Journal of Consulting and Clinical Psychology 1977, Vol. 45, No. 4, S24-S35

Neuropsychological Deficit, Ethnicity, and Socioeconomic Status Dominic Amante, Verne W. VanHouten, Josephine H. Grieve, Charles A. Bader, and Phillip H. Margules West Shore Mental Health Clinic, Muskegon, Michigan The results of a community study dealing with the ecological distribution of intellectual and various perceptual-motor deficits, presumed to be functionally related to neurological status, are presented. The available empirical evidence strongly suggests that levels of neurological integrity vary along a socioeconomic gradient and between ethnic groups. An environmentally based model of social causation is presented as the most appropriate theoretical explanation of the patterned distribution of neurological pathology across social class and ethnic-group lines. This model directs attention to the impact of such factors as rnalnutrition/undernutrition, adverse conditions of environmental stimulation, inadequate obstetrical and pediatric care, environmental deterioration, and other such forces presumed capable of inducing neurological differentiation between groups of children through time and across space. Further, the model in question is assumed to be an appropriate guide to the general area of prevention, indicated to be the most essential problem at the present point in time. During the course of the past 3 decades, several independent lines of empirical research have converged and, in composite, clearly suggest that rates of central nervous system damage/dysfunction in children, or its presumed symptomatic correlates, vary as a function of ethnic group membership and social class position (Birch & Gussow, 1970; Pasamanick & Knobloch, 1961). The prevalence of central nervous system pathology is inversely correlated with socioeconomic status, and there appears to be a definite concentration of such cases in the minority group populations. Further, there is growing recognition that subtle or severe neurological disorders, many of which appear to be etiologically related to various forms of obstetrical pathology, which are themselves linked with social class and ethnicity, are contributing factors to a broad spectrum of medical, behavioral, and social problems (Adamsons & Fox, 1975; Drillien, 1970a; Kawi & Pasamanick, 1959; Knobloch & Pasamanick, 1974; Small, 1973). These include, among others, mental retardation (Clarke & Clarke, 1974; Koch & Dobson, Requests for reprints should be sent to Dominic Amante, West Shore Mental Health Clinic, 2S2S Hall Road, Muskegon, Michigan 49442.

1976), minimal brain dysfunction (Gross & Wilson, 1974; Wender, 1971) or academic learning disabilities (Lerner, 1971; Myers & Hammill, 1976), certain forms of schizophrenia, and various other psychopathological outcomes (Bender, 1961; McNeil, Wiegerink, & Dozier, 1970; Mednick, 1970), and perhaps conventional crime and juvenile delinquency (Berman & Siegal, 1976; Brutten, Richardson, & Mangel, 1973; Tarnopol, 1970). Various cognitive and motor abilities—including general intelligence, gross motor processes, psycholinguistic skills, auditory discrimination or information-processing abilities, and visual-motor functions—are among some of the most basic psychological processes that many investigators cite as contributing factors to the range of outcomes referred to (Chalfant & Scheffelin, 1969; Deutsch & Schumer, 1970; Eisenberg, 1975; Goldfarb, 1970; Goldman, Fristoe, & Woodcock, 1970; Hingtgen & Bryson, 1972; Jensen, 1969; Kephart, 1968; Koppitz, 1975; Lezak, 1976; Reitan & Boll, 1973; Reitan & Davison, 1974). Many studies have been reported in the literature that have used a single or very limited assessment procedures—involving, for example, an intelligence test, a unitary measure of perceptual-motor skills, personality, or academic achievement—in an attempt to

