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PubMedDate not supplied

Asthma and allergic rhinitis in Quebec children.

BACKGROUND: The Health and Social Survey of Quebec Children and Youth, conducted on representative samples of children nine, 13 and 16 years of age, provided data on the prevalence and determinants of asthma and allergic rhinitis in Quebec. OBJECTIVES: To determine the prevalence of asthma and allergic rhinitis among children in the province of Quebec and to identify the determinants of these pathologies. METHODS: Three groups of more than 1100 children aged nine, 13 and 16 years were recruited. Respiratory symptoms were documented using the International Study of Asthma and Allergies in Childhood questionnaire. Questions enquiring about family income, smoking, degree of urbanization of the child's school's location and various variables related to indoor air were also included. The comparisons of proportions were done using the chi2 test. RESULTS: The prevalence rates for reported history of asthma varied from 14% to 15% depending on the age group. The prevalence of wheezing in the past year was 7% to 8%. Asthma was the primary cause of the limitation of activities due to a health problem in nine- and 13-year-old Quebecers, and the second most common cause in 16-year-old Quebecers. The prevalence of rhinitis, rhinoconjunctivitis and reported history of hay fever increased with age, reaching 28.0%, 15.9% and 21.1%, respectively, in the 16-year-old group. The prevalence of asthma and wheezing was associated with family history and allergies, and inversely related to family income. CONCLUSIONS: The prevalence of childhood asthma is high in the province of Quebec. It is a major cause of the limitation of activities due to a health problem for young Quebecers. A family history of asthma and an atopic predisposition are important determinants in the development of asthma in Quebec.

Adolescent↗
PubMed2005

Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland.

BACKGROUND: The use of psychotropic drugs is high in institutionalised elderly, which raises the question of its appropriateness. This study aimed to: (1) estimate the use of psychotropics, for each family, in terms of the prevalence and dosage among the elderly in nursing homes in French-speaking Switzerland and Quebec; and (2) assess, for each family of psychotropic drugs and for each care facility, the prevalence of use and departure from average prescription (ratio of observed-to-expected prevalence). METHOD: An administrative database was used for this cross-sectional analysis. The sample included 8183 Quebec and 7592 Swiss long-term care residents. Three classes of psychotropics (antipsychotics, antidepressants, hypnotics-anxiolytics) were defined as dichotomous variables. Logistic regressions were conducted to identify residents characteristics associated with the use of each psychotropic type and to compute expected prevalence. RESULTS: Swiss residents were slightly older and less dependent than Quebec residents. Use of psychotropic drugs was higher in Swiss than in Quebec residents, on the whole as well as for each family of drug. A total of 78.1% of Swiss residents used at least one drug as compared to 66.9% in Quebec. Ninety percent of residents were given less than 7 defined daily doses per week, irrespective of the drug family. According to Beer's criteria, only 4.9% of prescriptions were inadequate. In Quebec and in Switzerland, the prevalence of antidepressant use was associated with the prevalence of hypnotic-anxiolytic use. No ratios of observed-to-expected reached statistical significance. INTERPRETATION: There was a considerable use of psychotropics in Quebec and Switzerland with, seemingly, no dramatic departure from the average practice. Our data cannot tell if there is a global overuse of psychotropics, but indicated that dosage and medication selection seem adequate. Physicians should critically reassess the necessity of prescribed medications for their patients.

Activities of Daily Living↗
PubMed2004

Seasonal congestive heart failure mortality and hospitalisation trends, Quebec 1990-1998.

STUDY OBJECTIVE: To describe seasonal congestive heart failure (CHF) mortality and hospitalisations in Quebec, Canada between 1990-1998 and compare trends in CHF mortality and morbidity with those in France. DESIGN: Population cohort study. SETTING: Province of Quebec, Canada. PATIENTS: Mortality data were obtained from the Quebec Death Certificate Registry and hospitalisation from the Quebec Med-Echo hospital discharge database. Cases with primary ICD-9 code 428 were considered cases of CHF. RESULTS: Monthly CHF mortality was higher in January, declined until September and then rose steadily (p<0.05). Hospital admissions for CHF declined from May until September (moving averages analysis p<0.0001). Seasonal mortality patterns observed in Quebec were similar to those observed in France. CONCLUSION: CHF mortality in Quebec is highest during the winter and declines in the summer, similar to observations in France and Scotland. This suggests that absolute temperatures may not necessarily be that important but increased CHF mortality is observed once environmental temperatures fall below a certain "threshold" temperature. Alternatively better internal heating and warmer clothing required for survival in Quebec may ameliorate mortality patterns despite colder external environments.

