15-year undernutrition physical growth and intellectual ...bender visual-motor gestalt test. the...

Archives of Disease in Childhood, 1976, 51, 327.

15-year developmental study on effects of severe

undernutrition during infancy on subsequentphysical growth and intellectual functioning

M. B. STOCH and P. M. SMYTHEFrom the Child Psychiatric Unit and Department of Paediatrics and Child Health, University of Cape

Town, South Africa

Stoch, M. B., and Smythe, P. M. (1976). Archives of Disease in Childhood, 51,327. 15-year developmental study on effects of severe undernutrition duringinfancy on subsequent physical growth and intellectual functioning. Thisthird 5-year follow-up on the effects of severe undernutrition during infancy on

subsequent brain growth and intellectual development confirms the level of gross

retardation of intellect in the undernourished group when compared with the controls.A.s the subjects are now 15-18 years ofagethis mustbepermanent. All but 5 oftheunder-nourished group are now living in conditions comparable to the controls. Improvednutrition is manifest by catch-up in height, in that the mean difference between under-nourished subjects andcontrols has decreased by2 *73cm. Remarkably,thedifferenceinhead circumference has increased by 0 * 5 cm, the mean head circumference of the under-nourished now being 2 *8 cm less than that of the controls. The Bender Gestalt andHuman Figure Drawing tests did not correlate with the intelligence tests, indicating a

separate deficit of a marked disturbance of visual-motor perception in 17 of the under-nourished subjects, in 9 of whom these tests were highly significant of minimal braindysfunction (5 of the controls). In retrospect there is much evidence to suggest thecontrols were also suboptimal; 8 controls had abnormal electroencephalograms as did6 of the undernourished group.

This study was started in 1955, based on thehypothesis that the ill effects of undernutrition aredetermined firstly by its occurrence during theperiod of maximum growth and, secondly, by theduration of undernutrition relative to the totalperiod of growth. As brain growth in the human isvery rapid during the first year of life and almostcomplete by the end of the second year it seemedpossible that undernutrition during this criticalperiod might inhibit brain growth and that thiscould result in a permanent reduction in brain sizeand impaired intellectual development.To test this hypothesis a group of subjects

grossly undernourished during early infancy wascompared with a control group. Two previousreports on this study were published in 1963 and1967 (Stoch and Smythe). This third 5-yearstudy is of particular value as little further develop-

Received 7 August 1975.

mental change is likely to occur in these now adoles-cent subjects and the information gained from age-dependent tests can be interpreted with greatervalidity.

SubjectsA group of 20 coloured infants, 9 boys and 11 girls,

grossly undemourished during infancy, from CapeTown was collected over the period 1955 to 1959. Thisindex group was contrasted with a control group, match-ed for age and sex, selected from a creche-cum-nurseryschool serving a subpopulation of the same social classas the index group. Organic illness, apart from inter-current gastroenteritis, was absent in the infants. Whenfirst seen their mean weight was 5-53 kg at 17 months(boys 5-44 at 19 months, girls 5-61 at 15-5 months),which was below the 2*5 centile (Robertson, 1961).The mean weight of 8-16 kg of the control infants(boys 8-9 kg at 18 months, girls 8-8 kg at 17 months)was at the 10th centile. Both groups came from thelower social class unskilled workers with low incomes.

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Stoch and SmytheThere was at first a marked disparity in their livingconditions, with the index group at a distinct dis-advantage. The home environment except in the case

of 5 index subjects, is now barely distinguishablebecause of greater economic stability and foster place-ments.

MethodThe present follow-up was undertaken between

February 1972 and May 1973 when the average age ofthe subjects was 16 years (range 13-7-18-2 years.Each subject was tested on one or more occasions andeach parent or guardian was interviewed. Measure-ments of head circumference, height, and weight weremade. General intelligence was measured with theNew South African Individual Scale (NSAIS) (NationalBureau of Education and Social Research, 1964). Thistest, which resembles the Wechsler Intelligence Scalefor Children, has not been standardized for the popula-tion group of this study but the findings were consideredvalid for assessing differences between the two groups.Visual-motor perception was measured on the BenderVisual-Motor Gestalt Test (BG), (Koppitz, 1964).Body concept was assessed on the Human FigureDrawing (HFD) (Koppitz, 1968). Social integrationwas assessed on the Columbus, a projective test (Lange-veld, 1969). Psychosocial histories were also taken.Electroencephalograms and skull x-rays were done at theRed Cross War Memorial Children's Hospital.

