Keywords: Racism, Nationalism, Education, Ethnic Conflict, Multiculturalism, Ethnography Racism, Cyprus, schools, identity, ethnography, resistance

This article examines Greek-Cypriot teachers' constructions of Turkish-speaking children's identities in the Greek-Cypriot educational system. Drawing on interviews and classroom observations from a two-year ethnographic study conducted in three primary schools in the Republic of Cyprus, the author explores how Turkish-speaking children enrolled in these schools are racialised, ethnicised and classed within the dominant discourse of Greek-Cypriot teachers. The article discusses how the homogenised perceptions expressed by the majority of participating teachers in this study are illustrative of structural racism that reinforces these constructions in teaching practices. Yet at the same time, resistance is present in the discourse and practice of a few teachers; this resistance is expressed through a counterpositioning of the 'normal/ised' identities of Turkish-speaking children. The author argues that without structural transformation, the fact and practice of racism/nationalism/classism will go unaltered in schools.

Introduction

From and the 1970s onward, a substantial number of studies in different educational settings have shown that teachers hold negative stereotypes and low expectations of racial/ethnic minoritised children. The literature relating to (negative) teacher expectations and constructions of children from minoritised ethnic/racial backgrounds shows that these stereotypical representations are mapped onto educational policy and everyday teaching practices [START_REF] Archer | They never go off the rails like other ethnic groups": Teachers' constructions of British Chinese pupils' gender identities and approaches to learning[END_REF]. In his recent review of research in England during the last three decades, [START_REF] Stevens | Researching race/ethnicity and educational inequality in English secondary schools: A critical review of the research literature between 1980 and 2005[END_REF] asserts that an investigation on the racialised, ethnicised and classed constructions expressed by teachers should not focus on whether teachers or specific school processes are racist racialised/ethnicised/classed, are there any pockets of 'resistance' [START_REF] Youdell | Impossible Bodies, Impossible Selves: Exclusions and Student Subjectivities[END_REF] to the 'normal/ised' identities ascribed to Turkish-speaking children, and if so, how are these resistances manifest in school life?

Critical race theory and teachers' constructions of minoritised children

Critical race theory

Critical Race Theory has its origins in US legal scholarship but is increasingly used by educators around the world (such as the UK, Europe and Australasia) to analyse the continued salience of structural racism in educational settings [START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF].

According to [START_REF] Delgado | Critical Race Theory[END_REF], there are six unifying tenets that define the movement of CRT: (1) racism is ordinary; (2) the current system of White-overcolour ascendancy serves important purposes; (3) race and races are products of social thought and relations; (4) the dominant society racialises different minority groups at different times; (5) intersectionality and antiessentialism are present, whereas everyone has overlapping, conflicting identities and loyalties; and (6) there is shared minority experience that people of colour communicate about race and racism that White people are unlikely to know is present. Central to these tenets is the notion that racism is pervasive and systemic, not merely an individual pathology. Racism is ingrained in everyday practices, events, institutional policy rules and administrative Throughout this article, the majoritised (i.e. Greek-Cypriot) teachers' perceptions of the minoritised (i.e. Turkish-speaking) children are theoretically framed within CRT. Critical Race Theory is appropriate for the case of Cyprus because it offers insights and methodological tools to identify and analyze existing evidence of the structural and cultural aspects that maintain dominant racial positions (coupled with ethnic ones) in and out of schools (Spyrou 2009;[START_REF] Trimikliniotis | Mapping discriminatory landscapes in Cyprus: Ethnic discrimination in a divided education system[END_REF][START_REF] Zembylas | -in press 'Critical discourse analysis of educational policy of multiculturalism and intercultural education policy in the Republic of Cyprus[END_REF]). The ethnopolitical conflict in Cyprus is very much related to race, in other words, because existing evidence highlights how the ethnic Other is also viewed through racial lenses. According to this research, teachers' racialised/ethnicised/ classed constructions inform and reflect the larger (unjust) structures in the Greek-Cypriot educational system, indicating how the Greek-Cypriot educational system performs exclusion. Although the implementation of CRT in an American, European or other context would look different than its use in the Greek-Cypriot educational system, there is an important commonality: the challenge of racist practices through investigating the lived experience of minoritised peoples as a defence against universalistic discourses [START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF]Taylor, Gillborn and Ladson-Billings 2009).

Although a number of conceptual and methodological tools have grown out of (Taylor, Gillborn and Ladson-Billings 2009). By arguing that racism is endemic in both institutional structures and everyday 'business-as-usual', CRT helps analyze the ways in which majoritised teachers' constructions about minoritised students' identities constitute racialised, ethnicised and classed perceptions. Second, the theme of resistance (e.g.

through counter-storytelling) refers to challenging myths, assumptions and received wisdoms grounded in colour-blind ideologies and discourses of objectivity and neutrality [START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF][START_REF] Youdell | Impossible Bodies, Impossible Selves: Exclusions and Student Subjectivities[END_REF]. Thus CRT questions liberal views that are deeply embedded in education and society, exposing the racist inequities 'that are created and sustained behind an inclusive and progressive façade' (Gillborn 2008, p. 28).

Teachers' constructions of minoritised children's identities

The literature in many countries around the world shows that majoritised teachers perceive minoritised children 'differently'. A full exploration of teacher racism all over the world is beyond the scope of this article; however, a brief review of some research evidence is valuable: (a) in understanding how teachers perceive minoritised children's identities in other parts of the world-including conflict-ridden areas-and, (b) in appreciating the implications of these perceptions in teachers' practices.

Studies in England indicate the prevalence of racism in schools, mainly in terms of teachers' (un)intended attitudes, behaviours and practices [START_REF] Gillborn | Educational Inequality: Mapping Race, Class and Gender: A Synthesis of Research Evidence[END_REF][START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF]. In particular, it has been found that teachers treat Black, Muslim and Asian students in stereotypic or hostile ways and assume that these [START_REF] Bekerman | Working towards the de-essentialization of identity categories in conflict and pos-conflict societies: Israel, Cyprus, and Northern Ireland[END_REF]. These findings confirm anthropological and sociological findings in other disciplines that ethnic, racial and class identities, too, are social and cultural constructions, not biologically determined [START_REF] Jenkins | Social Identity[END_REF][START_REF] Woodward | Understanding Identity[END_REF]. These ideas emphasize that ethnicity and other identity constructions are neither static nor monolithic; rather, they are shifting, plural, fluid, relational, constantly negotiated and embedded within power relations.

Recognising the idea that children have a range of identities, with different ones acquiring salience in different contexts, can be useful in understanding how particular social positions-for example, race, class, ethnicity-are ascribed to children through discursive formations and ideologies such as racist talk and discriminatory practices [START_REF] Phoenix | Dealing with difference: The recursive and the new[END_REF][START_REF] Ross | Multiple identities and education for active citizenship[END_REF].

Little, if any research, has examined Greek-Cypriot teachers' constructions of Turkish-speaking children's identities in the Greek-Cypriot educational system.

Turkish-speaking children occupy an interesting position in the Greek-Cypriot educational system; Turkish Cypriots and/or Turks are generally represented in extremely negative ways as a result of the historical conflict between Greeks and Turks [START_REF] Spyrou | Constructing "the Turk" as an enemy: The complexity of stereotypes in children's everyday worlds[END_REF]). This article analyses, then, how Greek-Cypriot teachers perceive the race, ethnicity and class of their Turkish-speaking students, and what the implications of these perceptions are in teachers' practices.

The study The data reported in this article are drawn from a two-year ethnographic study (2007)(2008) in three primary schools in the Greek-Cypriot educational system, examining multicultural education and particularly the pedagogical practices, constructions of otherness and relations between the majoritised group (i.e. Greek Cypriots) and the minoritised Turkish-speaking children. The uniqueness of this study is that these three primary schools belong to a very small number of schools in the Republic of Cyprus in which Turkish-speaking students are enrolled; Greek Cypriots and Turkish

Cypriots have always been educated in segregated educational systems. Issues surrounding race, ethnicity and class are central in this analysis. But before providing further details on the participating schools and the research design it is valuable to provide some further information on the socio-political context of the study.

The socio-political context of the study

Cyprus emerged as an independent state in 1960 after a Greek-Cypriot struggle against British colonial rule. This anti-colonial rebellion of the Greek Cypriots (80% of the population), however, did not aim toward independence but enosis, union with Greece. At the same time, Turkish Cypriots, the largest minority on the island (18%), Although in the south policy documents and official curricula include strong statements about humanistic ideas and respect for human rights, justice, and peace, in practice non-Greek Cypriot children are seen as deficient and needing to be assimilated [START_REF] Panayiotopoulos | At a crossroads of civilizations: Multicultural education provision in Cyprus through the lens of a case study[END_REF]Zembylas in press). Various studies also demonstrate that school textbooks and national rituals, symbols, and celebrations systematically create dehumanized images of the Turks and Turkish Cypriots [START_REF] Bryant | Imagining the Modern: The Cultures of Nationalism in Cyprus[END_REF][START_REF] Zembylas | -in press 'Critical discourse analysis of educational policy of multiculturalism and intercultural education policy in the Republic of Cyprus[END_REF]).