Climate↗
PubMed1987

Canadian federalism and the Canadian health care program: a comparison of Ontario and Quebec.

The Quebec and Ontario health insurance and health service delivery systems, developed within the parameters of federal regulations and national financial subsidies, provide generally universal and comprehensive basic hospital and medical benefits and increasingly provide for the delivery of long-term care services. Within a framework of cooperative federalism, the health care systems of Ontario and Quebec have developed uniquely. In terms of vital statistics, the health of Ontario and Quebec residents generally is comparable. In viewing expenditures, Quebec has a more clearly articulated plan for providing accessible services to low-income persons and for integrating health and social services, although it has faced some difficulties in seeking to achieve the latter goal. Its plans for decentralized services are counter-balanced by a strong provincial role in health policy decision-making. Quebec's political culture also allows the province to play a stronger role in hospital planning and in the regulation of physician income than one finds in Ontario. These political dynamics allow Quebec an advantage in control of costs. In Ontario, in spite of some recent setbacks, physician interests and hospital sector interests play a more active role in health system bargaining and are usually able to influence remuneration and resource allocation decisions more than physician interests and hospital sector interests in Quebec.

Canada↗
PubMedDate not supplied

Comparison of the prevalence of cardiovascular risk factors between Quebec and other Canadian provinces: the Canadian heart health surveys.

OBJECTIVE: To compare the prevalence of different cardiovascular (CVD) risk factors between Quebec, a Canadian Province with a population of mainly French descendants, and other Canadian provinces. DESIGN: Cross-sectional surveys in the ten Canadian provinces using stratified, two-stage, replicated probability samples from health insurance registries. PARTICIPANTS: A total of 2,353 Quebec residents and 20,776 other Canadians aged 18 to 74 years were surveyed. INTERVENTION: Standardized interviews and measurement of CVD risk factors. RESULTS: Compared with other provinces, Quebec had a higher prevalence of smoking, (32% vs 25%), dyslipidemia (48% vs 43%), a similarly sedentary lifestyle (37% vs 38%), a lower prevalence of hypertension (19% vs 23%) and body mass index > or =27 (28% vs 33%). Prevalence of two of the above risk factors was greater in Quebec (29%) than in the other provinces (25%). The difference in the prevalence of dyslipidemia between Quebec and the other provinces remained after stratification by body mass index and smoking status. Combination of risk factors differed between Quebec and the other provinces. CONCLUSIONS: Different genetic backgrounds, cultural influences occurring at different times among different age groups, as well as different trends in CVD risk factors and their interaction may explain why cross-sectional surveys cannot fully explain the differences in CVD mortality between ethnic groups. Given these differences in CVD risk factors between Quebec and other provinces, the relatively high level of all risk factors in Canada justifies increased focus on the Canadian Heart Health Initiative and attention to regional and ethnic differences when addressing CVD risk factors.

Adolescent↗
PubMedDate not supplied

Expert consensus for training in perioperative echocardiography in the province of Quebec.

PURPOSE: Establish an expert consensus for training in perioperative echocardiography in the province of Quebec. METHODS: Cardiac anesthesiologists practicing in the province of Quebec with expertise in echocardiography were involved in the development of a multicentre expert consensus on training in perioperative echocardiography. Guidelines for training in adult echocardiography, transesophageal echocardiography and perioperative echocardiography by the American Society of Echocardiography (ASE), the American College of Cardiology (ACC) and/or the Society of Cardiovascular Anesthesiologists (SCA) were reviewed. RESULTS: A basic, advanced and director level of expertise were identified for training in perioperative echocardiography. The total number of echocardiographic examinations to achieve each of these levels of expertise remains unchanged from the 2002 ASE-SCA guidelines. However, the recommended proportion of examinations performed personally is increased in the Quebec expert consensus for both the basic and the advanced level of training to ensure proficiency in echocardiography while providing anesthesia care to the patient. A level of autonomy in perioperative echocardiography is also identified in the basic level of training as defined in the Quebec expert consensus. Maintenance of competence, certification in the perioperative transesophageal echocardiography (PTE) examination and duration of training are outlined for each of the three levels of training in the Quebec expert consensus but are not part of the recent 2002 ASE-SCA guidelines. CONCLUSION: Adequate perioperative echocardiographic training is an important aspect of cardiovascular anesthesia. The ACC, ASE and SCA guidelines for training in echocardiography were modified to reflect the expert consensus of anesthesiologists in the province of Quebec.