S24

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screen for general intelligence, neurological status, achievement potential, and so forth. Several studies in this general area with both socially disadvantaged and neurologically impaired subjects have clearly implicated such factors as intellectual deficits (Kennedy, VanDeRiet, & White, 1963), language or psycholinguistic problems (Deutsch, 1964; John, 1963), and visual-motor malfunction (Amante, 1975). The primary purpose of this empirical study, essentially an epidemiological field survey (Millon & Diesenhaus, 1972), was to derive a set of psychological measures representing various intellectual, perceptual-motor, and behavioral functions in a single sample and to relate them to two central sociological parameters—namely, socioeconomic status and ethnicity—and to selected indices of obstetrical competence. The basic hypothesis was that poor white and poor black subjects would exhibit considerably more evidence of cognitive dysfunction or various behavioral indicators suggestive of neurological pathology relative to general population (normative) data. Blacks were expected to exhibit more problems than whites of roughly comparable socioeconomic status because of greater environmental disadvantage (Birch & Gussow, 1970; Gottesman, 1968a). Method Subjects The study was conducted in Muskegon, Michigan and involved the individual testing of a random sample of 225 third-grade public and parochial school childres of both sexes representing a cross-section of subjectdrawn from all of the major ethnic groups and socio, economic levels present in the community. Children were selected from six public and three parochial schools. In terms of ethnic group composition, the sample included 158 white children, 60 black children, and 7 other children (most of them Spanish-Americans). These latter subjects were removed for purposes of data analysis, restricting the final sample (N = 218) to white (77 males and 81 females) and black (30 males and 30 females) children. From this data pool, varying numbers of subjects were drawn for specific analyses depending on certain controls that were applied and the availability of data in specific categories of interest.

A ssessment Considerations A multiplicity of psychological test data, educational achievement data, and behavioral ratings were used to

525

sample a broad range of functions. In addition, a variety of information concerning maternal and family background characteristics was obtained by means of a mailed-in questionnaire, which was completed by the child's parents or legal guardians. Only a portion of the available data is systematically analyzed in this report. All of the children were tested in school during regular hours by experienced master's level psychologists with the following battery of instruments: (a) The Culture Fair Intelligence Test (Scale II, Forms A and B), (b) the Wepman Auditory Discrimination Test (Forms A or B), (c) the Frostig Developmental Test of Visual Perception; and (d) the Bender Gestalt. The test battery was administered to each child in a random sequence to break up any response set(s) that might emerge during the course of the examination. In addition, hand, eye, and foot preference were assessed in the case of each child at the start of each examination and again at the end. The tests were administered, scored, and evaluated strictly in accordance with the directions and guidelines specified in the respective test manuals. The Hollingshead Index of Social Position was used to objectively measure socioeconomic status (Hollingshead, Note 1). Finally, ethnicity was assessed socially or subjectively, not genetically or formally, by means of observation and information provided by the schools.

General Methodological Considerations Permission to conduct the research project was obtained from the principals of each respective school, typically after first clearing the matter with the Board of Education or the Superintendent representing the district. The principals were then sent a written document indicating the nature of the proposed research, the theoretical rationale behind it, and the specific methodology contemplated to gather the data. A social worker thereafter contacted the teachers at each of the schools to personally brief them on the research study and to answer any questions they cared to raise. The sample of children was then randomly selected with the help of the school personnel. Prior to the scheduled testings, the school distributed an introductory letter and a questionnaire to the child's parents or guardians that assessed varied categories of demographic, social, and medical information. The parents were requested to forward the completed questionnaires directly to the investigators, and, in the event that they did so, the parents were later sent a comprehensive report letter specifying their child's performance on the battery of psychological tests used. They were also encouraged to contact the investigators directly if there were any questions concerning the parental report. Finally, the principals were sent a detailed report of the empirical findings pertinent to their school and were invited to draw on the help or consultation services of the agency (a community mental health center) represented by the investigators if that appeared to be appropriate. Thereafter, the data were coded, grouped, and statistically analyzed as indicated below.

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Results The questionnaire return rate varied by socioeconomic status, ethnicity, and public versus parochial school attendence. Generally speaking, the rate was positively correlated with socioeconomic status; proportionately more white than black families returned the questionnaire; and families from parochial schools had a higher return rate than did public school families. The return rate varied from a low of 63% at one of the predominately black inner-city schools to a high of 100% at two of the parochial schools. For the total sample, 80% of the parents returned their questionnaires, indicating a satisfactory measure of parental cooperativeness. If the questionnaire data were incomplete or unsatisfactory in any manner, the parents or guardians were contacted to remedy the situation. The data for all subjects were analyzed against the socioeconomic status level prevailing in the child's household at the time of birth. Interethnic Group Comparative Data