The current model of intercultural education being implemented in the Greek-Cypriot educational system is a mainstreaming programme in which language learners attend classrooms with Greek-speaking children (the majority). This model has developed in response to recent immigration in Cyprus. There are a number of schools ) that becomes even more complicated in schools where Turkish-speaking children are enrolled. Although there are a few such schools in the south and the Turkish-speaking student population in those schools is small (usually between 5-10% except in one case in which it rises to 1/3 of the student body), the situation is complex in light of the unresolved political problem.

Participating schools

The research reported here used a multiple case-design, in which each of the three primary schools constituted a unit of analysis [START_REF] Merriam | Qualitative Research and Case Study Applications in Education[END_REF]. The choice of these schools (which became multicultural only in the last few years) was based on the presence of Turkish-speaking children in the student population. The majority of Turkish-speaking children did not speak or understand any Greek. Also, there was regular migration between the south and the north part of Cyprus among Turkishspeaking students, thus influencing their education and school participation. Free meals were provided to these students in all three schools, but no lessons or extra language classes were conducted in the children's mother tongue (except in one of the schools-the one with the highest percentage of Turkish-speaking children). These The Hill School (HS) is a pseudonym for a primary school located in a small city and has 16 teachers (all Greek Cypriots) and 140 students of which 70% are Greek Cypriots, 12% Turkish-speaking students, and 18% students from various other countries. The socio-economic background of students is considered low and the Greek-Cypriot population is mainly comprised of refugees who fled from the north to save their lives in the aftermath of the Turkish invasion in 1974.

The Town School (TS) is a pseudonym for a primary school located in a small town; it has 12 teachers (all Greek Cypriots) and 330 students from which 21% are non-Greek Cypriot students (they come from different cultural backgrounds) and 8%

are Turkish-speaking students.

Finally, the Sea School (SS) is a pseudonym for a primary school located in a fairly large city (by Cypriot standards) and has 12 teachers (10 Greek Cypriots and two Turkish Cypriots who are responsible for the teaching of Turkish to Turkishspeaking students). Greek lessons are also offered to Turkish-Cypriot parents in the afternoon; a theatre group, consisting of Greek-Cypriot and Turkish-speaking parents, has also been formed. The Sea School has 139 students from which 37% are Turkishspeaking, 50% are Greek-Cypriots, and the rest from various cultural backgrounds.

The socio-economic background of most students is considered low.

Data collection and analysis

This The data collection methods included interviewing, ethnographic observations for eight consecutive weeks in each school (from 7:30 am to 1:05 pm, that is for the duration of the school day), and collection of documents (curriculum and policy documents, school demographic information, teaching materials and children's work).

Semi-structured interviews were conducted with a total of 3 school principals, 18 teachers, and 60 children (aged 7-12). This article examines data collected in semistructured interviews with 18 teachers (12 women and 6 men) and 3 principals (two women and one man), all Greek Cypriots. All interviews were conducted by the author and/or a research assistant and were tape-recorded and transcribed in Greek; all necessary quotes were translated for this article, which deals only with teachers' perceptions about Turkish-speaking children. Teachers and principals were asked questions about a range of issues including their feelings and aspirations of Turkishspeaking children, their views on the achievement of these children at school, the ways that the school and the educational system treats these children, and generally To ensure validity, the research assistant and I worked separately and collaboratively to analyse the data, using an interpretive method of coding [START_REF] Erickson | Qualitative methods in research on teaching[END_REF]) to ascertain confirming and disconfirming evidence of assertions arising from our data sources. We independently read and coded the data following the opencoding techniques outlined by [START_REF] Strauss | Grounded theory methodology: An overview[END_REF]. Building on this analysis, we interpreted the data by developing themes, categories and tentative hypotheses.

First, the analysis was undertaken both per teacher respondent and per school (withincase analysis). Second, a comparative analysis between the schools (cross-case analysis) was completed.

The following pages examine a range of interview excerpts highlighting the Greek-Cypriot teachers' constructions of Turkish-speaking students' identities. Researcher: What do you mean by that?

Teacher: I refer to these children's Turkish identity and the fact that Turks are our historical enemies.

Researcher: How does this influence you as a teacher?

Teacher: It gives you an awry feeling… I mean they are children but they are also of Turkish origin. It's impossible to get this out of your mind.

In this short exchange, this teacher identified almost all the issues raised by most teachers when they referred to Turkish-speaking students. She talked about Turkish-speaking children being poor, dark-coloured, unclean, and of different ethnic origin and argued that the sensitivity about these issues was further accentuated as a 15 result of the historical conflict with the Turks. Importantly, these issues were used to justify the rejection of Turkish-speaking children; however, the burden of rejection was placed on minoritised children. Yet, the majority of the teachers we interviewed admitted that Turkish-Cypriot children were not yet fully accepted. 'They are becoming more and more accepted, but their ethnic origin always sticks out,' said the principal at Town School, and added: 'They have a Turkish origin, you know… with the occupation of our country, this influences our feelings about them. They come here and they have all these benefits from the government. We don't like that.'

Several teachers in all three primary schools referred to the financial aid that Turkishspeaking families received from the government and expressed resentment for this. 'I am sorry but this makes me very angry,' said one male teacher at Sea School and continued: 'I know how it's going to sound but I'll say this anyway. They [Turkish-

speaking families] come here and go to the occupied areas [the north] whenever they like, they are extremely poor and uncivilised, and yet they receive more financial aid than our [Greek-Cypriot] poor families. This is not fair.'

Many teachers in all three schools talked openly and freely about the language and culture 'deficiency' of Turkish-speaking children. As a female teacher at Hill School admitted:

We do everything possible to help these children learn the language and become a bit more civilised because they have no manners from home. But no matter what we do, these children are incapable of learning the Greek language.

[…] We are pressured to show that Greek-Cypriot children are not left behind as a result of the low level at which Turkish-speaking students are permanently. The Turkish-speaking students' difficulties to participate in class activities were obvious through our ethnographic observations. For example, we were present in several incidents in which the teacher was simply teaching to the rest of the class, ignoring the Turkish-speaking students who did not do anything or simply drew pictures on their notebook. When asked to comment why Turkish-speaking students seemed to be ignored, one (male) teacher at Town School explained:

Look… I stopped insisting on having them sit next to our children or putting a lot of pressure on them. It's impossible to include these children as long as they don't learn to speak Greek. They got the message, OK it's our fault too, but they got the message that, "I am here just to be and whether I do something or not, whether I can do something or not, nobody will pay attention to me." This is a common secret among us, so I don't have too many expectations from them.

Most teachers denied the existence of discriminatory and racist perceptions or practices-either systemic or solely individual-against Turkish-speaking children.

More importantly, embedded in these assumptions about the absence of any racial discrimination in the three schools was a belief that the majoritised group (i.e. Greek Cypriots) had the right to determine 'the rules of the game' and even be 'racist.' As one female teacher at the Hill School asserted, 'We do everything possible to be fair. and its unequal implications for Turkish-speaking children. Instead, these teachers were free to express their decidedly racist views under the cover of the 'threat' of extinction as a (Greek) community.

At the same time, however, most teachers (regardless of school) claimed that Turkish-speaking students were mostly integrated in Greek-Cypriot schools without major problems. These claims, in conjunction with the 'racist' assertions identified earlier, indicated that there were conflictual or ambivalent discourses 'within' individual teachers. Consider, for example, the following two interview excerpts by the same teacher at the Sea School:

The most important thing is to treat all children equally. When you have a conflict, for example, between Greek Cypriots and Turkish Cypriots, you don't approach the incident as a problem between two ethnic groups. You don't make distinctions between them on the basis of their ethnic or cultural origin.

To Like teachers in the other two schools, this teacher delineated between two types of students on the basis of their origin. Greek Cypriot students were 'normal'-well behaved, diligent, and polite-while Turkish-speaking students were aggressive, unclean, poor and did not care about their education. However, this normalisation seemed to be grounded in a 'colour-blind' and 'equality for all' rhetoric. In other words, there was a mixing of claims about the educational system being objective, equal and colour-blind with perceptions that Turkish-speaking students misbehaved, were poor and somehow deficient. The majority of teachers brought the issue of 'low socioeconomic status' and 'being dirty' as characteristics of Turkish-speaking students; therefore, to some extent there was evidence that the 'racism' of teachers involved class issues, too.