ResultsComparisons were made of the means of the

index and control groups (n = 40) and the sub-groups of boys (n = 18) and girls (n = 22).

Physical measurements. The difference inhead circumference for both boys and girls is highlysignificant (Table I). There is no significantdifference in height or weight between the twogroups of boys but the girls differ significantly inboth these measurements. As the only physicalmeasurement in which the boys differ is headcircumference, it appears that catch-up in theirsomatic growth has been achieved but smaller headcircumference is permanent. In contrast, thegirls' groups have maintained a difference in allphysical measurements.

Psychological tests. The difference of 16 85full scale points between the groups is significant(Table II). This difference is most marked be-tween the boys (24 * 55). The much smallerdifference between the girls is due to the lowscore of the control girls, which is 13 * 6 points lowerthan the control boys.The verbal quotient follows a pattern similar to

the full scale quotient. There is a significantdifference between the groups (17 *50), a markeddifference between the boys (25 - 10), and a muchsmaller difference between the girls (11 -27) whichis again due to the lower score of the control girls.The difference of 17 06 points between the controlboys and control girls is significant at the 0 * 05 level.In the non-verbal quotient the groups also differsignificantly (14X3) though the difference is moremarked for boys (19-89) than girls (9 72). In theindex group there is no difference between boys

ILE IPhysical measurements

TABLE IINew S. African Individual Scale (quotients)

Group Boys Girls

Index Control P Index Control P Index Control P

Full scale 56-00 72-85 <<0 005 55-78 80-33 <0 005 56-18 66-73 <0 05Verbal 55*00 72*50 <0005 56*78 81*88 <0005 53*55 64*82 <005Nonverbal 65 60 79 90 <0 005 63 00 82 89 <0005 67 73 77 45 <0|05

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Developmental study on effects of severe undernutrition during infancyand girls in all three quotients. In both groups ofgirls there is a significant difference between theverbal and nonverbal quotients (Table III), thenonverbal being higher.

TABLE IIIDifferences between verbal and nonverbal quotients

within subgroup

Subgroup Difference P

Control boys 1-01 NSIndex boys 6-22 NSControl girls 12*63 <0 *05Index girls 14-18 <0-01

Subtests. In the statistical analysis of thesubtests of the NSAIS (Table IV) the control boyssurpassed the index in all the verbal tests in con-trast with both groups of girls, who did not differin the important subtests of vocabulary and verbalreasoning.

In the non-verbal subtests of pattern completionand blocks the boys and girls within each group

differed significantly.

Bender Visual-Motor Gestalt test. The abilityto copy geometric designs is a reflection of the

maturity of visual-motor perception. Up to theage of 11 years errors indicate either perceptualimmaturity or a defect in neurological functioning.By 11 years the development of visual-motor per-

ception is complete and significant errors can onlyreflect impaired neurological function (Bender, 1938Koppitz, 1964).The index group made an average of 3 * 65 errors

(Table V) at the age of 16, which suggests a deficitin their visual-motor perception, seeing that ampletime has been allowed for maturational lag. Theindex boys made more errors than the girls, theonly measurement in which the sexes of this groupdiffer significantly (P <0 05). The errors were

scrutinized for indications of minimal braindysfunction (MBD) as described by Koppitz(1964) in children ranging in age from 5-11 years.3 of the index group made no errors and 9 (5 boys,4 girls) made 21 errors, highly significant for MBD.10 of the controls made no errors, while 5 subjects,all girls, made 8 errors, highly significant for MBD.7 index subjects had a perceptual age below 7 years.whereas the lowest control's was 7 * 75 years.