Anesthesiology↗
PubMed1998

Mutation at the phenylalanine hydroxylase gene (PAH) and its use to document population genetic variation: the Quebec experience.

We describe variation at the PAH locus in the population of Quebec. We successfully analyzed 135 of 141 chromosomes from phenylketonuria (PKU) probands (95.7% of the sample), and eight additional chromosomes from a small number of probands with non-PKU hyperphenylalaninemia (HPA). The full set of chromosomes harboured 45 different PAH mutations: i) seven polymorphisms (IVS2nt19, IVS3nt-22, IVS6nt-55, Q232Q, V245V, L385L, Y414Y); ii) four mutations causing non-PKU HPA (T92I, E390G, R408Q, D415N); iii) 34 mutations causing PKU. Only six mutations (M1V, R261Q, F299C, S349P, R408W and IVS12nt1) occurred in the whole province at relative frequencies > 5%: most are rare and probably identical by descent. By studying associations of mutations with polymorphic haplotype alleles, we found examples of mutations on different haplotypes that were identical by state, but not by descent because they were recurrent mutations (E280K and R408W); and examples of mutations identical both by state and by descent because of intragenic recombination (S67P, G218V, V245A and IVS12nt1). Ten mutations were first described in Quebec and five are still unique there; three of these 'Quebec' mutations are reported here for the first time (c.125A-->T (K42I); [c.470G-->A; c.471A--C] (R157N); c.707nt-55 (IVS6nt-55). The PAH mutations stratify by geographic region and population, their distributions validating hypotheses about European range expansion to North America during three separate phases of immigration and demographic expansion in the Quebec region over the past four centuries. The PAH homozygosity value (j) is 0.06 for the total Quebec sample (0.5-0.08 by regions), and the corresponding homoallelic fraction of mutant PAH genotypes is 24%. These findings are a documentation of genetic diversity in the Quebec population.

Alleles↗
PubMed2001

Clinical results of an investigation of paediatric upper limb myoelectric prosthesis fitting at the Quebec Rehabilitation Institute.

This study was designed to investigate the satisfaction level of young users of myoelectric prostheses who received an upper limb myoelectric prosthesis, to assess their dropout rate and to identify which factors influence the use or non-use of the upper limb myoelectric prosthesis in the eastern part of Quebec (Canada). The users were fitted between 1990 and 1999 at the Quebec Rehabilitation Institute, a major rehabilitation centre located in the province of Quebec. This rehabilitation centre provides cutting-edge expertise not only for the eastern part of Quebec, but also across the entire province, because it is one of only two highly specialised centres serving all of Quebec. A literature review was completed to compile the results obtained in other rehabilitation centres and to identify factors influencing the use or non-use of paediatric upper limb myoelectric prostheses. The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) was used in order to assess the degree to which the children were satisfied with their prostheses. Eighteen (18) children were fitted and trained to use an upper limb myoelectric prosthesis. A total of 10 children and parents agreed to participate. Some 80% of participants said that they were satisfied with their prostheses. A dropout rate of 53% for the overall group (participants and non-participants) seems high compared with that of other studies. Recommendations linked to factors identified in the literature are made. The authors conclude that a multidisciplinary team and structured training and follow-up can improve the clinical results pertaining to all the factors proposed in the literature.

Adolescent↗
PubMed2003

Cardiac procedure use and outcomes in elderly patients with acute myocardial infarction in the United States and Quebec, Canada, 1988 to 1994.

