CHAPTER
IV
The
Present
Study
GENERAL FEATURES
N exploration of the effects of early
mal-nutrition on the development of
neuro-integrative functioning in school children
can of course be carried out definitively
only by means of a prospective longitudinal
study of children at risk and of
appropriate-ly selected control subjects. We are
cur-rently engaged in conducting such an
in-vestigation. However, since the findings of
a prospective longitudinal study become
available only after a long period of delay,
it was decided that a certain amount of
pertinent information could be obtained
through a carefully conducted
cross-sec-tional retrospective study of
neurointegra-tive organization in children of school age.
The present monograph is the result of such
an investigation.
To explore the effects of malnutrition on
neurointegrative development it was
de-cided to carry out a cross-sectional study of
intersensory functioning in the total
popu-lation of primary school children in a
vil-lage in which detailed prior information
in-dicated the presence of a significant
preva-lence level of serious acute or prolonged
malnutrition during infancy and the
pre-school years. For purposes of the
investiga-lion malnutrition was defined
retrospective-ly on the basis of height for age in all
chil-dren ranging in age from 6 to 11 years.
When the child showed a significant
dim-inution of stature with respect to his
age-mates in the total village population of
chil-dren, he was assumed to have an increased
likelihood of having been at earlier risk of
malnutrition. On this basis, at each age
level, a group of children representing the
lowest 25% of the height distribution was
identified and designated as the group
hav-ing the greatest likelihood of having been
at earlier nutritional risk. The functioning
of this group was compared with that of the
children in the village who were in the
tal-lest quartile for age and so, assuming all
other factors to be equal, representing
those with the least likelihood of having
ex-perienced a significant degree of
malnutri-tion earlier in life. In this way groups of
children with common ethnic background
were identified and represented the upper
and lower quartiles by height of individuals
in the age groups studied.
Clearly, at least three important variables
must be controlled for when height for age
is being used as an index of prior
nutrition-al risk. The first relates to parental stature
and thus to familial factors affecting height.
Since height at school age may reflect not
only the individual’s nutritional background
but also his parental endowment it was
necessary in designing the study to obtain
anthropometric information on parents as
well as on children in order to control for
this variable.
A second consideration is that low stature
during the years studied may represent a
general maturational lag in the course of
which both height and intersensory
func-tioning may both be subnormal. To control
for this possibility it was necessary to study
a second sample of children of the same
ages who exhibited equivalent differences
in height but who had little or no likelihood
of ever having been at nutritional risk.
Finally, since no integrative capacity is
unaffected by environmental influences,
comparative information on the social,
eco-nomic and educational status of the
fami-lies from which the children derived had to
be obtained. Details of the procedures used
for obtaining background data on the
chil-dren studied will be presented at a later
point.
The indicator of neurointegrative
de-velopment selected for study was
intersen-sory organization. This was done for two
reasons. In the first place a considerable
DESCRIPTION OF THE RURAL VILLAGE central zone of the Republic of
Guatema-la, CA. It lies at an altitude of 6,780 feet
above sea level and is 22 miles from the
capital city. The climate is characterized by
two well defined seasons, one dry and one
with heavy rains, which are popularly
re-ferred to as “summer” and “winter.”
The population was composed of 333
SUPPLEMENT
psychologybolb02 and evolutionary
physi-ology’o3 has accumulated which suggests
that the emergence of complex adaptive
capacities is underlain by the growth of
increasing liaison and interdependence
among the separate sense systems.
Sherrington’#{176}’ in considering this process
has gone so far as to argue, “The naive
would ilave expected evolution in its course
to have supplied us with more various sense
organs for ampler perception of the world.
The policy has rather been to bring by
the nervous system the so-called ‘five’ into
closer touch with one another.. . . A central
clearing house of sense has grown up.
Not new senses, but better liaison between
old senses is what the developing nervous
system IlaS in this respect stood for.” In
ad-dition, a variety of studiesbo5,106 indicate
that the basic mechanisms involved in
primary learning (i.e., the formation of
con-ditioned reflexes) is probably the effective
establishment and patterning of
intersenso-ry organization.