For purposes of data analysis, a subsample of blacks (n = 58) was systematically compared with a subsample of whites (n = 58) roughly matched for geographic residence and socioeconomic status. The socioeconomic status level was restricted to Class IV (working class) and Class V (lower class) families. Blacks consistently exhibit evidence of more psychological deficit than whites on all of the psychological tests. More than one quarter (28%) of the black subsample as compared with 3% of the white subsample scored well into the intellectually subnormal range— operationally defined as a mean IQ of 85 or lower—on the Culture Fair Intelligence Test. Fifty percent of the blacks as compared with 40% of the whites appeared to be perceptually handicapped in terms of Bender Gestalt test performance indicators. Moreover, when perceptual-motor problems were present on the Bender Gestalt, they appeared to be more severe in the case of blacks. For example, whereas 17% of the blacks and 21% of the whites scored in the error range of plus one and two standard deviations above the mean, 33% of the blacks and 19% of the whites

scored in the range of two or more standard deviations above the population mean. Interethnic group differences on the Frostig test also support the inference that blacks suffer more visual-motor malfunction than do whites. Sixty-eight percent of the black subsample obtained a perceptual quotient (PQ) of 90 or less on the Frostig in comparison to 41% of the white subsample. Finally, whereas 62% of the black children exhibited evidence of either a mild or a serious auditory discrimination handicap, only 40% of the white children were so characterized. Further, as in the case of the Bender Gestalt, the prevalence of serious as compared with mild problems was greater for blacks. For example, in terms of error frequency, 23% of the blacks and 26% of the whites appeared to exhibit evidence of a mild auditory perceptual problem, whereas 39% of the blacks but only 14% of the whites had more serious auditory discrimination problems. Consistent with a good deal of empirical data in the field (Jensen, 1969), a 12-point IQ differential between blacks and whites was observed with no controls for the level of perceptual-motor skill functioning. However, both groups exhibited a level of general intellectual function that was well within the average range of variability in terms of normative population data (typically represented by a mean IQ of 100 and a standard deviation of 15 or 16). The observed differences reached statistical significance at the .01 level (see Table 1). However, when the interethnic group IQ differential was evaluated with and without a control for the level of visual-motor function, interesting group differences began to appear or were eliminated. For example, using the Bender Gestalt to separate both black and white subjects into perceptually normal and abnormal groups, marked differences were noted. Compared to the no-control condition, the IQ rose in both blacks and whites when the perceptually impaired subjects were removed, but the difference between groups remained significant at the .01 level with a measured IQ differential of 10 points. Relative to the nocontrol condition, the IQ in both groups dropped when the perceptually handicapped subjects were added, and the difference between

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Table 1 Intellectual Differences Between Black and White Working-Class and Lower-Class Children with and Without Control for Perceptual-Motor Status Variable Intellectual level (culture fair IQ) M1Q SD n Control for perceptual—motor status (Bender Gestalt) Perceptually normal MIQ SD n Perceptually impaired MIQ SD n Control for perceptual— motor status (Frostig) Perceptually normal (PQ of 91 or more) MIQ SD

n Perceptually handicapped (PQ of 90 or less) MIQ SD n

Blacks

Whites

Difference

Twotailed t

df

91 11 58

103 9 58

12

6.82**

114

96 9 29

106 8 35

10

4.61*

62

86 10 29

98 8 23

12

4.30**

50

101 7 18

105 9 32

4

1.61

48

86 9 39

102 7 22

16

6.83**

59

Note. PQ = perceptual quotient. * p < .05. ** p < .01.

these two groups remained significant at the .01 level. Similar but more pronounced differences between and within groups appeared when the Frostig test was used as a control for visualmotor status, an observation resulting in all probability from the fact that the Frostig is a more inclusive measure of visual-motor functions than the Bender Gestalt. It is important to observe that the IQ differential is reduced to 4 points in the case of perceptually normal black children and white children, a difference that failed to reach statistical significance. However, the difference between groups was increased to 16 IQ points in the case of perceptually handicapped subjects, an observation we believe is largely the result of the fact that cases of more serious perceptual-motor malfunction are more highly concentrated in

blacks as compared to whites of roughly comparable socioeconomic status. A similar change was noted in the case of interethnic group differences in auditory discrimination when the same set of controls was systematically applied. Black children had a mean PQ of 85 in contrast to whites, who had a mean of 90. The difference between the two groups is significant at the .01 level. These differences were reduced but not eliminated when we controlled for perceptual-motor status with the Bender Gestalt. With control, the differences between perceptually normal black subjects and white subjects was reduced to 3 PQ points (significant at the .05 level) and was increased to 7 PQ points in the case of the perceptually impaired subjects (significant at the .01 level). The pattern of more pronounced differences between perceptually impaired black subjects