Resistances in the discourse and enacted curriculum of some teachers

In this section, I highlight some of the resistances enacted through the teaching practices of five teachers and the leadership of one of the principals in the three participating schools. Although the racialised, ethnicised and classed constructions are difficult to change, unravelling resistances to 'normal/ised' teachers' perceptions creates openings (e.g. see [START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF][START_REF] Youdell | Impossible Bodies, Impossible Selves: Exclusions and Student Subjectivities[END_REF] for alternative constructions of Turkish-speaking children's identities. Some of the resistances in the discourse and practice of these teachers are discussed below.

First, it is important to acknowledge how the principal at Sea School assumed at activist role in the community and engaged in practices that struggled to create a His vision was 'to create a school that works in a just way… so that student outcomes are not related to students' ethnic or cultural background, colour, language, or race. I want my school to be successful for all students.' Discussions with this principal highlighted the negative implications of teachers' racialised, ethnicised and classed constructions, referring specifically to the marginalization of Turkish-speaking children. He also emphasised that it was his 'moral duty' to engage in challenging stereotyped perceptions, no matter where they came from.

Furthermore, the principal at Sea School took a clear stance against discourses and teaching practices that were discriminating towards Turkish-speaking children.

Just like CRT theorists point out, this principal highlighted that racism, nationalism (especially in Cyprus) and classism 'were not problems of individuals but of societies' and that stereotyped perceptions were constructed to maintain the privilege of the hegemonic group (i.e. Greek Cypriots). Clearly, the majority of teachers we interviewed defended themselves as not being implicated in racism/nationalism/ classism, yet this principal insisted that teachers' stereotyped perceptions were present. Thus he challenged his teachers on every opportunity (e.g. staff meetings, breaks, one-to-one basis) and encouraged them to consider: 'Why is it that Turkishspeaking children are always framed as failures and then eventually fulfil these expectations?' Or, 'What are the consequences of rendering Turkish-speaking students as "misbehaved" or "backward"?' As he further explained: This teacher also emphasized that discourses about fairness and neutrality were essentially rhetorical ways of covering discrimination. Her efforts to resist racialised, ethnicised and classed perceptions turned the majority of her colleagues against her. The truth is that we [teachers] often discuss about Turkish-speaking students, not because we care about them but because they create problems. This is the truth, in all honesty. I don't ever remember a colleague expressing concerns about these children, coming up with ideas and things to do to help them and include them in the school community. Usually, the discussion is about what "this Turkish-Cypriot student did to me today," and things like that. At a teachers' meeting, I dared once to say that these children were justified to behave the way they did because they knew they were not welcomed here and that we resented their presence. I was fiercely attacked by several colleagues who said I had a "Turkish-friendly" attitude.

When it was discovered (with the help of this teacher) that the school administration at Town School did not allocate the proper number of hours for the support of Turkish-speaking students to learn Greek and receive help based on the existing government policy, we asked the principal to explain her decision. The principal was visibly distressed:

Look, I think it's fairer to our children [Greek Cypriots] as well to take some hours from the support allocated to Turkish-speaking students. Besides, we were told to allocate these hours the way we think it's right. I considered it fairer to do it in this way because I think it's unfair to give all the periods to non-native students and give nothing to Greek-Cypriot children.

Implications and conclusion

There are two key findings in this study; the first has to do with how Greek-Cypriot teachers perceive Turkish-speaking children, and the second highlights the openings that are manifest through teacher resistance. First, it is shown that Greek-Cypriot teachers perceive Turkish-speaking children in racialised, ethnicised and classed ways, and the socio-political structures in Cyprus influence teachers' negative discourses and practices toward these children. Most of the classic studies on teacher racism suggest that teachers are running racist regimes in their classrooms either without realising it, or meaning to, or while they deny it to researchers. The remarkable finding in this study is that several teachers say they are racist, claiming that they are justified to act in these ways in light of the political situation in Cyprus; in other words, there is not a 'mismatch' between spoken account and actual practice.

Teachers' perceptions, then, entail a sense of 'right' to be racist, because this 'right' is perceived as a defence mechanism against Turkish efforts to dominate all over Cyprus and change its demographic character [START_REF] Zembylas | -in press 'Critical discourse analysis of educational policy of multiculturalism and intercultural education policy in the Republic of Cyprus[END_REF]. Clearly, this claim reveals the intensely negative representations of the Turks and how these representations are influential to the ways teachers behave toward all Turkish-speaking individuals, including children.

The second key finding is that despite negative discourses and practices toward Turkish-speaking children, there is resistance on the part of a few teachers and a school principal; this resistance is expressed through liminal performance Although teacher resistances do not seem to have any major effect on transforming the structural inequalities that persist on an everyday basis [START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF]Taylor, Gillborn and Ladson-Billings 2009) and are often veiled as formal equality for all [START_REF] Vaught | I don't think I'm racist": Critical race theory, teacher attitudes, and structural racism[END_REF], it is important that the 'normal/ised' identities of Turkish-speaking children do not remain unchallenged. These (small) openings are essentially possibilities for cultivating individual and collective political consciousness and criticality against fixed and reified identities of the past [START_REF] Zembylas | -in press 'Critical discourse analysis of educational policy of multiculturalism and intercultural education policy in the Republic of Cyprus[END_REF]. Data in this study tell us that these openings exist because individual teachers enact their agency to invent pedagogies that challenge past identity categories. The However, an important sociological point emanating from the use of Critical Race Theory in the present study is that while this position (i.e. 'I don't think I'm racist') exists, there is additionally the position of some teachers who admit it is their 'right' to be racist when their country is perceived to be in danger. This finding also complicates theoretical understandings of teachers' ambivalent justifications of their The issue raised by some teachers that it is their right to be racist in the sociopolitical circumstances of Cyprus is arguably a far more challenging one to address.

Yet, becoming aware of colour-blind views does not necessarily lead to empathy among teachers but may even result in a reinvention of racist frameworks [START_REF] Vaught | I don't think I'm racist": Critical race theory, teacher attitudes, and structural racism[END_REF]. This suggests that racism adapts to new ideologies and contexts (e.g. conflict in Cyprus), accommodating the discourse within a framework of racial and ethnic superiority for security, survival or other justifications. Therefore, as long as a conflict remains unresolved, it is unlikely that the multiple aspects which sustain this framework will just fade away [START_REF] Bekerman | Working towards the de-essentialization of identity categories in conflict and pos-conflict societies: Israel, Cyprus, and Northern Ireland[END_REF].

Without large-scale structural transformations of the educational system of which teachers are part (e.g. new curricula and educational goals; different philosophies, pedagogical practices and educational materials; political will for social change), the fact and practice of racism/nationalism/classism will go unaltered in schools [START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF][START_REF] Zembylas | -in press 'Critical discourse analysis of educational policy of multiculturalism and intercultural education policy in the Republic of Cyprus[END_REF]). These findings raise deeper issues about how to effectively challenge 'racist' teachers' perceptions and practices in conflict-ridden societies, and continue to remind those of us involved in peace and intercultural education that however difficult or improbable we are to find some perceptions, there is hardly any other choice but to look constantly for critical and hopeful alternatives. The term Turkish-speaking is purposely used in this article in that it is more inclusive than the term Turkish Cypriots because most Roma in Cyprus speak Turkish. It is not always easy to distinguish who is ethnically Turkish Cypriot and who is Roma; therefore, the term 'Turkish-speaking' is preferred to refer to all Turkish-speaking groups. When it is important to make a distinction between Turkish Cypriots and Roma, this is explicitly stated in the text.