The second reason for using intersensory
competence as an indicator of
neurointe-grative development stems from the fact
that Birch and Leffordbo7 have shown that
adequacy of intersensory interrelations
im-proves as a clearly defined growth function
in normal children between the ages of 6 to
12 years. In school children, comparable in
age with the ones we were planning to
study, they found that the interrelations
among three sense systems-touch, vision
and kinesthesis-improved in an age-specific
manner, and resulted in developmental
curves that were as regular as those for
skeletal growth.
DESIGN OF THE STUDY
The design of the study was based upon
the view that it was feasible to conduct a
comparative study of neurointegrative
func-tioning in school age children in whom
extremes of difference in height at school
ages were to be used as an index of
pre-school nutritional adequacy. Since height as
such may with equal readiness be an
indi-cator of maturation or constitution as of
an-tecedent malnutrition, height as such had to
be controlled for by studying a comparison
sample of children who differed in stature
but among whom it was most improbable
that the shortest children had been
sub-jected to nutritional stress. It was therefore
decided to replicate the rural study on
an upper class urban sample of school
children#{176}8 who were most unlikely to have
been at nutritional risk and whose
varia-tions in height would be unrelated to either
primary or secondary malnutrition. The
rural community study was ecologic in its
organization and sought to relate growth
achievements as well as intersensory
de-velopment to the social, economic,
educa-tional and physical characteristics of the
families from which the children derived.
In this connection the findings obtained
through studying the urban group could be
treated not only with respect to the
prob-lem of stature but also as a device for
teas-ing out the relations between growth and
function in a socially differentiated rural
group by comparing it with a socially and
economically homogeneous urban group in
which height differences existed but cOuld
not be related to conditions of nutrition,
health, or social standing.
General Aspects of the Community
Method
and
Procedure
All the rural school age children lived in
the village of Magdalena, M.A. This
com-munity, inhabited by people who belong to
the Cakchiquel linguistic group, is located
TABLE II
CALORIE CONTRIBUTION OF THE PROTEIN, FATS, AND
CARBOHYDRATES CONSUMED IN MAGDALENA, MA.,
IN THE YEARS 1950 AND 1968
families making up a total of 1,620 persons,
323 of whom were below 5 years of age.
Eighty-one and six tenths percent of the
population were self-identified as Indian.
The crude mortality rate was 43 per
thousand during the period 1901 to 1905
and has diminished progressively reaching
the figure of 15.3 in 1958-1962. The infant
mortality rate (deaths in infants less than 1
year old per 1,000 live births) has remained
generally unchanged, although with
marked annual variations, for more than 50
years. The corresponding figures for the
pe-riod 1906 to 1910, and 1961-1962 were,
re-spectively, 121 and 138. During the years
1948 to 1962 the number of deaths in the
age group 6 to 12 accounted for 2.8% of the
total deaths. Diarrhea was the main
regis-tered cause of death followed by measles,
“worms” and “dropsy”.109 The birth rate has
been stationary around 44 births per
thou-sand during the past 15 years.
Production and Commerce
The villagers are small farmers whose
main crops are corn and beans, some greens
such as lettuce and cabbages, and
vegeta-bles including carrots and green peppers
grown in small family gardens. Flowers are
cultivated for commercial purposes in
sepa-rate plots. There is commercial interchange
between the village and the capital city, as
well as with the City of Antigua, the main
town in the Department.
Pattern of Food Consumption
The analysis of three dietary surveys
con-ducted during May, June, and November
of 1963 and a comparison with the data
ob-tained for the same village in 1950 by
Flores and Reh11#{176}revealed a small increase
in the consumption of milk derivatives,
greens, bananas, grains, roots and fats, and
a reduction in the intake of corn and fruits.
Nevertheless, the present diet continues to
be protein poor and is not significantly
more adequate than that consumed 13
years ago. Table II is illustrative both of
the poor nutritional quality of the current
diet and of this lack of improvement.11’
Source
Percentages Contributed to the Total Caloric Value of the Diet
Period Studied
May 1950
May 196-3
June 1963
Nov. 1963
Protein Fats
Carbohydrates
l’2 8
80 1 11
77
12 10 78
12 10 78
Migration
Approximately 10% of the families make
an annual transient emigration to the
coast-al region at the time of the coffee harvest.