AMANTE, VANHOUTEN, GRIEVE, BADER, AND MARGULES

528

Comparative Socioeconomic Differences in Whites

Figure 1. Profile differences on the Froslig between black (n = 58) and white (« = 58) working-class and lower-class children.

and white subjects, as opposed to perceptually normal subjects, is again apparent. Frostig subtest profile differences between black children and white children can be seen in Figure 1. The shape of the curves for both ethnic groups is similar, but blacks consistently made more obvious errors than did their white counterparts (see Table 2). The most extreme group differences (significant at the .01 level) involved Subtests III (Shape Constancy), I (Eye-Motor Coordination), and V (Spatial Relationships), in order of importance. Black-white differences on Subtest IV (Position in Space) reached significance at the .05 level. Only on Subtest II (FigureGround Perception) were significant interethnic group differences absent. In short, the profile pattern of abilities was similar in both groups, but the level of performance favored the whites. Table 2 Data Analysis Frost ig subtest

Statistic

1

M SD

17.4 2.9

M SD

19.0 3.4

2

3

4

5

Blacks 18.0 10.7 2.0 3.2

6.7 1.2

6.1 .9

Whites 13.1 18.S 1.5 2.5

7.2 .9

6.7 .7

Social class differences in white children were examined in a separate set of analyses. In most of these analyses, Classes I, II, and III are grouped together to form a nonmanual class, and the children drawn from Classes IV and V are combined in a manual class. The analyses are restricted to white children of known socioeconomic status at the time of the child's birth who are biologically related to their parents. All of the children were drawn from public schools for each analysis, with the exception of an analysis involving the Frostig test. The reason for this is that the public school subjects differ significantly from parochial school subjects of roughly comparable socioeconomic status along a variety of test-related dimensions exclusive of the Frostig. There are clear-cut differences between the nonmanual class (n = 30) and the manual class subjects (n = 64) in terms of general intelligence as measured by the Culture Fair test. Rates of intellectual subnormality were more than twice as high in the manual class children in comparison with the nonmanual class subjects. The evidence indicates that 3% of the nonmanual class subjects were intellectually subnormal, whereas 7% of the manual class subjects were characterized by such intellectual deficits. The nonmanual class children had a mean IQ of 109 with a standard deviation of 9 versus a mean IQ of 102 and a standard deviation of 11 in the manual class subjects. The observed difference was significant at the .01 level. Interclass differences on the Frostig test (N = 127) were also apparent. The available data were grouped into three social classes: the nonmanual class subjects (n = 48), as specified earlier; a group of working class, or Class IV subjects (n = 47); and a final group of lower-class, or Class V subjects (n = 32). There is a positive correlation between socioeconomic status and the level of visual-motor development. The mean PQ for the sample of nonmanual class subjects was 95, and the standard deviation was 6. Twenty percent of these subjects were characterized by a low PQ—that is, a PQ of 90 or lower. The mean PQ for the working-class subjects was 92 and

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the standard deviation was 8, Thirty-six percent of these subjects had a low PQ. Finally, the mean PQ for the lower-class subjects was 91, with a corresponding standard deviation of 7. Thirty-four percent of these subjects had a low PQ. The differences between the mean PQs of the nonmanual class and the working class subjects was significant at the .05 level, and the difference between the nonmanual class and the lower-class sample reached significance at the .01 level. Similar to the data reported earlier in the case of black subjects and white subjects, perceptual processes were less highly developed as compared with general intelligence in both nonmanual class and the remainder of the sample. Social class differences on the Bender Gestalt, although in the expected direction, failed to reach significance. Thirty-three percent of the nonmanual class subjects exhibited evidence of perceptual-motor problems, most of them mild. The comparable statistic for the manual class was 37%, and again most of the cases involved mild perceptual-motor problems. It should be carefully noted, however, that although the overall prevalence of problems varies little in this sample between classes, the proportion of cases involving serious perceptual-motor problems was twice as great in the manual class as compared with the nonmanual class children. The nonmanual class subjects had a mean Bender Gestalt error score of 3.5 and a standard deviation of 2.9 as compared with a mean of 3.8 and a standard deviation of 2.4 observed in the case of the manual class children. Error frequency on the Bender Gestalt varied from a low of 3.0 (Class II) to a high of 4.2 (Class V). There were no significant differences between classes in terms of auditory discrimination skills. Discussion Considerable empirical evidence has accumulated over the past several decades indicating that systematic black-white differences exist along a variety of biological and behavioral dimensions (Baughman & Dahlstrom, 1968; Miller & Dreger, 1973), one of the most important of which involves general intelligence (Kennedy et al., 1963). It has proved difficult in some of the studies to separate the