Human Figure Drawing. The HFD was selectedas it provides a measure of developmental maturity,awareness of the body in space, and relation of one

part to another-skills which have strong implica-

ILE IVDifferences in new S. African Individual Scale subtests (P values)

Group Boys Girls

VerbalVocabulary <0 * 005 <0 * 005 NSComprehension <001 <001 <005Verbal reasoning <005 <0 *005 NSProblems <0 * 005 <0 005 <0005Memory <001 <005 <005

Non verbalPattern completion <0005 <0005 <001Blocks <0005 <005 <005Absurdities NS <005 NSForm board NS NS NS

TABLE VBender Visual-Motor Gestalt test

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Stoch and SmytheTABLE VI

Human Figure Drawing

tions for body concept. Subjects were requested todraw a person and name the sex, then to draw theother sex. In Table VI a score of 5 representsaverage developmental maturity (Koppitz, 1968).The HFD scores of the control groups are signi-ficantly superior.Ten HFD's of the index group (5 boys, 5 girls)

are strongly indicative of organic deficits in con-

trast to 6 (3 boys, 3 girls) controls (P <0 01).Because of the subjects' advanced ages the distor-tions in their drawings were considered highlysignificant. Projective evidence of emotional dis-turbance and poor sex identification were noted inboth groups but not quantified as scoring was toosubjective. In the index group there was a signifi-cant correlation between HFD and BG (r -- 0 7).This suggests that the perceptual deficit which they

are experiencing is linked to the field of spacialrelations. The extreme distortion in visual-motorperception and body concept can be seen in the BGand HFD of some of the index subjects (Figs. 1-4).The lack of any correlation between the BG and

the NSAIS quotients in the index group suggests a

specific perceptual disability apart from their poorintelligence test performance. Table VII showshow in children of matched intelligence quotientsthe developmental level differs in their BG and intwo of their HFDs.

(a) (b)

FIG. 1.-Index subject. (a) Human figure drawing. (b) Bender Gestalt.

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Developmental study on effects of severe undernutrition during infancy 331motives, and strength of identity. In scoring, thecomposite total in these four areas represents thesubject's emotional and social maturity or socialintegration. The control group was significantlysuperior (P <0 05).

Psychosocial findings. In view of the im-portance of sociocultural influences on intellectualdevelopment, the changes which have occurred overthe past 15 years have been assessed. Here again

(a) (b)FIG. 2.-Index subject. (a) Bender Gestalt. (b) Human figure drawing.

Columbuts test. In this projective test verbalresponses to stimulus cards were rated for fouraspects of social personality: interpersonal relation-ships, attitude towards the future, maturity of

not only were group findings contrasted, but withineach group the sexes were contrasted. At presentthere are no significant differences in socioeconomicstatus or housing between the two groups. How-

(a) (b)FIG. 3.-Index subject. (a) Human figure drawing. (b) Bender Gestalt.



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Stoch and Smythe

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FIG. 4.-Control subject: hwnan figure drawing.

ever, from the psychosocial interviews it was foundthat the control parents coped significantly better(P <0 01) in handling their children and thesechildren were socially more mature (P <0 01).The index group had significantly less culturallearning opportunities (P <0 001) based on theDeprivation Index of Whiteman and Deutsch(1968). and a greater number of traumatic lifeexperiences (P <O*001).

In the index group there has been a considerableshift from the initial state of marked social depriva-tion to increased stability, while a slight deteriora-tion has occurred in the controls (Table VIII).Despite a similar number of years at school theachievement of the index group is significantly lowerand their 'drop out' rate after leaving school is morethan twice as high as the controls.

Special investigations. (i) X-rays showed nosignificant difference in the thickness of the cortexof the skull between the two groups, nor between theleft and right hemispheres of each individual.Gyral markings on the skull were not seen. Therewas no significant difference in the size of the sin-uses, some of which were large. (ii) 6 of the indexgroup had abnormal EEGs as did 8 controls.

DiscussionIn 1955 we were the first to formulate the hypo-

thesis that the human brain might be most vulner-able to the effect of undernutrition during the first 2years oflife as this is the period ofmost rapid growth.Since at that time no interest was shown in theeffects of undernutrition on intellectual performancespecifically at this age, it was not unreasonable andhardly 'reprehensible' (Dobbing, 1974) to pose thequestion, 'Does undernutrition during infancyimpair brain growth and subsequent intellectualdevelopment?' (Stoch and Smythe, 1963).Very severely undernourished children were

deliberately chosen on the presumption that if these

TABLE VII

Comparisons ofBG and HFD in index* and control subjects matched for NSAIS quotients

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Developmental study on effects of severe undernutrition during infancyTABLE VIII

Sociodemographic data

Index Control

Boys (9) Girls (11) Boys (9) Girls (11)

Legitimate births 1 6 9 11Living with nuclear family 4 7 8 11Social stabilty at birth 0 0 9 11Social stabilty at present 6 9 7 10Size of family 4 5 7-7

grossly undernourished children showed no sub-sequent intellectual impairment, then nutritionalfactors could clearly play no significant role inintellectual development. The striking deficitsin intellect which, with time, became increasinglyapparent have raised many questions of the partplayed by factors other than nutrition and thenature of the link between the nutritional patho-logical process and the functioning of the brain.