2 Various polls show that Turks, in general, are negatively viewed in Europe. Certainly negative discourse and discrimination toward Turkish-speaking children in European countries is bound to add to how they are racialised and treated in schools (Stevens 2008). As it will be shown through the data presentation, the larger context of anti-Turk sentiment in the Greek-Cypriot community is mostly grounded in the Turkish occupation of the northern part of Cyprus rather than Turkey's EU membership, and has an impact on teachers' perceptions of Turkish-speaking children.

  are examined: (1) How do Greek-Cypriot teachers perceive the race, ethnicity and class of their Turkish-speaking students, and how does the CRT concept of the structural racialisation of minoritised groups illuminates these teachers' constructions of Turkish-speaking children's identities within the Greek-

  and often unnoticed ways, yet the actions associated with everyday racism are seen as derogatory by persons of colour. Critical Race Theory, then, calls attention to the existence of structures in the broader society that are created and maintained through institutions, relationships and practices.

  aimed at taksim, ethnic partition. Past issues such as the Ottoman occupation of Greece and Cyprus and the recent traumas of ethnic division -first in the 1960s when the Turkish Cypriots were the main victims, and then in 1974 when Turkey invaded and divided the island, displacing many thousands of Greek Cypriots and Turkish Cypriots -came to signify an intractable conflict in the region. The Turkish invasion of 1974 separated the two communities-Greek Cypriots reside in the south and Turkish Cypriots in the north. Despite numerous diplomatic efforts and the partial lift of restrictions in movement across the dividing line in 2003, the partition of Cyprus Republic of Cyprus became a full EU member in May 2004, while Turkey applied to become an EU member. Recent debates around issues of EU membership for Turkey further complicate the relations between Greek Cypriots and Turkish Cypriots: arguments from the Greek-Cypriot side emphasize that Turkey cannot become an EU member, unless it ends the division of Cyprus, while arguments from the Turkish-Cypriot side highlight that Turkey needs to continue having guarantor powers over Cyprus 2 .Greek-Cypriot and Turkish-Cypriot children have always been educated separately. Currently, Greek Cypriots attend schools in the south and Turkish Cypriots in the north. In the south, however, 'multicultural' schools, attended by children from various cultures, including children whose parents are migrant workers or are married to someone from another culture, have emerged. Occasionally, Turkish-speaking children (i.e. Turkish Cypriots and Roma), whose parents stayed in the south after the war of 1974 or moved there recently, enrol in these schools.

  of a Zone of Educational Priority (ZEP). ZEP networks have schools with high numbers of non-Greek Cypriot students but this is not the rule; there are a number of other schools in the Greek-Cypriot educational system with high numbers of non-Greek Cypriot students that are not in a ZEP network. ZEP schools receive additional help-such as extra hours for assisting non-indigenous students to learn the language. Research also shows that Greek-Cypriot teachers are ill prepared to deal with the challenge of multicultural education[START_REF] Panayiotopoulos | At a crossroads of civilizations: Multicultural education provision in Cyprus through the lens of a case study[END_REF][START_REF] Trimikliniotis | Mapping discriminatory landscapes in Cyprus: Ethnic discrimination in a divided education system[END_REF] Zembylas and Iasonos in press

  the Hill School, the Town School, and the Sea School 3 ; the first and the third school were part of a ZEP network.

how

  Turkish-speaking children learn and interact with other children. Ethnographic observations were recorded by the research assistant in field notes and focused on the ways that Greek-Cypriot teachers and students interacted with Turkish-speaking children in the classroom, the schoolyard and the staffroom. The possible bias this process might occasion was counterbalanced by cross-analysis of the data conducted evaluator who checked our interpretations. The data sources also included documents of student work and teachers' planning related to various aspects of their teaching.

  First, I explore data exposing the racialised, ethnicised and classed perceptions of the majority of Greek-Cypriot teachers who participated in this study, showing how their perceptions are linked to larger structural, systemic issues of race, ethnicity and education. Second, I highlight the resistance that is present in the discourse and enacted curriculum of a few teachers. I close with a discussion of the implications of the racialised, ethnicised and classed constructions expressed by teachers in terms of resisting structural racism and enacting alternative pedagogical practices. Τhe racialised, ethnicised and classed perceptions of Greek-Cypriot teachers about Turkish-speaking children's identities Greek-Cypriot teachers (13 of the 18) in the three participating schools classified Turkish-speaking children according to racial, ethnic and class categories. One typical understanding of Turkish-speaking children is captured in the conversation that follows. During this conversation, a female teacher at Hill School discussed the cultural characteristics of Turkish-speaking students, explaining why they were not accepted by the majority of Greek-Cypriot students 4 : Teacher: First of all, Turkish-speaking students are distinguished by their external appearance. They have a darker skin complexion, they are extremely dirty and untidy, especially the Roma, and they don't speak any Greek. They usually stink and this is a cultural thing. Anyway, they don't have the habit of cleaning themselves and so our children [Greek Cypriots] don't like to play or sit in class with them. […] And there is, of course, the hostility against the Turks.

  But it's their[Turkish-speaking children's] responsibility to learn the rules of the game and adapt to our way of life. Why should we change for them?' Another (male) teacher at Town School put this more bluntly: 'Look, given the threat we face to Greeks, I think we are justified to be a bit racist. It's a matter of survival.' In general, these teachers failed to recognize the systemic, structural component of the Greek-Cypriot privilege in the Greek-Cypriot educational system

  tell you the truth, Turkish Cypriots are the most disruptive and unfocused children in the whole school. They always find ways to avoid learning and engage in misbehaviour. […] Our children are polite, diligent, attentive and clean. They are completely the opposite from Turkish Cypriots. […] The Turkish-Cypriot families are poor and don't really care about their children's , this lack of interest passes on to the children themselves.

  and the parents need to be convinced first that it is morally unacceptable to subscribe to deficit thinking for minority students or students who come from low socio-economic background. It's not the students' fault but the system's failure that sustains the disappointing outcomes for these students. Naturally, there is a lot of resistance. […] Non-indigenous students are blamed essentially for everything that happens at the school. […] So, I encourage my staff to attend workshops, conferences and seminars and bring back specific ideas with which they can change how we deal with these issues. Another example of resistance was found at Town School. A teacher expressed repeatedly her public disagreement at the ways her colleagues treated Turkish-speaking children. As she explained in an interview: Non-native children want attention and in this school they don't get it. Here the situation is "cool" for everyone. The culture is very Greek Cypriot… The teachers don't talk to Turkish-speaking children with respect. This situation stigmatizes Turkish-speaking children and the stereotypes are perpetuated among all children. […] I don't hesitate to tell you that there is a lot of racism here. […] Children say things like "If you are touched by Melike you will get sick". This is blunt racism! And some teachers and the principal herself are in front of such incidents and they just laugh.

  teacher at Hill School resisted the 'normalization' of Turkishspeaking children by sharing with colleagues her experiences from providing individualised instruction to these children in pull-out sessions. As she pointed out in an interview: Turkish-speaking children are totally different when they are by themselves.In the regular classroom, they seem isolated and scared and do not participate in discussions, because they don't feel comfortable with their knowledge of Greek. When they are by themselves in these supportive instructions, they are happy, expressive and alive. […] I try to communicate this to my colleagues but […] they don't believe that these children have the potential to learn, if you show them love and respect.Teacher resistance, although isolated and small, attempted to provide alternative constructions about Turkish-speaking children's identities through highlighting the problematic features of fixing these children to particular static descriptions. The positioning and counter-positioning of Turkish-speaking children's identities contained important implications for these children's survival and success in the Greek-Cypriot educational system. The dominant discourse of racialised, ethnicised and classed perceptions about Turkish-speaking children and the normalization of these children's identities showed how the dominant group racialised this particular minoritised group. The teachers and the principal who resisted this dominant discourse were critical of racialised, ethnicised and classed perceptions and the mechanisms through which such perceptions occurred in systemic ways. By applying a counter-construction of Turkish-speaking children's identities, an enacted and turned the 'normal' identities of these children into contested spaces, even in minor ways.

  reasons why these openings exist range from teacher individual sensitivity to the catalytic intervention of school leadership that brings important structural changes in school life.The findings of this study are important because they demonstrate how the teachers' racialised, ethnicised and classed perceptions of a minoritised group of children intersect with larger structural, systemic issues of race, ethnicity and education in a conflict-ridden society. Previous research (e.g. see[START_REF] Vaught | I don't think I'm racist": Critical race theory, teacher attitudes, and structural racism[END_REF] has shown the range of social and structural components which influence the common phrase 'I don't think I'm a racist' as well as the discursive functions of self-justification and disarming criticism about accusations of racism.

  equality and fairness can be used as a point of departure to identify practices where solidarity might be possible[START_REF] Anthias | Racialised Boundaries: Race, Nation, Gender, Colour and Class and the Anti-racist Struggle[END_REF]. Critical Race Theory provides the conceptual frame to problematize how perceptions and practices establish, assert, and reinforce power differentials and hierarchies, and how individuals draw on the resources of stereotypes to reproduce racism/nationalism/ classism. Racialised/ethnicised/classed discourses are facilitated by relevant modes of engagement and are perpetuated through the cultivation of particular practices-such as collective behaviour and school policies that contribute to the formation of inclusions/exclusions[START_REF] Gillborn | Racism and Education: Coincidence or Conspiracy[END_REF]. Unavoidably, then, it is important to analyze the modes through which such perceptions are authorized by, implied and manifest in teacher practices and school policies. Therefore, providing systemic opportunities for teachers and school staff-in conjunction with implementing equal treatment of Turkish-speaking children-to problematize exclusive practices, and considering what those practices do on Turkish-speaking children, are crucial for exploring alternative pedagogical practices and policies.