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effects due to socioeconomic status from those related to ethnicity. There is some evidence that group differences in measurable IQ, indexed by the Stanford-Binet and the Wechsler Intelligence Scale for Children, decrease markedly when blacks are compared with whites of comparable socioeconomic status, who reside in similar geographic areas, and who probably have received comparable prenatal care (Nichols & Anderson, 1974). However, our results indicate a persistence of the interethnic group IQ differential when comparing blacks and whites of similar socioeconomic status and geographic residence on the Culture Fair Intelligence Scale. This may indicate that reported empirical results depend on the specific cognitive function (s) measured by various test instruments, they may reflect differences related to the adequacy of prenatal care, or they may involve differences due to sample selection techniques. Various other studies, however, indicate a persistence of broad interethnic group differences in the IQ when (a) various measures of intelligence are used (Shuey, 1966), (b) national regional differences in the IQ are well-known (Klineberg, 1951; Montagu, 1963), and (c) there appear to be marked differences in health status and in terms of the quantity and quality of nutrition, prenatal and postnatal medical care, and perhaps environmental stimulation in the case of blacks and whites of similar socioeconomic status (Birch & Gussow, 1970; Malina, 1973; Mussen, Conger, & Kagan, 1974). Unless these and various other factors are carefully controlled, interethnic group IQ differences often persist and are not eliminated simply by controlling the variance due to a few socioeconomic factors. Since many of these environmental factors are known to alter the level of neurological integrity, it is imperative from a methodological point of view to control for neurological status differences between ethnic groups prior to testing for intellectual differences. For example, if it were true that a central component of the black-white IQ differential results from interethnic group differences in neurological status, most of which in turn appear to be environmentally based, then it would be predicted that this marked IQ differential would diminish

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AMANTE, VANHOUTEN, GRIEVE, BADER, AND MARGULES

or disappear altogether if levels of neurological integrity were comparable in the case of both blacks and whites of similar socioeconomic status (Amante, Margules, Hartman, Storey, &Weeber, 1970). This is exactly what was observed in this study when perceptually normal black subjects were compared with perceptually normal white subjects of similar socioeconomic status. The small interethnic group IQ differential of 4 points failed to reach statistical significance. This finding should be replicated before too much interpretative weight is assigned to it. If it proves to be generally true, however, a major theoretical problem will involve the attempt to determine the extent to which interethnic group differences in neurological status are largely a function of genetic inheritance (Jensen, 1969), environmental disadvantage beginning in the prenatal period and extending through the postnatal phase of development (Gottesman, 1968a), or represents a composite factor resulting from the joint interaction of both sources of variance (Loehlin, Lindzey, & Spuhler, 1975). Theoretical Issues Waller (1971) has presented evidence indicating that the process of social mobility is functionally related to measurable discrepancies between social class origins and general intelligence in the case of sons. He demonstrated that intelligence independently contributes to two key indicators of achievement or socioeconomic status—namely, education and occupation. The significance of this observation is that it increases the probability that the social stratification system will remain "open" to some extent and will not congeal into a caste system wherein status is ascribed rather than achieved. Waller's evidence is consistent with the theoretical propositions advanced by Dobzhansky (1950, 1968), Gottesman (1968b), and Jensen (1969), all of whom observed that genetic inheritance, assumed to be a central determinant of general intelligence, is therefore one causal factor related to social stratification. It is important to recognize that genetic influences on intelligence are mediated through the effects of inheritance on the structural