Controls. The validity of our findings hasbeen questioned on the grounds of the more favour-able early environment of subjects in the controlgroup (Scrimshaw and Gordon, 1968). Thereason for selecting the control children from a daynursery school-cum-creche was to try to ensure

adequate nutrition in a group of children taken fromthe lowest socioeconomic subpopulation. Withtime it has become apparent that the control groupdid not have optimal nutrition and did not have as

marked as enviromental advantage as was original-ly supposed. The initial gain from the stimulus ofnursery school attendance will have evened off afterthe first 6 months at school. The quality ofmother-ing received by the two groups during infancy was

probably not so different. Though the mothers ofthe index subjects were all negligent, apathetic, andirresponsible, they did not abandon their childrenbut nursed them ineffectually. Control mothers,being in full-time employment, were separatedfrom their children when they were at an averageage of 1 * 3 years. At that time they spent their daysin an understaffed cr&che but evenings and week-ends with the parents. In the index group, be-cause of smaller families, there was more parent-child interaction than in the control group. Thehigh rate of illegitimacy in the index group has

been unfavourably compared with the controlfamilies, but two of the control girls now have

illegitimate children, and none of the index girls.The latest assessment shows that only 5 of the index

subjects remain in a less favourable environmentthan the controls.

2

There is considerable nutritional as well as

other evidence to suggest that the controls were

suboptimal. Originally their mean weight was

at the 10th centile. Currently their weight andheight is low when compared with a random sampleof school children of the same age. Their fullscale quotient when adjusted by adding 1 SD is stillbelow the expected average range. Only 50%achieved perceptual maturity as assessed op theBG, and no less than 40% had abnormal EEGs.From this it appears that had the index group beencompared with adequately nourished controls an

even more striking difference might well have beenshown. Genetic factors are unlikely to haveinfluenced the findings in that no significant differ-ence was found between the parents of the two

groups in head circumference, intelligence tests

(Raven's Matrices, 1956), and school achievement.

Head circumference. The single most sur-

prising finding is that the mean difference of thehead circumference has increased over the 10-yearperiod when difference in mean height decreased.

1962 1967 1972 DifferenceDifference inmean headcircum-ference(cm) 2-28 2-46 2-79

Height (cm) 8 8 7 95 6-07+0-51-2-73

As the significance of head circumferencesmeasurements has been questioned (Evans, Moodie,and Hansen, 1971), it is necessary to repeat that ithas never been suggested that there is any correla-tion between head circumference and IQ. Whathas been stated is that there may be a relation be-tween infantile undernutrition, suboptimal headcircumference, and suboptimal brain growth. Infact, from this study it appears that suboptimal headcircumference may be the most sensitive physicalindex of prolonged undernutrition during infancy.

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Stoch and SmytheA close correlation has been found between headcircumference and brain weight and protein (DNA)content (Winick and Rosso, 1969). Furthermore,the reduced head circumference in malnourishedchildren accurately reflects the reduced number ofcells and reduced lipid content present in theirbrains (Winick, 1971). While accepting that wholebrain DNA content represents the more numerous

glial cells better than the number of nerve cells,this must nevertheless represent suboptimal growth.The increase in head circumference of both

groups over the last 5 years is ascribed to increase inskull and scalp thickness. Skull thickness as

measured on x-rays was fractionally greater in thecontrol group than in the index, but not enough toaccount for the increasing difference in circumfer-ence. While it appears that over the last 5 yearsthere has been some increase in brain mass in thecontrol group greater than that in the index groupthe skull x-rays of both groups were noted for theirthickness, for absence of any gyral markings, andin some subjects for abnormally large sinus develop-ment, changes typically seen in conditions of defec-tive brain growth.

Psychological test findings. Over the fullperiod of this study the differences between theintelligence scores of the two groups have remainedsignificant, and since the previous intelligencetesting was done 5 years ago the difference in fullscale quotient has remained unchanged. Thedeficit in intellectual function appears to be per-manent.