  . and KARAHASAN, H. 2006 'The politics of memory and forgetting in pedagogical practices: Towards pedagogies of reconciliation and peace in divided Cyprus', The Cyprus Review, vol. 18 no. 2, pp. 15-35. ZEMBYLAS, M., and IASONOS, S. in press 'Leadership styles and multicultural education approaches: An exploration of their relationship', International Journal of Leadership in Education. MICHALINOS ZEMBYLAS is Assistant Professor of Education in the School of Social Sciences and Humanities, Open University of Cyprus. ADDRESS: 5 Ayiou Antoniou Str., Strovolos 2002, Nicosia, CYPRUS Email: m.zembylas@ouc.ac.cy Notes 1

3

  Pseudonyms are used for individuals and locations to protect anonymity. Material omitted by the author [text] Material added by the author for the sake of clarity Page 31 of 31 URL: http://mc.manuscriptcentral.com/rers ethnic@surrey.ac.uk Ethnic and Racial Studies

  These insights, in conjunction with the use of CRT, are valuable for two reasons: first, they help pay attention to the ways in which individual practices are linked to larger social processes that are unjust or unfair to

	processes of injustice and unfairness. minoritised children; second, the notion that racism is not an individual pathology is
	asserted and the cultural system that tolerates racist practices (or occasionally resists
	to those) is exposed.
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study draws on critical ethnographic methodologies (Carspeckem and Walford 2001; Madison 2005); insights from critical ethnographic methodologies are used to look for teacher discourses and practices with the purpose of exposing and critiquing

  in social justice and anti-racism. For example, this principal referred to the importance of being committed to social justice values and beliefs that aimed at changing school structures and practices that 'are unfair to some students.'

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URL: http://mc.manuscriptcentral.com/rers ethnic@surrey.ac.uk

  and classed practices; contextual concerns are manifest in simultaneous claims that there should be equal opportunities for all children (see[START_REF] Rattansi | Rethinking youth identities: Modernist and postmodernist frameworks[END_REF]), yet it is rightful to be racist under some circumstances.

	racialised, ethnicised Other studies in Cyprus on these topics seem to highlight this ambivalence in
	prospective Greek-Cypriot teachers (e.g. see Zembylas 2008) or Greek-Cypriot
	children of young age (e.g. see Spyrou 2009).
	F By looking through the ambivalences of teachers' constructions in these three o r schools, we are able to see not only what is problematic, but also to discover a
	window of opportunity for addressing the problematic aspects of the racialised, P e ethnicised and classed framework in schooling. For example, teachers' discourse on
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Stefan J Cano

Holly B Posner

Margaret L Moline

Stephen W Hurt

Jina Swartz

Tim Hsu

Dr Jeremy C Hobart
email: jeremy.hobart@pms.ac.uk

The ADAS-cog in Alzheimer's Disease clinical trials: Psychometric evaluation of the sum and its parts

Keywords: Alzheimer's disease, clinical trials, rating scales, reliability, validity

Background & Aims: The Alzheimer's Disease Assessment Scale Cognitive Behaviour Section (ADAS-cog), a measure of cognitive performance, has been used widely in AD trials. Its key role in clinical trials should be supported by evidence that it is both clinically meaningful and scientifically sound. Its conceptual and neuropsychological underpinnings are well-considered, but its performance as an instrument of measurement has received less attention.

Objective: To examine the traditional psychometric properties of the ADAS-cog in a large sample of people with AD.

Methods: Data from three clinical trials of donepezil (Aricept®) in mild-to-moderate AD (n=1421; MMSE 10-26) were analysed at both the scale-and component-level. Five psychometric properties were examined using traditional psychometric methods. These methods of examination underpin upcoming FDA recommendations for patient rating scale evaluation.

Results:

At the scale-level, criteria tested for data completeness, scaling assumptions (eg component total correlations= 0.39-0.67), targeting (no floor or ceiling effects), reliability (eg Cronbach's alpha = 0.84; test retest intraclass correlations = 0.93) and validity (correlation with MMSE = -0.63) were satisfied. At the component-level 7 of 11 ADAS-cog components had substantial ceiling effects (range 40-64%).

Conclusions:

Performance was satisfactory at the scale level, but most ADAS-cog components were too easy for many patients in this sample and did not reflect the expected depth and range of cognitive performance. The clinical implication of this finding is that the ADAS-cog's estimate of cognitive ability, and its potential ability to detect differences in cognitive performance under treatment, could be improved. However, because of the limitations of traditional psychometric methods, further evaluations would be desirable using additional rating scale analysis techniques to pinpoint specific improvements.

*Tests included scaling assumptions (corrected-item-total correlations; CITC), reliability (alphas, test-retest intraclass correlation coefficients), and validity (correlations between the ADAS-cog and MMSE) ** This table shows selected psychometric analyses of sub-samples as defined by the MMSE: 10-14 (middle left column); 15-20 (middle column); 21-26 (middle left column) The analyses and interpretation of the statistics presented in this table relating to scaling assumptions, reliability and validity are further described in Appendix 1. **reliability (Cronbach's alpha), ^ test-retest reproducibility (intraclass correlation), s screening, b baseline

INTRODUCTION

Alzheimer's disease (AD) is a terminal dementing neurodegenerative disease that impacts on cognition and behaviour. [START_REF] Blennow | Alzheimer's disease[END_REF] It is the most common form of dementia, affecting approximately 27 million people worldwide, [START_REF]Alzheimer's Association. Alzheimer's Disease Facts and Figures[END_REF] and incidence rates are expected to quadruple by the middle of this century. [START_REF] Brookmeyer | Forecasting the global burden of Alzheimer's disease[END_REF] Considerable interest and resources have been targeted at slowing AD progression as reflected in the growing number of clinical trials in AD. [START_REF] Aisen | Effects of rofecoxib or naproxen vs placebo on Alzheimer disease progression: a randomized controlled trial[END_REF] The most widely used primary outcome measure in these clinical trials has been the AD Assessment Scale -Cognitive Behaviour Section (ADAS-cog). [START_REF] Mohs | The Alzheimer's Disease Assessment Scale: An instrument for assessing treatment efficacy[END_REF][START_REF] Rosen | A new rating scale for Alzheimer'sdisease[END_REF] It was developed in the early 1980s in response to the then perceived lack of appropriate instruments available to test the efficacy of AD drug treatments, [START_REF] Mohs | The Alzheimer's Disease Assessment Scale: An instrument for assessing treatment efficacy[END_REF][START_REF] Rosen | A new rating scale for Alzheimer'sdisease[END_REF] to assess the "severity of dysfunction and research in patients with Alzheimer's Disease". [6(p1360)] Since its inception, the ADAS-cog has been used in over 127 AD clinical trials, and although developed specifically for AD, it has frequently been used in non-AD populations, including mild cognitive impairment, [START_REF] Farlow | Impact of APOE in mild cognitive impairment[END_REF] vascular dementia, [START_REF] Malouf | Donepezil for vascular cognitive impairment[END_REF] and Parkinson's disease. [START_REF] Emre | Rivastigmine for dementia associated with Parkinson's disease[END_REF] Of particular relevance to the present study is that clinical trials are increasingly focusing on people earlier in the disease process and with less severe AD. As awareness increases, diagnoses are likely to be made much earlier than they were 25 years ago.

If the ADAS-cog is to be considered fit for future measurement of all severities of AD including milder forms, it should satisfy stringent criteria as a reliable and valid measure of cognitive performance. Awareness of this issue is now widely recognised by international regulatory agencies concerning the use of patient rating scales. The ADAS-cog was developed with sound consideration of relevant neuropsychological consequences of AD, but without being subjected to rigorous psychometric techniques of rating scale construction. Although we are unsure as to the precise reasons the ADAS-Cog was developed in this way, the lack of standard rating scale construction methods may have resulted from a lack of awareness. As such, although these methods have existed for decades, they have been rarely applied to clinical rating scale research.