During a period of 1 to 4 weeks the whole
family leaves the village. Actual emigration,
that is leaving the village permanently, is so
rare that it can be confidently stated that
for practical purposes there is no
emigra-tion. The same is substantially the case for
immigration.
Transportation
Buses to and from the capital city are
available daily, and twice a week a bus
runs to and from Antigua, the
administra-tive and political head of the Department
of Sacatepequez.
HEIGHT MEASUREMENTS
The standing height of all the children
aged 6 to 11 was measured by two
pediatri-cians previously trained in standardized
procedures and compared one against the
other through a series of exercises until they
achieved replicate measurements varying
by no more than 0.4 cm.112 All
measure-ments were made by means of a firm wall
board with a simple counterweight
at-tached to the head block. The child was
helped to stand erect with heels, buttocks
and shoulders tangentially against the wall
board. The position of the child with the
heels together, and feet at an angle of 45#{176}
TABLE III
AGE AND SEX DISTRIBUTION OF THE
RURAL CHILDREN STUDIED
Boys Girls Total
6
7 8
9
10 11
6
21
11
16
16 9
13
10
9
11
9 12
19
31
20 27 25
21
Total 79 64 143
shape of them on the base of the apparatus
and positioning each child to these
draw-ings. Parents’ heights were measured in the
same way.
All the measurements were then arranged
in decreasing order of magnitude. Quartiles
were calculated for each age and sex. All
the children who fell in the upper and
lower height quartiles were selected to be
tested for intersensory development. The
number, age, and sex of children included
in the rural sample are shown in Table III.
CHILD’S SOCIAL AND ECONOMIC ENVIRONMENT
A picture of the child’s social, cultural,
familial and economic background was
ob-tained by means of individual interviews of
parents, observation of practices, detailed
evaluations of housing and sanitary
condi-tions, conducting a census, and through
parallel anthropologic studies. The forms
used for these inquiries are presented in the
Appendix. The general areas evaluated
in-cluded the following:
(a) The family-a list of the persons
mak-ing up the home and the family, civil status,
age, the degree of relation with the child,
their self-identification as to ethnic group,
the languages spoken in and outside the
home with adults and children.
(b) Factors that may influence
health-such as house sanitation, personal hygiene,
presence of poisonous animals and vectors
of disease, crowding of adults and children,
and presence of domestic animals in the
home without separation from the persons.
(c) Educational background-literacy and
schooling of the parents, and use of such
communications media as books, radio, and
newspapers.
(d) Occupations and leisure time
prac-tices-sources of income for each member
of the household, contribution to the home
budget; the family budget for food and
other purposes; the use of free time; the
or-ganizations to which they belonged; and
the attachment to religious organizations
and practices were determined.
(e) Availability of food in the family-the
actual food produced by the family, the
technique of production, the disposition of
food produced, percent of produce sold,
used for animal feed, left for seed, wasted
because of inadequate storage; the types
and amounts of food purchased were
as-sessed.
To provide background data three
di-etary surveys were conducted in a sample
of 57 family households, with the main
ob-jective of assessing the food consumption
pattern and the adequacy of the diets in
comparison to figures available for
prac-tices 13 years before.
THE URBAN CHILDREN
The comparison group of school age
chil-dren were all students at a private school
whose pupils were drawn from upper
mid-dle class and upper class families. Family
income was uniformly high and educational
background of the parents in all cases was
beyond the secondary school level.
Num-bers, age, and sex of the urban children are
presented in Table IV.