Children who experience emotional deprivationduring infancy subsequently have poor expressiveand reasoning abilities. However, these verbalskills are also affected by the understimulatingenvironment of the lower social class backgroundof both groups in this study. Difference in verbalskills was more marked between the two groups ofboys than the girls, the significant fact being therelatively low scores of the control girls. Thecontrol boys, who came from a similar social back-ground, were able to overcome to some extent theirenvironmental handicaps and achieved relativelyadequate verbal levels. In contrast to otherfindings (Jensen, 1973; Hertzig et al., 1972) wherethe underprivileged subpopulation achieved higherverbal than nonverbal scores, in this and in our

previous study nonverbal scores were higher thanthe verbal. This is an unexpected finding in viewof their visual-motor perceptual difficulties andmay be a reflection of a linguistic gap between thesubjects of this study and the subpopulation inwhich the NSAIS was standardized. The biggest

drop over the last 5 years has been in the verbalquotient of the index group, especially the girls.In fact the verbal scores might have been even lowersince 6 of the index group performed at or belowthe floor level of the verbal scale in contrast to 2 ofthe controls. In the nonverbal subtests all thesesubjects scored above the floor level, while inHertzig's series 17 out of 54 failed to achieve thefloor level. This difference may be accounted forby the inclusion in the NSAIS of the poorlycorrelating subtests of Absurdities and FormBoard, the only tests which showed no significantdifferences between any of the groups. The signi-ficant differences in the subtests of Pattern Com-pletion and Blocks in the index group point tospecific visual perceptual synthetic and analyticdisabilities.The Bender Visual Motor Gestalt Test and

Human Form Drawing were used to explore visualmotor perception and body concept. The poortest performance found in the index group did notcorrelate with their intelligence scores. The errorsmade indicate a deficit in their neurointegrativesystem, as similar errors are commonly made bychildren with minimal brain dysfunction. TheBender specificallymeasures visual-motor perceptionabilities which are essential for acquiring basicscholastic skills. At the age of 16 five of the indexgroup were at a level fit only for first year instructionat school.There is no documented evidence that environ-

mental factors, apart from very extensive sensorydeprivation, such as blindness, could at this ageaccount for the defects in the visual-motor per-ception found in the index group. On the contrary,Nissen's study (Bender, 1938) of West Africanchildren has shown that native children withoutprevious experience with pencil and paper copydesigns with the 'same ability as an averageAmerican-born and educated child'. The HFDcorrelates well with the BG (r = 0 7). If there isreversibility and catch-up of impaired perceptualfunctioning this should become apparent on testsbased on a developmental scoring system whichshow improvement with age, but in both the BGand the HFD there was no correlation with age andno support for improvement with time. Of particu-lar value in this 15-year continuous study is that nofurther maturational perceptual changes are likelyto occur and some clarification of the associateddisturbance of brain function with the nutritionalpathology has been possible.

Catch-up. The concept of catch-up impliesthat given better feeding after a period of under-

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Developmental study on effects of severe undernutrition during infancy 335nutrition, rehabilitation of the effects of under-nutrition can be achieved. Feeding and welfarefacilities were made available to these subjects,though it was not possible to ensure that they gotthe food. The fact that there has been catch-upgrowth in height in the index group does howeverimply that nutrition has improved. The fact thatthis occurred at a time when the difference in headcircumference has increased supports our originalhypothesis that not only is the period of growthspurt important, but also the duration of under-nutrition relative to the total period of growth.Timing is important, as catch-up growth may bepossible with good nutrition if it occurs within theperiod of time when growth of that particularstructure normally continues. We reject the sug-gestion that catch-up growth can occur at any time(Evans et al., 1971). There is no evidence thatnature's time clock for growth can be significantlyaltered by nutrition. Teeth appear on a timeschedule irrespective of the state of nutrition; thegreat bulk of brain growth occurs in the laterintrauterine stage and during the first 2 years of life,and catch-up is likely to be limited to this period.At the same time, specific facets of brain structure,such as neuronal cell multiplication, may belimited to an even shorter period. As cell multipli-cation apparently ceases at 6 months of age theseearly months may be the most critical of all (makingthe world-wide decline of breast feeding in develop-ing countries possibly disastrous in its implication).