and/or functional characteristics of the central nervous system (Jensen, 1969). As indicated earlier, however, it is abundantly clear that levels of neurological integrity are influenced not only by genetic inheritance but also by a broad spectrum of environmental forces impinging upon the organism during the entire life span from conception to death (Koch, 1967; Schechter, Toussieng, Steinlof, & Pollack, 1972; Yacorzynski, 1965). Many of these environmental factors interact closely with genetic variables, and in some cases they either mimic genetic inheritance or are confounded with it. There are two factors to consider here. One involves the intergenerational effects of malnutrition or undernutrition that seem to lower the level of obstetrical competence on the part of the maternal host and consequently appear to adversely affect fetal neurological development during the prenatal period (Birch, 1972; Zamenhof, Marthens, & Grauel, 1971). The second involves various other forms of intrauterine pathology arising from a diversity of sources that are difficult if not impossible to separate from inheritance (Campion & Tucker, 1973; Pollin, Stabeneau, Mosher, & Tupin, 1966). Concerning this latter point, it is interesting to observe that rates of intrauterine pathology run higher in the case of monozygotic as compared with dizygotic twins, a methodological problem that seriously complicates the interpretation of concordance rates for schizophrenia and probably other presumably genetically determined outcomes, including general intelligence. To complicate matters further, there is definite reason to assume that various other social or environmental factors operate to influence affective, motivational, cognitive, or behavioral variables that although probably unrelated to the level of neurological status, definitely influence the manifestation or expression of general intelligence (Guilford, 1967; Mussen et al., 1974; Yarrow, Rubenstein, Pedersen, & Jankowski, 1972). It is truly a difficult empirical task to separate the various interacting factors and to accurately determine their differential impact. Finally, as far as the interethnic group differentials in IQ are concerned, our results suggest that blacks are characterized more obviously by specific perceptual-motor problems

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than by a simple global intellectual deficit. This conclusion is consistent with Sylvia Farnham-Diggory's (1970) research studies and also with L'Abate, Osling, and Stone's (1973) recent review of the literature dealing with black-white academic achievement differentials. This observation may be theoretically significant. For example, in terms of hierarchical theories of general intelligence—such as those of Kephart (1973) and Jean Piaget (Piaget & Inhelder, 1969)—the suggestion is that high-level symbolic or cognitive functions would be adversely affected in blacks because of the defective nature of some of the basic underlying perceptual-motor processes that are ontogenetically antecedent to abstract or formal thought. It is therefore of major interest to observe in this study that when the level of visual-motor functioning is taken into account in making interethnic group comparisons involving general intelligence (and also auditory discrimination), the blackwhite IQ differential is reduced to the level of chance variability in the case of perceptually normal children. Environmental Factors The empirical data reported in this article clearly support the hypothesis that levels of neurological integrity vary along a socioeconomic continuum and between ethnic groups. Our central theoretical proposition is that a variety of environmentally based factors, most of them closely related to these two sociological parameters, represent the primary determinants of the ecological distribution of central nervous system damage or dysfunction (Amante et al., 1970). Further, there is evidence that certain adverse conditions—including higher rates of physical pathology, undernutrition and malnutrition and inadequate obstetrical and pediatric care— appear to be considerably more prevalent within the lower-class black population as compared with the lower-class white population (Birch & Gussow, 1970; Kosa & Zola, 1975; Loehlin et al., 1975). Presumably, these factors at least partly determine the interethnic group differences in terms of the frequency of neurological pathology among black populations and white populations of roughly