BACKGROUND: Studies from the early 1990s have documented greater intensity of treatment for patients with acute myocardial infarction (AMI) in the United States compared with Canada, with little difference in health outcomes. Little is known about whether treatments and outcomes are changing differently over time in the two countries, and whether the differences vary with patient age. METHODS: We conducted a retrospective cohort study of trends in cardiac procedure use, mortality, and recurrent AMI for patients 65 years or older hospitalized with AMI in the United States and Quebec. We examined Medicare claims and enrollment data from the United States (1.5 million) and provincial claims data from Quebec (35,000) between 1988 and 1994. RESULTS: Use of cardiac procedures grew more rapidly between 1988 and 1994 in the United States, particularly for patients 75 years or older; unlike in Quebec, these cardiac procedures were performed soon after AMI. Both countries experienced significant declines in 1-year mortality: the decline averaged 1.27% points per year in the United States and 1.05% points in Quebec (P = ns). For AMI patients 75 years or older, 30-day and 1-year mortality declined approximately twice as rapidly in the United States as in Quebec (P < 0.01). The decline in mortality in the United States relative to Canada was significantly greater among patients 75 years or older but not among those age 65 to 74 years. Readmission rates with recurrent AMI were almost unchanged. CONCLUSIONS: Over time, the use of cardiac procedures in elderly patients with AMI has risen more rapidly in the United States than in Quebec. These differences in procedure trends were associated with reductions in overall long-term AMI mortality in both countries.

Aged↗
PubMed2002

Discriminative and predictive validity assessment of the quebec task force classification.

STUDY DESIGN: A prospective cohort study of workers with low back pain who had been absent from work for more than 4 weeks was conducted. OBJECTIVE: To assess the discriminative and predictive validity of the Quebec Task Force Classification for workers during the subacute phase of disability from back pain. SUMMARY OF BACKGROUND DATA: The Quebec Task Force Classification was designed for clinical decision making, prognosis establishment, quality of care evaluation, and scientific research in low back pain. METHODS: For this study, 104 workers absent from work because of back pain were classified according to the first four categories of the Quebec Task Force Classification 4 weeks after their first day of work absence. They then were randomized into four treatment groups: standard care (control), clinical-rehabilitation intervention, occupational intervention, and the Sherbrooke model (a combination of the clinical-rehabilitation and occupational interventions). Functional status, pain level, and work status were assessed at baseline and after 1 year. Duration of full compensation and back-related costs were calculated over a mean follow-up period of 6.5 years. The discriminative validity of the Quebec Task Force Classification was evaluated using Kendall tau correlation coefficients. Predictive validity was evaluated using logistic regression analyses. Age, gender, comorbidities, body mass index, and treatment group were considered as potential confounders. RESULTS: Significant but low correlation coefficients were found between Quebec Task Force Classification categories and functional status scores at baseline. Subjects classified as having distal radiating pain (categories 3 and 4) at baseline were more likely to have a lower functional status, higher pain level, and no return to regular work at the 1-year follow-up evaluation. They also were more likely to accumulate more days of full compensation and to cost more after a mean follow-up period of 6.5 years. CONCLUSION: The Quebec Task Force Classification demonstrated good predictive ability by discriminating between subjects with and those without distal radiating pain.

Adult↗
PubMed2005

The privatization of wine sales in Quebec in 1978 and 1983 to 1984.

BACKGROUND: In 1978, grocery stores in Quebec were allowed to sell domestically produced wine along with wine that was imported and bottled by the Liquor Board in Quebec. This right was extended in 1983 to include imported wine that was bottled by privately owned manufacturers in Quebec. Larger grocery store chains were also allowed to sell wine in 1984. The aim of this study was to evaluate the effects of these policy changes on alcohol sales, primarily on sales of wine and total sales but also on sales of spirits and beer. METHODS: Interrupted time-series analysis (ARIMA) with a quasi-experimental control area design was used. Canada, with the exception of the province of Quebec, was the control area. All time series were differenced to remove long-term trends. Possible permanent effects of the policy changes on alcohol sales were measured by means of intervention variables. Alcohol sales, in liters of pure alcohol per inhabitant aged 15 and above, were used as the dependent variable. Alcohol prices and the inhabitants' disposable income were used as control variables. RESULTS: Contrary to earlier studies regarding these policy changes in Quebec, the results presented in this study showed a significant and permanent effect of the policy change in 1978. The sale of wine increased by 10%, but the effect was not so large as to affect total sales. Sales of spirits and beer were not significantly affected. In 1983 to 1984, no immediate significant increase in sales of wine was found. CONCLUSIONS: The estimated effect of the policy change in 1978 was modest compared with results presented in most earlier studies regarding the privatization of wine sales in other jurisdictions. One explanation could be that the policy change in Quebec was valid only for a limited number of wines, which accounted for only a fraction of the total alcohol sales market.