PROCEDURE FOR TESTING INTERSENSORY
ORGANIZATION
The method used for studying
intersenso-ry integration was that developed and
de-scribed by Birch and Lefford.107
Equiv-alence relationships among the visual,
hap-tic and kinesthetic sense modalities were
explored for geometric form recognition.
corn-338
TABLE IV
AGE AND SEX DISTRIBUTION OF THE UPPER SOCIAL
CLASS URBAN CHILDREN STUDIED
Age
(yr) Bo1js
-Girl .8 Total
6 10 10 20
7 15 5 20
8 9 11 20
9 10 10 20
10 9 11 20
Ii 10 10 20
Total 63 57 120
plex sensory input obtained by active
manual exploration of a test object. Such
exploration involves tactile, kinesthetic, and
surface movement sensations from the
sub-jects’ fingers and hand, such as are obtained
in manipulating an object. Tile kinesthetic
sense, in this study, refers to the sensory
in-puts obtained through passive arm
move-ment. In the current investigation such a
motion entailed sensory input from the
wrist, elbow and shoulder joints and from
the arm and shoulder musculature as its
principal components.
To study intersensory equivalence in the
perception of geometric forms, a paired
comparison technique was utilized. A form
presented to one sensory system (standard)
was compared with forms presented in
an-other sensory system (variable). Thus, a
visually presented standard was compared
with a series of forms presented haptically
or kinesthetically. Similarly, a haptically
presented standard was compared with a
kinesthetically presented series. On the
basis of such examination the existence of
cross modality equivalences and
non-equiv-alences between tile visual and haptic
sen-sory systems, between the visual and the
kinesthetic sensory systems, and between
tile haptic and kinesthetic sensory systems
could be determined.
Eight blocks, selected from the Seguin
Form Board, were used as the test stimuli.
The forms used were the triangle, hexagon,
square, hemicircle, cross, diamond, star,
and circle. These forms are presented in
Figure 2. The same blocks were used as the
visual and haptic stimuli. As a visual
stimu-lus the block was placed on the table
di-rectly in front of the subject. For haptic
stimulation, the subject’s hand, positioned
behind an opaque screen, was placed on a
block by the experimenter. The subject
then actively explored the form with his
hand outside his field of vision. Kinesthetic
information was provided by placing the
subject’s preferred arm behind a screen
and, with the arm out of sight, passively
moving it through a path describing the
geometric form. This was accomplished by
placing a stylus held in normal writing
po-sition in the subject’s hand. The examiner
gripped the stylus above the point at which
it was held by the subject and then moved
the stylus and hand through the path of a
track describing the geometric form
in-scribed in a linoleum block. The track
forms were made from 4 in. by 5 in.
lino-A
Ji
0
Fic. 2. Geometric forms used for testmg
TABLE V
ORDER OF PRESENTATION OF STANDARD AND
VARIABLE STIMULI FOR TESTING INTERSENSORY FUNCTIONING
* TRI = tr = triangle; HEX = hx = Hexagon;
SQU = sq = square; H-C = he = hemi-circie;
CR0 = cr = cross; DIA = di = diamond;
STA = st = star; CIR = cr = circle.
SUPPLEMENT
leum blocks in which the patterns were
in-scribed to a depth of % in., forming a track
through which the stylus could be moved.
The outline dimensions of the track were of
the same size and shape as those of the
var-ious blocks used for visual and haptic
stim-ulation.
For all sensory modalities the forms were
always presented so that the long axes were
parallel to the frontal plane of the subject.
In a kinesthetic trial the movement was
al-ways started at the topmost point of the
figure and continued in a clockwise
direc-tion for the right hand and in a
counter-clockwise direction for the left hand. In
putting the subject’s hand through the
mo-tion, a short pause (approximately a
sec-ond) was made at each point of the course
where there was a change of direction. For
each kinesthetic trial the subject’s hand was
put through only one complete circuit from
topmost point to topmost point.
Three cross-modality interactions were
explored for intersensory equivalences:
visual and haptic interaction, visual and
kinesthetic interaction, and haptic and
kin-esthetic interaction. Paired stimuli were
presented for comparison, the first member
of the pair to one sense modality and the
second member of the pair to the other
sense modality. In a given series of
presen-tations the first member of the pair was
held constant as a standard against which
varying second members were compared
successively. At the end of a complete
se-ries of trials a new standard stimulus was
introduced against which the various forms
presented to the other modality were
com-pared. This procedure was repeated until
the subject was examined with each of the
eight forms serving as standard.