531

comparable socioeconomic status. Most of the problems appear to be common to the state of poverty, but some of them may be socioculturally specific to certain ethnic groups and as such are transmitted intergenerationally via a process of differential socialization (Mechanic, 1968). In a very general sense, we might argue that the distribution is a function of a broadranging interrelated set of cultural, social, demographic, political, and economic forces (Kosa & Zola, 1975; Lambert & Heston, 1972; Lengthening Shadows, 1971; Pettigrew & Pettigrew, 1964; Pratt, 1971; Rosen, 1971). The reference here is to such factors as population growth and concentration; the level and form of industrial technology; prejudice and discrimination in the areas of education, employment, and medical care; patterned economic activity involving fluctuating levels of income and cyclic phases of employment and unemployment; and interclass and ethnic group patterns of sociocultural learning involving the acquisition of maladaptive values, attitudes, perspectives, beliefs, and health- or medically oriented behavioral phenomena. Minority group status and poverty life-styles involving powerlessness, social isolation, alienation, and economic deprivation are central to this theoretical mode of analysis (Lewis, 1966; Matza, 1971; Miller & Riessman, 1968; Moynihan, 1969). These various social forces appear to be related to the environmental determinants of health at the community level, the availability and adequacy of medical care services, the prevalence of nutritional problems, the nature of one's living conditions, and the quality and quantity of ambient stimulation. In short, social forces appear to be the primary determinants behind the ecological distribution of central nervous system pathology (Hurley, 1969; Jordan, 1971). These forces lead to a sequence of events or processes that eventuate in the selective impairment of large segments of our population; they determine an incidence and prevalence level of central nervous system pathology that appears to fluctuate in a discernible pattern through time and across space; they are related to the conditions that prevent or perpetuate the disorder ; and they appear to critically affect the

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AMANTE, VANHOUTEN, GRIEVE, BADER, AND MARGULES

manner in which the condition is diagnosed, treated, or otherwise handled. Malnutrition and Undernutrition Malnutrition, involving a pathological imbalance of essential nutrient element intake, and undernutrition, which involves a reduction of caloric level, clearly appear to be two of the most important environmental factors capable of adversely affecting neurological integrity in both the prenatal and postnatal phases of development. Severe or mild ("subclinical") malnutrition or undernutrition are conditions known to be widespread in developing or preindustrial societies throughout the world, and in industrial societies their incidence and prevalence is inversely correlated with socioeconomic status and varies with ethnic group membership (Barnes, 1971; Birch & Gussow, 1970; Scrimshaw, 1967; Winick, 1976). There is every reason to assume that these conditions are intimately related to the ecological distribution of neurological pathology within and between societies. Nutritional deprivation, or inadequacy, is one causal factor that may, in some cases, lead to permanent neuroanatomical defects and/or to a broad spectrum of neurophysiological disorders (Eichenwald & Fry, 1969; Prescott, Read, & Coursin, 1975). Nutritional factors are related to myelinization; they differentially influence the two central phases of neurological development—hyperplasia (neuronal or glial cell formation) and hypertrophy (the increase of neuronal or glial cell size)—and they are intimately related to various processes of enzymatic and metabolic system development, integration, and maturation (Chase, 1973; Coursin, 1972; Cravioto, 1968; Monckeberg, 1973; Winick, 1975). At the psychological level, malnutrition or undernutrition can create a number of affective, motivational, cognitive, or behavioral effects, including hypoactivity, perceptualmotor problems, learning or performance decrements, attention span deficits, changes in reflex patterns, and so forth (Barnes, 1971; Winick, 1976). Developmental processes involving different cell types occur in different regions of the central nervous system in accordance with different time tables (Altman, 1971; Stein, Susser, Saenger, & Morolla, 1975; Winick,

1975). The brain is not a homogeneous organ. Consequently, the effects of malnutrition/undernutrition vary depending on the time that it initially appears, its severity, and its duration. Time-limited or mild nutritional inadequacy can have few obvious adverse effects, but profound or chronic nutritional deficits occurring during critical phases of neurological development, or encompassing both the prenatal and the postnatal phases of growth and development, are likely to be considerably more consequential in terms of neurological and other developmental indices observable at the behavioral level. It is often presumed, for example, that low neonatal birth weight (5| pounds [2,500 gm] or less) is one possible outcome of fetal malnutrition/undernutrition, which, in turn, results from a diversity of factors (Birch, 1971; Drillien, 1970b; Gruenwald, 1970; Winick, 1976). An important point to recognize is that nutritional inadequacy is only one of a host of clustered factors in socially disadvantaged populations that, in composite, may eventuate in various neuropathological outcomes (Pollitt, 1969; Read, 1975). Malnutrition/undernutrition clearly appears to be an extremely important variable, but its precise weighting in the complex set of interacting factors remains to be empirically demonstrated. Finally, it is important to recognize that some of the neurophysiological effects resulting from nutritional deficits are very similar to those reported in the case of sensory or perceptual deprivation (Bennett, Diamond, Krech, & Rosenzweig, 1964; Geller, 1971; Schapiro, 1971). Similar effects also seem to result from disease states and infection, many of which are synergistically related to malnutrition or undernutrition (Eichenwald & Fry, 1969; Scrimshaw, 1967). Conclusions It seems clear that the ecological distribution of central nervous system pathology in children is the end product of a complex set of interacting environmental forces that differentially influence developmental outcomes throughout the life span. A theoretical proposition that we believe should be carefully considered is the possibility that a given child, or group of children, could be subjected to multiple neurological insults throughout the