At its introduction, data on the ADAS-cog were provided on inter-rater and test-retest reliability in small samples of AD (n=27) and normal elderly (n=28). [START_REF] Rosen | A new rating scale for Alzheimer'sdisease[END_REF] Since then, it has undergone additional scale-level psychometric evaluations, [START_REF] Kim | Factor structure and reliability of the Alzheimer's Disease Assessment Scale in a multicenter trial with linopirdine[END_REF][START_REF] Weyer | Alzheimer's Disease Assessment Scale: reliability and validity in a multicenter clinical trial[END_REF][START_REF] Doraiswamy | The Alzheimer's Disease Assessment Scale: Evaluation of Psychometric Properties and Patterns of Cognitive Decline in Multicenter Clinical Trials of Mild to Moderate Alzheimer's Disease[END_REF] with some authors suggesting possible key limitations. [START_REF] Wesnes | P4-401: Identifying cognitive enhancement in man: Identifying efficacy in the dementias [abstract[END_REF][START_REF] Dichgans | Donepezil in patients with subcortical vascular cognitive impairment: a randomised double-blind trial in CADASIL[END_REF] The reason as to why psychometric evaluations of rating scales before their use are important requires a brief overview of the key issues surrounding the use of rating scales as outcomes measures.

Measurement requires the construction of an instrument for carrying out the practical process of measuring. Some variables, like height, can be measured directly and by relatively straightforward means. Other variables, like cognitive performance, need to be approached indirectly through quantifying their manifestations. It is important here to note that in its role as a clinical assessment tool the relevance of evaluating the ADAS-Cog using rating scale testing methods is appropriate but less crucial than to do so for its role as a measurement instrument for clinical research. This is because clinical assessment and measurement are different processes that have different requirements. We have previously summarised these, [START_REF] Hobart | Rating scales as outcome measures for clinical trials in neurology: problems, solutions, and recommendations[END_REF] but the key issue is that measurement has a specific meaning with respect to the quantification of attributes. By contrast, clinical assessment is, frequently, a qualitative process. Here instrument development is not straightforward and requires the construction of tools that transform numerically graded manifestations into measurements of underlying variables. Indirectly measured variables are often called latent (hidden) variables to emphasise this fact.

Rating scales are constructed to measure latent variables. It is customary for a rating scale to consist of a set of items, each of which represents a different manifestation. In relation to the ADAS-cog we have referred to these as components, as the eleven questions used are more detailed, time consuming and involved than traditional rating scale items. Every item is scored, and item scores are combined to give a total score for each person. This value is a measure of the variable quantified by the set of items.

Whether a rating scale generates clinically meaningful and scientifically sound measurements depends on decisions during its construction and its performance during testing. The decisions concern the components selected to form the set, their clinical grading and numerical scoring, and how components are combined to give a single value. Performance is tested against a number of predefined measurement (psychometric) criteria.

The original ADAS-cog measures cognitive performance by combining ratings of 11 components (Word Recall, Word Recognition, Constructional Praxis, Orientation, Naming Objects and Fingers, Commands, Ideational Praxis, Remembering Test Instruction, Spoken Language, Word Finding, Comprehension) representing six broad areas of cognition: memory, language, ability to orientate oneself to time, place and person, construction of simple designs and planning and performing simple behaviors in pursuit of a basic, predefined goal. [START_REF] Mohs | The Alzheimer's Disease Assessment Scale: An instrument for assessing treatment efficacy[END_REF][START_REF] Rosen | A new rating scale for Alzheimer'sdisease[END_REF] Seven of the eleven ADAS-cog components are scored as the "number incorrect". For example, in the commands component, the number of five commands performed incorrectly (none, 1, 2, 3, 4, or all 5). The remaining four ADAS-cog components are scored from 0 (no limitations) to 5 (max limitations) as the examining clinician's perception of: remembering test instructions, spoken language ability, word finding, and comprehension. Scores for the 11 components are summed, without weighting, into a total ADAS-cog score. Low total scores indicate better cognitive performance. Appendix 1 shows the component structure of the ADAS-cog. Note that the 11 components have different score ranges.

This process appears clinically appropriate but requires empirical proof that it "works". This means that evidence is needed to support the choice of items forming the set, scoring of the individual items, and appropriateness of combining item scores into a single score. Also evidence should be available demonstrating that the single score is a reliable and valid measure of cognitive performance. Psychometric methods provide formal frameworks for gathering this evidence.

There are two main types of psychometric method; traditional and modern. [START_REF] Hobart | Rating scales as outcome measures for clinical trials in neurology: problems, solutions, and recommendations[END_REF] Traditional methods are the most widely used analytic strategy for determining rating scale reliability and validity and will be reported here. [START_REF] Novick | The axioms and principal results of classical test theory[END_REF] These are the psychometric methods best understood by clinicians and clinical researchers, and underpin the forthcoming FDA guidelines for rating scales. [START_REF]Patient reported outcome measures: use in medical product development to support labelling claims[END_REF] The aim of this study was to provide clinicians and researchers with a traditional psychometric evaluation of the ADAS-cog, which goes beyond the existing published examinations in type (ie detailed evaluations of data quality, scaling assumptions, targeting, reliability, validity) and kind (ie the inclusion of scale-and importantly component-level analyses).

METHODS

Setting and Participants

Anonymized screening and baseline data from three large clinical trials of donepezil [START_REF] Rogers | A 24-week, double-blind, placebo-controlled trial of donepezil inpatients with Alzheimer's disease[END_REF][START_REF] Burns | The effects of Donepezil in Alzheimer's disease -Results from a multinational trial[END_REF][START_REF] Seltzer | Efficacy of Dopenzil in early-stage Alzheimer disease: a randmoized-controlled trial[END_REF] in people with AD were pooled for analysis. The inclusion criteria were: healthy ambulatory people aged ≥50 with a diagnosis of probable AD, of mild to moderate severity (Clinical Dementia Rating

Data analysis

Many clinicians are familiar with reliability and validity testing, but a more thorough traditional psychometric evaluation involves the assessment of six properties: data quality, scaling assumptions, targeting, reliability, validity and responsiveness. Data completeness concerns the extent to which a scale's components are completed in the target sample, and the percent of people for whom it is possible to report a single score. Tests of scaling assumptions examine whether it is appropriate statistically to sum the 11 components to generate a single scale score. Targeting assesses the match between the range of cognitive performance measured by the ADAS-cog and the range of cognitive performance in the sample. Reliability describes the extent to which scale scores are free from random error. Validity refers to the extent to which the ADAS-cog measures cognitive performance. Responsiveness is the ability to detect accurately true change in cognitive performance when it has occurred. We examined five of these six psychometric propeties (see Appendix 2) which are extensively documented elsewhere. [START_REF] Hobart | The SF-36 in multiple sclerosis (MS): why basic assumptions must be tested[END_REF][START_REF]Assessing health status and quality of life instruments: attributes and review criteria[END_REF][START_REF] Cano | The International Co-operative Ataxia Rating Scale (ICARS): An appropriate rating scale for Friedreich's Ataxia?[END_REF]

RESULTS

Sample

1,418 of 1,421 patients tested provided sufficiently complete ADAS-cog component scores. The sample is characterized in (Table 1). The main analyses were undertaken in the total sample. Additional targeting, reliability and validity analyses were conducted in MMSE subgroups [START_REF]Patient reported outcome measures: use in medical product development to support labelling claims[END_REF][START_REF] Hobart | Rating scales as outcome measures for clinical trials in neurology: problems, solutions, and recommendations[END_REF][START_REF] Kim | Factor structure and reliability of the Alzheimer's Disease Assessment Scale in a multicenter trial with linopirdine[END_REF][START_REF] Weyer | Alzheimer's Disease Assessment Scale: reliability and validity in a multicenter clinical trial[END_REF][START_REF] Doraiswamy | The Alzheimer's Disease Assessment Scale: Evaluation of Psychometric Properties and Patterns of Cognitive Decline in Multicenter Clinical Trials of Mild to Moderate Alzheimer's Disease[END_REF] moderately severe; 15-20 moderate; 21-26 mild) to examine the impact of cognitive impairment on the psychometric properties of the ADAS-cog. The outcomes of the original clinical trials and further specification of the study populations are provided elsewhere. [START_REF] Rogers | A 24-week, double-blind, placebo-controlled trial of donepezil inpatients with Alzheimer's disease[END_REF][START_REF] Burns | The effects of Donepezil in Alzheimer's disease -Results from a multinational trial[END_REF][START_REF] Seltzer | Efficacy of Dopenzil in early-stage Alzheimer disease: a randmoized-controlled trial[END_REF]

Psychometric properties

Data completeness (Tables 2&3)

Data completeness was high. The proportion of component-level missing data was low (≤0.02%). ADAS-cog total scores could be computed for 99.7% of the sample (1418/1421).

Comprehension

Data completeness

Component MD (%)** 0 0 0 0 0 0 0 0 0 0 0

Scaling Assumptions

Possible range 0-10 0-5 0-5 0-5 0-5 0-8 0-12 0-5 0-5 0-5 0- Scaling Assumptions (Tables 2&3)

The ADAS-cog satisfied most criteria for scaling assumptions. For example, componenttotal correlations (corrected for overlap) for the eleven ADAS-cog components ranged from 0.39-0.67 satisfying the recommended criteria. This supported the scale components as measures of a common underlying construct, and indicated that components contained a similar proportion of information about that construct.