Alcoholic Beverages↗
PubMed1999

Prevalence and geographic disparities in certain congenital anomalies in Quebec: comparison of estimation methods.

The purpose of this study was to estimate the prevalence of congenital anomalies in Quebec from MED-ECHO hospitalization records and from records of stillbirths. The results are first compared with those from the Canadian Congenital Anomalies Surveillance System (CCASS) for Quebec and Canada; then the data are examined by period and region of residence. The study results show that, for the congenital anomalies selected for the study, the prevalence rates measured for Quebec from the MED-ECHO data tend to be lower than the prevalence rates for Canada, whereas the rates estimated by CCASS are higher for Quebec than for Canada. The MED-ECHO data cover practically all Quebec births, compared with only 15% coverage by CCASS, and therefore provide a more accurate picture of congenital anomalies in Quebec.

Canada↗
PubMedDate not supplied

Adolescent suicide in Quebec and prior utilization of medical services.

BACKGROUND: Psychopathology is the main risk factor for adolescent suicide but several studies have shown that only a small proportion of suicide victims receive mental health care during the months preceding their suicide. The goal of this study is to describe the utilization of medical services by Quebec adolescent suicide victims during the year preceding their suicide. METHODS: All suicides of persons aged 19 or less that occurred during a five-year period were retrieved from the Quebec Coroner's database. Corresponding medical services utilization data were retrieved from the Quebec physician payment database (RAMQ) and the Quebec hospitalization database (MED-ECHO). Data were analyzed in terms of types and intensity of medical services (physical or psychiatric), types of providers (general practitioners, psychiatrists, and other medical specialists), and timing of interventions relative to the date of suicide. RESULTS: 78% of all Quebec adolescent suicide victims utilized medical services during the year before their suicide. However, only 12% of all victims received medical attention for psychiatric problems, and only 9.9% met with a psychiatrist during that same period of time. General practitioners and non-psychiatric medical specialists provided medical attention for psychiatric problems to only 5.6% and 0.7% of those future suicide victims with whom they met in outpatient settings, and the intensity of their interventions was low. INTERPRETATION: These results suggest that the level of recognition and treatment of psychopathology in Quebec adolescents who later commit suicide is low, despite the fact that a large proportion of them meet with physicians during the year preceding their suicide. This suggests that information and training programs pertaining to adolescent suicide and psychopathology should be implemented for GPs and non-psychiatric medical specialists as well.

Adolescent↗
PubMed1994

Mutation profiles of phenylketonuria in Quebec populations: evidence of stratification and novel mutations.

Independent phenylketonuria (PKU) chromosomes (n = 109) representing 80% of a proband cohort in Quebec province carry 18 different identified mutations in 20 different mutation/haplotype combinations. The study reported here, the third in a series on Quebec populations, was done in the Montreal region and predominantly on French Canadians. It has identified three novel mutations (A309D, D338Y, and 1054/1055delG[352fs]) and one unusual mutation/RFLP haplotype combination (E280K on Hp 2). The relative frequencies and distribution of PKU mutations were then compared in three regions and population subsets (eastern Quebec, French Canadian; western Quebec, French Canadian; and Montreal, non-French Canadian). The distributions of the prevalent and rare mutations are nonrandom and provide evidence for genetic stratification. The latter and the presence of eight unusual mutation/haplotype combinations in Quebec families with European ancestries (the aforementioned four and M1V, I65T, S349P, and R408W on Hp 1) corroborate demographic and anthropologic evidence, from elsewhere, for different origins of French Canadians in eastern and western Quebec.

DNA Mutational Analysis↗
PubMed1994

A study of factors affecting dental expenditures in Quebec: 1962-1991.