The order of presentation is given in
Table V. In this table the column headings
represent either visual or haptic
presenta-tions of the standard stimuli. The stimuli
listed in the columns represent successive
forms which the subjects were asked to
match with the standard. When the
modali-ty represented in the column heading was
vision, the modality used in the
compari-Standard Stimuli’
TRI hEX SQU 11-C CEO DIA STA Chit
Variable Stimuli sq ci di st tr he hx tr er st hx cr hx ci sq di he tr st tr sq di lix he sq ci er er he tr ci he st di sq hx hx di cr tr sq ci er st he di er he ci hx di tr sq st tr di he sq st hx er st ci er ci he hx st ci sq tr di
sons was either haptic or kinesthetic. When
the modality represented in the column
heading was haptic, the modality used in
the comparisons was kinesthetic. Thus for
column 1, a visually presented triangle
would be successively matched with a
hap-tically presented square, circle, diamond,
etc. When the paired comparisons
repre-sented by the first column were completed,
the pairs represented by the second column
were given, and so on. The second
mem-bers (variable stimuli) of the pairs are in
prearranged random order from column to
column. The form representing the
stan-dard stimulus was represented twice among
the variable stimuli. The described order of
presentation was followed for visual-haptic
comparisons, visual-kinesthetic comparisons,
and haptic-kinesthetic comparisons.
The combination of these various factors
resulted in three sets of comparative
judg-ing tasks. They were presented to the child
in the following order: visual-kinesthetic series, visual-haptic series and
haptic-kines-thetic series. All subjects were tested
indi-vidually in a quiet room alone with the
ex-aminer. In order to familiarize the subject
with the forms, before beginning the
judg-ments, he was given the Seguin Form
Board Test. The form board was presented
340
as seen from the subject’s position. With
the subject watching, the 10 pieces were
stacked in three piles at the head of the
board in a standard manner. The subject
was instructed to put the blocks back into
the right place. This task in effect
repre-sented a visual-visual comparison series;
the form of the block and the form of the
depression on the Seguin Board were
visu-ally matched by the subject. Number and
kind of errors made were noted by the
ex-aminer. No time score was obtained.
Following this preliminary test, a screen
was placed on the table, and the following
explanation was given: “In this next game, I
am going to show you a form like this
cir-cle. Then I am going to move your hand
around like this.” The procedure was
dem-onstrated by moving the arm through a
triangle, square, and circle. “You are to tell
me if the shape your hand moves around is
the same as the shape that you see in front
of you. To make the game more interesting,
I am not going to let you see which shape
your hand is going to go around. I will hold
your hand behind this screen. You are not
to look. We will do it like this.”
The task was then demonstrated with
hand behind the screen using a circle as the
visual standard test object and the square,
triangle and circle as kinesthetic test
ob-jects.
When the examiner was sure that the
subject had understood the nature of the
task, the visual-kinesthetic testing series
was begun. The subject was asked for a
judgment of “same” or “different” for each
paired comparison presented. If the subject
was doubtful, he was asked to guess. No
repetitions of trials were given. No
affirma-tions or corrections were made during the
test period.
The instructions for the visual-haptic
se-ries were essentially the same as for the
visual-kinesthetic except for minor changes
to make the wording appropriate to the
haptic stimuli. In this series the blocks were
placed in the subject’s hand out of his field
of vision behind the screen. They were
compared to the standard visual stimuli
which was a block placed in the subject’s
field of vision on the table before him. A
judgment of “same” or “different” was
elic-ited.
For the haptic-kinesthetic series, the
in-structions were again the same with minor
changes appropriate to the situation. In this
series, however, vision was excluded by
having the subjects wear a pair of darkened
goggles. The standards in this series were
the haptic stimuli. They were presented to
the hand to which no kinesthetic stimulus
was being applied. After comparison, as
above, a judgment of “same” or “different”
was elicited after each trial.
Judgments were scored as right or
wrong. Two kinds of error were
distin-guished: an error made when nonidentical
forms presented across modalities were
judged as being the same, and an error
made when identical forms were judged as