However, Table 3 shows that ADAS-cog component mean scores and variances were not especially similar. Whilst this implies some criteria for scaling assumptions were not satisfied, it is important to note that ADAS-cog components have different numbers of response categories. Thus, mean scores and variances were similar for components with the same/similar numbers of response categories providing evidence that these criteria were fulfilled.

Targeting (Tables 2,3; Appendix 3)

The ADAS-cog total scores spanned approximately 83% of the entire scale range, with no significant floor and ceiling effects, and were not notably skewed. This was also found for the Word Recall, Word Recognition, and Orientation components. However, 8/11 components (Naming Objects and Fingers, Commands, Constructional Praxis, Ideational Praxis, Remembering Test Instruction, Spoken Language, Word Finding, Comprehension) had significant floor/ceiling effects (40%-64%) and were notably skewed (+1.0 to +2.0). These findings indicate adequate scale-tosample targeting but potentially poor component-to-sample targeting. They indicate that the range of cognitive performance measured by these 8 components is poorly matched to the ranges of cognitive performance in this sample.

Reliability (Tables 2&3)

Cronbach's alpha, and test-retest ICCs for the ADAS-cog scale were high (0.84 and 0.94), supporting their reliability. Component level ICCs (range 0.75 -0.83) were also well above the suggested minimum of 0.50.

Validity (Table 2)

Correlations between the ADAS-cog and MMSE were near our prediction at both screening (-0.63) and baseline (-0.74). Correlations between the ADAS-cog at baseline and sociodemographic variables (age and sex) were -0.01 and -0.07, respectively, indicating that ADAS-cog scores were not biased by these variables. These findings provided evidence for convergent and discriminant construct validity.

MMSE subgroups (10-14 moderately severe; 15-20 moderate; 21-26 mild; Table 4)

Targeting analyses revealed that ADAS-cog component-level ceiling effects progressively increased as the severity of AD, measured by the MMSE, decreased (range: moderately severe -0-32%; moderate -0-59%; mild 0-82%; Table 4). Reliability, as assessed by Cronbach's alpha and test-retest ICCs were low (range 0.62 to 0.75 and 0.71-0.77, respectively). Finally, the examination of group differences validity revealed a stepwise decrease in ADAS-cog score as the MMSE score increases. The mean scores for the three groups are significantly different, in line with prediction (F=404.22, p<.0001). However, correlations between ADAS-cog and MMSE scores within each group were low to moderate (0.17 -0.49) and much lower than the predicted association between these two measures of cognitive performance, and that found in the total sample.

DISCUSSION

At the scale level, the ADAS-cog met most traditional psychometric criteria in this large dataset of people with mild and mild-to-moderate AD, supporting the findings of previous research.[ 5 6 12 13] However, a closer examination of the component level findings, a form of analysis rarely undertaken in previous ADAS-cog research, [START_REF] Doraiswamy | The Alzheimer's Disease Assessment Scale: Evaluation of Psychometric Properties and Patterns of Cognitive Decline in Multicenter Clinical Trials of Mild to Moderate Alzheimer's Disease[END_REF] revealed suboptimal scale-to-sample targeting. The key issue here is that we would expect patients in this study to have a range of cognitive abilities. Despite this, over half the ADAS-cog components have substantial percentages of people (often >75%) scoring either 0 or 1, implying few or no problems in cognitive performance. As there is likely to be more clinical heterogeneity in patients' abilities than these components imply, this indicates a targeting problem, or mismatch, between the components' difficulties and patients' abilities in this sample. This is important because the limited component level targeting will impact on the overall ability of the ADAS-cog to detect cognitive differences between people and groups and potentially be less sensitive to the effects of interventions, as reflected in the findings of others. [START_REF] Doraiswamy | The Alzheimer's Disease Assessment Scale: Evaluation of Psychometric Properties and Patterns of Cognitive Decline in Multicenter Clinical Trials of Mild to Moderate Alzheimer's Disease[END_REF] Our findings demonstrate the importance of targeting rating scales to the individuals within a study sample. Specifically, the range of cognitive performance measured by the ADAS-cog should be well-matched to the range of cognitive performance present in the study sample so that the scale has the ability to detect variability among and within individuals. Poorly targeted scales most likely underestimate changes over time and differences between groups, which is particularly relevant for future AD clinical trials that are tending to recruit people with milder AD. The issue becomes more evident when targeting was examined in AD severity subgroups, demonstrating that the componentlevel ceiling effects progressively increased as the severity of AD decreased. This underscores the importance of examining component level targeting and demonstrates a misleading aspect of scalelevel results.

The problem of targeting could be improved by developing the components of the ADAS-cog so that they span a wider and more appropriate range of measurement. Although component-level floor and ceiling effects will almost always exist to some extent, they should be minimized if the potential of the ADAS-cog to detect change is to be maximized. However, although demonstrating these issues, the information provided by the traditional psychometric analyses used here does not provide specific guidance on how the ADAS-cog items might be improved. Alternative approaches are needed to elaborate upon these findings and propose an evidence-based strategy for restructuring and expanding the existing ADAS-cog components.

Results from this study may have important implications for clinical research. Developments in our understanding of AD have led to attempts to produce treatments aimed at slowing or altering disease progression. Appropriate evaluation of these treatments is dependent on rigorous measurement of clinically meaningful outcomes. Although the ADAS-cog offers clinicians a method of quantifying cognitive performance in people with AD, our findings highlight important limitations. This research emphasizes the importance of fully testing measures before clinicians and researchers apply them in clinical practice and treatment trials. In particular, it highlights the value of the component-level analyses, not typically undertaken, that identified problems with the ADAS-cog that were not detected by standard tests of scale reliability and validity.

Our study has three key limitations. First, the dataset was formed from baseline and screening data from proprietary clinical trial data. It would be valuable to repeat these analyses in non-proprietary data, in other large datasets, to ensure generalisability of our findings to the wider mild to moderate AD population. Second, the current dataset did not allow for analyses of responsiveness to clinical change of cognitive performance over time. Although examinations of responsiveness will be useful to elaborate on and substantiate our present findings, they should not detract from addressing the component level targeting problems identified. Validity testing was also limited. In particular, we were restricted in the extent to which we could examine aspects of construct validity. Essentially, we were limited to using the MMSE as an external measure; a less detailed, and comprehensive measure of cognitive performance. Thus, further examinations would be beneficial, including head-to-head comparisons with other more comprehensive neuropsychological measures of cognitive performance.

A third limitation is, although the current dominant paradigm for rating scale testing procedures, traditional psychometric analyses have many clinically important limitations, which we have outlined in detail elsewhere. [START_REF] Hobart | Rating scales as outcome measures for clinical trials in neurology: problems, solutions, and recommendations[END_REF][START_REF] Hobart | Improving the evaluation of therapeutic intervention in MS: the role of new psychometric methods[END_REF] In relation to the current study there are two key issues.

First, these methods are sample and scale dependent. This is clearly seen when we compare the performance of the ADAS-cog in terms of scaling assumptions (range of item-total correlations), reliability (alphas, test-retest ICCs), and validity (correlations between the ADAS-cog and MMSE) in the three AD severity subgroups (as described above in the results above and presented in Table 4).

These results, if taken at face value, imply that the measurement performance of the ADAS-cog is AD severity dependent. However, the variability in results can be explained by the limited variance of the estimates in each subgroup. This is because traditional psychometric methods are largely based on correlational analyses, and correlations are strongly influenced by variability in the entities correlated.

Unfortunately, traditional psychometric methods do not enable us to determine if the differences detected are real (ie scale performance is dependent on AD severity) or simply an artefact of the data distributions. More sophisticated psychometric approaches, for example an analysis of differential item functioning using Rasch analysis, are required to make that distinction.

The second key issue relating to traditional psychometric analyses is that they provide limited information at the component level; particularly about the adequacy of the response options.

Importantly, there are concerns over the use of traditional analyses in scales (for discussion see reference 11), such as the ADAS-cog, that combine components with differing number and type of response categories. Therefore, once further examinations are required utilising newer sophisticated rating scale analysis techniques that overcome these limitations, such as Rasch measurement methods, [START_REF] Andrich | Rasch models for measurement[END_REF][START_REF] Rasch | The MOS 36-Item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions and reliability across diverse patient groups[END_REF] to better diagnose the specific issues surrounding the performance of the ADAS-cog. [START_REF] Hobart | Rating scales as outcome measures for clinical trials in neurology: problems, solutions, and recommendations[END_REF] In this study, the ADAS-cog showed the potential to be a scientifically strong measurement instrument. However, our study also suggests that the ADAS-cog has limited ability to detect cognitive performance differences between people, changes over time, and the impact of treatment mild AD. Our analyses of the ADAS-cog by MMSE sub-group (Table 4) indicate that these limitations are more pronounced the milder forms of AD. The natural extrapolation of these findings is that the situation may be more problematic in people with mild cognitive impairment. Thus, in order for this scale to be a valuable cognitive performance measure in these patient groups, these limitations may need to be addressed.