The issue of dental manpower planning has received considerable attention in Quebec in recent years. Quebec dentists agree that there is a need for detailed information regarding the impact of economic factors on the supply of and demand for dental care in the province. This study examines the impact of economic factors on dental care expenditures in Quebec between 1962 and 1991. The functional form of the econometric model used by the authors is similar to the one used in a study of the growth of the U.S. dental sector between 1950 and 1989. The dependent variable is per capita dental expenditure, and the three independent variables are: dentist/population ratio, per capita personal disposable income; and percentage of the population with dental insurance coverage. All data come from secondary sources. The findings indicate that per capita dental expenditure has grown substantially in Quebec over the past three decades, with the rate of growth slowing dramatically during the 1980s. Dental insurance coverage, the number of dentists in the community and the disposable income of the population all have a positive impact on dental expenditure in Quebec. However, it is clear that the incomes of Quebec dentists may decrease in the future if: no restrictions are placed on the number of new dental graduates entering the profession; dental insurance programs are curtailed; or dental disease levels continue to fall.

Dentistry↗
PubMed1996

Biomedical research in Quebec: the history of the Fonds de la recherche en santé du Québec.

The author describes the history of the Fonds de la recherche en santé du Québec, from after World War II to the present day. The Conseil de la recherche médicale du Québec (Quebec Medical Research Council) was created in 1964 to bring Quebec up to speed in biomedical research through programs that complemented those of the Medical Research Council of Canada. The council progressively evolved, becoming the Conseil de la recherche en santé du Québec (Quebec Health Research Council) in 1974 and the Fonds de la recherche en santé du Québec (FRSQ) in 1982. The FRSQ covers all aspects of medical research, in its broadest sense. Quebec's progress in biomedical research has been spectacular and has had direct and considerable influence on the quality of medical education and patient care. From 1982 to 1996, various Quebec governments have devoted more than +500 million to the FRSQ, a testimony to their comprehension of the importance of this area and to their farsightedness. The FRSQ and its predecessor organizations have been a major force in improving and maintaining the quality of medical teaching and care in Quebec during the last three decades.

Academies and Institutes↗
PubMed1997

[Cardiac surgery in Quebec: Do we have too many centers? Too many surgeons? Too many patients?].

OBJECTIVE: In restructuring the Quebec health care system with hospital budget cuts, salary ceiling of physicians and a small number of practising cardiac surgeons, the future of this specialty needs to be defined beyond individual self-interest. To evaluate the actual situation and to suggest changes that will improve surgical care delivery in cardiac surgery, surgeon and centre case loads in the province of Quebec were reviewed. DESIGN: Retrospective study. SETTING: Province of Quebec, 1994. PATIENTS: Patients who underwent coronary artery bypass grafting in 1994. RESULTS: The rate of coronary bypass grafting in Quebec was similar to that in Canada as a whole. The number of patients undergoing coronary artery bypass grafting increased at a rate of 6.5%/year during the five years preceding 1994, when operations numbered 5000. Thus, 7000 procedures will be performed in the year 2000 if the actual increase remains similar. There are 12 centres performing cardiac surgery in Quebec, with one centre/600,000 population and 3.4 surgeons/centre, compared with one centre/800,000 population and 3.7 surgeons/centre in Canada. In the year 2000, to accommodate 7000 cases, 18 centres will be required for a minimal case load per centre (300 cases/centre) or nine centres for an optimal case load per centre (700 cases). CONCLUSION: Each centre of cardiac surgery should perform an optimal volume of cases to achieve maximal use of human and physical resources devoted to the care of cardiac surgical patients in the province of Quebec.

Cardiac Care Facilities↗
PubMedDate not supplied

[Cigarette usage in Quebec from 1985 to 1994: a comparison with Canada].

Smoking is responsible for the highest number of avoidable illnesses and deaths in Canada. Cigarette smoking declined considerably in the adult population between 1965 and 1986, but what has happened over the past decade? Quebec and Canadian public surveys were used to compare types of cigarette use in Quebec and Canada between 1985 and 1994, as well as to compare them by sex. In recent years, the prevalence of smoking has increased among Quebec men only. Differences between Quebec and Canada can be seen in the evolution of the quit rate and the prevalence of smokers. There does not appear to be any indication that differences in cigarette smoking between Quebec and Canada are being eradicated. In Quebec, the evolution of this habit differs according to sex, which indicates that certain factors affect men and women differently. The public survey data make it possible to follow trends in the medium and long term, whereas it is difficult to accurately track the evolution of cigarette smoking from one year to the next, given the small size of the samples in each region and the slow evolution of behaviour.

Adolescent↗