concluded that theophylline can usefully be added as a third-line drug in chronic asthma, but that since half the patients are likely only to benefit from a dose greater than 300 mg twice daily, while the other half may have high serum levels above this dose, it is essential to measure serum levels in order to use the drug effectively and safely.

Abnormal diurnal weight gain among long-term patients with schizophrenic disorders

We found diurnal weight gain to be abnormal among 65 long-term patients with schizophrenic disorders. Patients were weighed at 7 a.m. and 4 p.m. serially and diurnal weight gain was normalized (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.2 +/- 1.5% for 47 male patients compared (P = 0.001) with 0.6 +/- 0.4% for 11 male controls. NDWG was 1.7 +/- 0.7% for 18 female patients compared (P less than 0.0001) with 0.5 +/- 0.3% for 14 female controls. We hypothesize that NDWG may be an index of both the severity and duration of the schizophrenic disorder.

Temperament and psychiatric disorder: the genetic contribution to behaviour in childhood

The studies stemming from the New York longitudinal study of temperament in childhood are summarised and conceptual difficulties and problems arising from them are described. An alternative model of temperament provided by Buss and Plomin is also considered. Finally, a new typology of temperament is proposed. It is based on the suggestion that ordinary, non-pathological behaviours, in extreme form, can be viewed as manifestations of emotional disorder, hyperactivity and antisocial disorder. Empirical evidence derived both from twin studies and from epidemiological investigations is put forward to support this view.

Operationalizing a nursing philosophy

A traditional philosophy statement can be transformed into a positioning statement that articulates a "vision" for a department of nursing and provides a framework when planning to thrive rather than merely survive in today's changing and competitive health care environment. Internal and external forces appropriately assessed enable nurse executives to empower staff to respond proactively to change and prepare for the future.

A twin study of genetic influences on reading and spelling ability and disability

The reading skills of 285 pairs of 13-year-old twins drawn from the general population were studied. The twins were independently tested using standardized measures of intelligence, reading and spelling ability. The genetic contribution to reading ability was assessed by examination of correlations in monozygotic (MZ) and same-sex dizygotic (DZ) twins, and by analysing differences between MZ and DZ twins in concordance of reading disability rates. The results suggested that, at this age, genetic factors play only a moderate role in general reading backwardness or specific reading retardation. However, when spelling ability was investigated, a heritability of 0.53 was obtained, increasing to 0.75 when intelligence was controlled. Strong genetic influences on spelling were also found when concordance rates for spelling disability were compared for MZ and DZ pairs.

Psychology and the health of children

Inappropriate behaviour and adverse social circumstances in childhood are responsible for a high proportion of physical morbidity and mortality not only in childhood itself but also in later life. Evidence is provided to support this statement, and the processes whereby social adversity in childhood lead to later ill health are considered. Recent evidence suggesting that, contrary to popular belief, health promotion in childhood could substantially reduce the prevalence of physical morbidity is reviewed. Emphasis is placed on the part played by techniques based on cognitive-behavioural approaches in the recent more successful examples of health promotion.

Topical sodium cromoglycate in the management of atopic eczema--a controlled trial

A double-blind, group comparison trial of a topical cream containing 4% sodium cromoglycate (SCG) was undertaken in forty-six patients with chronic atopic eczema. A statistically significant improvement was seen after 9 weeks in the actively treated patients compared with the placebo group. However, in general, no benefit was observed in severe eczema, perhaps due in some part to the seemingly late onset of action of SCG. Measurement of total serum IgE before and after the trial showed an increase in levels which was apparently unrelated to treatment with SCG or placebo or to a change in severity of the eczema. The amount of SCG in the urine was small and very variable, indicating low percutaneous absorption. The calculated bioavailability ranged from 0.01% to 2.75% of the applied dose. These results together with follow-up studies suggest that topical SCG as a long-term measure may be useful in the management of mild or moderately severe eczema, reducing the frequency of acute exacerbations.

Behaviour problems and language abilities at three years and behavioural deviance at eight years

A representative sample of 535 children were followed up from their third to their eighth birthday using measures of language ability and behaviour. At age 8 yr it was found that there were significantly more boys with behavioural deviance than girls, and that children from manual social class backgrounds also showed more behavioural deviance. The only difference between the immigrant and non-immigrant children was a less frequent occurrence of neurotic deviance in the immigrant group. It was found that behaviour problems at age 3 yr were strongly related to behavioural deviance at school at age 8 yr, particularly for boys. This medium-term stability in behaviour problems had not been found in previous studies looking at younger children. A low score on a measure of language structure at age 3 yr was found to be related to a high rate of neurotic deviance at age 8 yr even when behaviour at age 3 yr was controlled. The implications of these findings for the early identification and intervention with children at risk for later behaviour deviance are discussed.