Overall, although the ADAS-cog's psychometric performance was found to be satisfactory, more than half of its components may underestimate differences in cognitive performance in people with mild and moderate AD. The limited distributions indicate widespread targeting issues which may lead to problems in detecting clinical change when it occurs. This has important implications for the inferences of present and future clinical trials of AD using the ADAS-cog. Given the limitations of traditional psychometric methods, further evaluations would be desirable using more sophisticated modern rating scale analysis techniques to pinpoint the specific improvements that are required to maximise the ADAS-cog as a measure of cognitive performance in people with AD. the ADAS-cog components (column 1) and their response options represented by their scores (eg Word Recall component includes ten words, all words recalled correctly = 0, nine words recalled correctly = 1 ... none of the words recalled = 10; column 2) proportion (percentage) of patients endorsing each of the response options (column 2, as rated by the assessing clinician) for each of the eleven components of the ADAS-cog from the screening (column 3) and baseline (column 4) data.

1 or 2 )

 2 , with a Mini-Mental State Examination (MMSE) score between 10 and 26 and uncomplicated by stroke.

Table 1 : Respondent Characteristics (N=1421)

 1

	Characteristics	Mean, SD (range)
	Age	72, 8 (50-94)
	Gender	Percentages
	Female	59
	Male	41
	Ethnicity
	White	95
	Black/Caribbean	2
	Hispanic	2
	Other	1

Table 2 : ADAS-cog Scale level analyses* -Data Completeness, Scaling Assumptions, Targeting, Reliability, Validity (N=1421)

 2 In brief, data completeness includes percentage of missing data and computable scale scores; scaling assumptions involved tests of the legitimacy of summing components based on component means, standard deviations and item total correlations; targeting involved analyses of sccale score distributions; reliability included tests of random error including internal consistency and test retest reproducibility; validity invloved within and between scale correlational analyses and known groups analyses focussing on MMSE sub-samples.

		ADAS-cog TOTAL
	Psychometric property
	Data completeness**
	Computable scale scores (%)	100
	Scaling Assumptions
	Corrected ITC	0.39 -0.67^
	Targeting
	Possible range	0-70
	Range midpoint	35
	Score range	3-61
	Mean score	24.0
	SD	10.7
	F/C effect (%)	0/0
	Skewness	0.7
	Reliability
	Internal consistency
	Cronbach's alpha (n=1418)	0.84
	SEM	4.3
	95% CI	+/-8.4
	Mean IIC (n=1418)	0.39
	Range IIC	0.18 -0.70
	Test Retest reproducibility
	ICC Consistency***	0.93
	ICC Absolute***	0.93
	Correlation ***	0.93
	Validity****
	Correlation with MMSE	0.63
	**<0.5% MD rounded to 0
	^Range ITC
	***TRT between screening and baseline
	**** expanded in Table 4

* The analyses and interpretation of the statistics presented in this table relating to data completeness, scaling assumptions, targeting, reliability, validity are further described in Appendix 2 and also presented in Tables

3, 4

and Appendix 3.

Table 3 : ADAS-cog Component level analyses -Data Completeness, Scaling Assumptions, Targeting, Reliability* (N=1421) Psychometric property

 3

	Word	Naming	Comm-	Construct-	Ideational	Orientation	Word	Remembering	Spoken	Word
	recall	objects	ands	ional praxis	praxis		recognition	test instruction	language	finding
	(BASED	and
	3)	fingers

Table 4 : ADAS-cog psychometric analyses by MMSE subgroups (score ranges 10-14, 15-20 and 21-26) *

 4

	Subgroup by MMSE score

ACKNOWLEDGMENTS

None

FUNDING

Eisai Medical Research, Inc.

COPYRIGHT LICENCE STATEMENT

The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd, and its Licensees to permit this article (if accepted) to be published in Journal of Neurology, Neurosurgery, and Psychiatry and any other BMJPGL products and to exploit all subsidiary rights, as set out in our licence.

COMPETING INTERESTS

TH and MM are employees of Eisai Medical Research. JS is an employee of Eisai Global Clinical Development. HP is an employee of Pfizer (previously as employee of Eisai Medical Research). SH was retained as a consultant to Eisai Medical Research. JH and SC were supported in part through a grant from Eisai Medical Research.

Data Completeness

The extent to which ADAS-cog components are scored and ADAScog total scores can be computed.

Computing the percent of missing data for each component, and the percent of people for whom a scale score can be computed.

[27]

• Component-level missing data is <10% [START_REF]World Health Organisation Quality of Life Assessment Group. The World Health Organisation Quality of Life Assessment (WHOQOL): development and general psychometric properties[END_REF] • Computable scale scores >50% completed components. [START_REF] Ware | SF-36 Health Survey manual and interpretation guide[END_REF] • A total score can only be computed if all components are scored as they have substantially different ranges.

Scaling Assumptions

The extent to which it is legitimate to sum a set of component scores, without weighting or standardisation, to produce a single total score.[ 30 31] Summing ADAS-cog component socres is considered legitimate, when the components:

1. Are approximately parallell ( ie they measure at the same point on the scale).

2. Contribute similarly to the variation of the total score (ie they have similar variances), otherwise these should be standardised.

3. Measure a common underlying construct (ie cognitive performance) [START_REF] Guttman | Some necessary conditions for common-factor analysis[END_REF] otherwise combining them to produce a single score is not appropriate.

4.

Contain a similar proportion of information concerning the construct Scale scores should span the entire range; floor (proportion of the sample at the maximum scale score for the ADAS-cog) and ceiling (proportion of the sample at the minimum scale score) effects should be low (<15%); [START_REF] Mchorney | Individual-patient monitoring in clinical practice: are available health status surveys adequate?[END_REF] and skewness statistics should range from -1 to +1. [START_REF] Hays | Psychometric considerations in evaluating health-related quality of life measures[END_REF] There is no published criteria for component level targeting. Therefore, we applied the scalelevel criteria. This is frequently overlooked but important. [ Two types of reliability were examined at both scale and component level. Each quantifies a different source of random error:

1. Internal consistency reliability estimates the random error associated with total scores from the intercorrelations among the components. [START_REF] Cronbach | Coefficient alpha and the internal structure of tests[END_REF] 2. Test retest (TRT) reproducibility, based on the agreement between people scores at screening and baseline, estimates the ability of components and scales to produce stable scores. [START_REF] Hays | Psychometric considerations in evaluating health-related quality of life measures[END_REF] 1. Recommended for adequate scale internal consistency is Cronbach's alpha coefficient ≥0.80, [START_REF] Cronbach | Coefficient alpha and the internal structure of tests[END_REF] and item internal consistency is item total correlations >0.40.

2.

Recommended for adequate TRT reproducibility are scale-level intraclass correlation coefficients (ICC) ≥0.80 [START_REF] Nunnally | Psychometric theory[END_REF] and item level ICC ≥0.50. [START_REF] Duruoz | Development and validation of a rheumatoid hand functional disability scale that assesses functional handicap[END_REF]

Validity

The extent to which a Three aspects of construct validity were scale measures what it intends to measure and is essential for the accurate and meaningful interpretation of scores. [START_REF] Kaplan | Health status: types of validity and the index of well-being[END_REF] tested:

1. Convergent construct validity was examined by computing correlations between ADAS-cog and the mini mental state examination (MMSE [START_REF] Folstein | Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician[END_REF]). a 2. Discriminant construct validity was examined by computing correlations between the ADAS-cog and sociodemographic variables (age and sex) to determine the extent to which they were biased by these variables.

3. Group difference construct validity was examined by comparing ADAScog mean scores for the three MMSE defined groups.

1. We hypothesised that the ADAS-cog and MMSE would be highly negatively correlated (r>-0.70) as the two scales measure cognitive performance but are scored in opposite directions.

2. We predicted ADAS-cog scores should not be notably biased by these variables and, therefore, correlations would be low <0.30.

3. We predicted a stepwise change in ADAScog scores across the groups, and that the means scores would be signifincatly different.

a The MMSE is a 30-item rating scale used to assess aspects of cognitive performance (including arithmetic, memory and orientation), and is commonly used in screening for dementia, and also to classify AD as mild