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D. B., & Weeber, L. J. The epidemiological distribudevelopmental cycle, beginning during the tion of CNS dysfunction. Journal of Social Issues, perinatal period, leading to a cumulative 1970, 26, 105-136. neurological deficit as the central determining Barnes, R. H. Nutrition and man's intellect and befactor behind the symptomatic phenomena havior. Federation Proceedings, 1971, 30, 1429-1433. ultimately observed. The probability of this Baughman, E. E., & Dahlstrom, G. W. Negro and white children: A psychological study in the rural south. occurrence would be expected to be very high New York: Academic Press, 1968. in the case of minority group and/or socially Bender, L. The brain and child behavior. Archives of disadvantage children. If indeed this is the General Psychiatry, 1961, 4, 531-547. case, then perhaps the impact of specific Bennett, E. L., Diamond, M. C., Krech, D., & Rosenzweig, M. R. Chemical and anatomical plasticity of etiological events or processes at a given point the brain. Science, 1964, 146, 610-619. in time—such as low birth weight, anoxia, Berman, A., & Siegal, A. W. Adaptive and learning disease, and so forth—could be either inskills in juvenile delinquents: A neuropsychological tensified or compensated for by other events analysis. Journal of Learning Disabilities, 1976, 9, 583-590. or processes at successive developmental stages including prenatal or postnatal nutrition, the Birch, H. G. Functional effects of fetal malnutrition. Hospital Practice, March 1971, 134-148. quality and quantity of medical care, condi- Birch, H. G. Malnutrition, learning, and intelligence. tions of environmental stimulation, and perAmerican Journal of Public Health, 1972, 6, 773-784. haps other factors (Heber & Garber, 1975; Birch, H. G., & Gussow, J. D. Disadvantage*! children: Health, nutrition and school failure. New York: Sameroff & Chandler, 1974; Willerman, 1972). Harcourt, Brace & World, 1970. In summary, there is increasing empirical Bronfenbrenner, U. The psychological costs of quality evidence indicating that various neuropsyand equality in education. Child Development, 1967, chological characteristics, including general in38, 909-925. telligence and academic achievement, are sig- Brutten, M., Richardson, S. O., & Mangel, G. Something's wrong with my child. New York: Harcourt, nificantly shaped by virtue of the types of Brace & Javanovich, 1973. environmental encounters experienced, par- Campion, E., & Tucker, G. A note on twin studies, ticularly during the prenatal and postnatal schizophrenia and neurological impairment. Archives stages of neurological development (Bronfenof General Psychiarty, 1973, 29, 460-464. brenner, 1967; Hunt, 1969; Schain, 1972; Chalfant, J. C. & Schcffelin, M, A. Central processing dysfunction in children: A review of research (NINDS Towbin, 1971). This observation, we believe, Monograph No. 9) Washington, D. C.: U. S. Departis of critical importance in that it suggests ment of Health, Education, and Welfare, 1969. the possibility of one rational approach to the Chase, H. P. The effects of intra-uterine and postnatal undernutrition on normal brain development. area of prevention (Adamsons & Fox, 1975) Annals of the New York Academy of Sciences, 1973, that may lead to the control (or elimination) 205, 231-244. of interethnic group and social class differen- Clarke, A. M., & Clarke, A. D. B. Mental deficiency: tials in neurological integrity, which, in turn, The changing outlook. New York: Free Press, 1974. appears to be one major contributing factor Coursin, D. B. Nutrition and brain development in infants. Merrill-Palmer Quarterly of Behavior and to a variety of serious social problems conDevelopment, 1972,18, 177-202. fronting the nation.

Reference Note 1. Hollingshead, A. B. Two-factor index of social position. Unpublished manuscript, Yale University, 1957.

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Received January 15, 1976 •