Environmental effect on intelligence per-formance as against organic brain damage.Undoubtedly tl:e index group suffered from en-vironmental deprivation owing to the higherincidence of illegitimacy, deprivation of learningexperience apart from school, poorer parentalnurturance, and more personal traumatic experien-ces. The control group, however, also sufferedreal disadvantages and over the period of observa-tion the early differences between the two groupshave to a considerable extent been eliminated.Difficult as it is to separate environmental fromnutritional factors in the poor performance of thesechildren, it does not seem possible that the signifi-cantly low head circumference in the index group,the errors in the BG and HFD, and the high inci-dence of abnormal EEGs in both groups can beexplained on any other than an organic basis.A clearer definition not only of timing and dura-

tion of the period of undernutrition but also ofspecific nutritional deficiencies is required. Wehave previously suggested (Stoch and Smythe,1967) that marasmus, occurring as it does at a

younger age, is more serious in its effects thankwashiorkor. The subjects of this study weresevere cases of marasmus but the majority ofsubsequent studies have been done on childrenwith kwashiorkor, a less prevalent form of under-nutrition, and if energy requirements are less re-stricted in kwashiorkor this could allow somebrain growth to continue at the expense of otherbody tissues. Furthermore, the effect on intellec-tual development of little physical activity and of thelistlessness which occurs in undernourished childrenneeds to be assessed.

ConclusionOver the period of 15-18 years that this group of

children have been followed since the initial periodof severe marasmic undernutrition during the firstyear of life, evidence has accumulated of grcssirreversible intellectual impairment, despite im-proved environmental conditions and improvednutrition as indicated by catch-up in height. Thesmall head circumference, deficits in visual-motorperception, disturbed body concept, and the highincidence of abnormal EEGs, can only be explainedon a basis of organic brain dysfunction, dominantlyat a central neurointegrative level.

The assistance of Dr. P. M. Leary in reporting on theEEGs, is gratefully acknowledged.

REFERENCES

Bender, L. (1938). A Visual Motor Gestalt Test and its Clinical Use.American Orthopsychiatric Association, New York.

Dobbing, J. J. (1974). The later growth of the brain and itsvulnerability. Pediatrics, 53, 2.

Evans, D. E., Moodie, A. D. and Hansen, J. D. L. (1971). Kwash-iorkor and intellectual development. South African Medicaljournal, 45, 1413.

Hertzig, M. E., Birch, H. G., Richardson, S. A., and Tizard, J.(1972). Intellectual levels of school children severely mal-nourished during the first two years of life. Pediatrics, 49, 814.

Jensen, A. R. (1973). Educability and Group Differences. Methuen,London.

Koppitz, E. M. (1964). The Bender Gestalt Test for Young Children.Grune and Stratton, New York.

Koppitz, E. M. (1968). Psychological Evaluation of Children'sHuman Figure Drawings. Grune and Stratton, New York.

Langeveld, M. J. (1969). The Columbus. Karger, Basel.National Bureau of Education and Social Research. (1964). New

South African Individual Scale. Department of Education,Arts and Science, Pretoria.

Raven, J. C. (1956). Coloured Progressive Matrices. Lewis,London.

Robertson, I. (1961). Weight charts of coloured infants and pre-school children. South African Medical Journal, 35, 466.

Scrimshaw, N. S., and Gordon, J. E. (Eds.). Malnutrition, Learning,and Behaviour, p. 278. M.I.T. Press, Cambridge, Massachu-setts.

Stoch, M. B., and Smythe, P. M. (1963). Does undernutrition dur-ing infancy inhibit brain growth and subsequent intellectualdevelopment? Archives of Disease in Childhood, 38, 546.

Stoch, M. B., and Smythe, P. M. (1967). The effect of under-nutrition during infancy on subsequent brain growth and in-tellectual development. South African Medical Journal, 41,1027.



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336 Stoch and SmytheWhiteman, M., and Deutsch, M. (1968). Social disadvantages as

related to intellective and language development. SocialClass, Race and Psychological Development, p. 86. Ed. byM. Deutsch, I. Katz, and A. R. Jensen. Holt, Rinehart andWinston, New York.

Winick, M. (1971). Cellular growth during early malnutrition.Pediatrics, 47, 969.

Winick, M. and Rosso, P. (1969). Head circumference and cellular

growth of the brain in normal and marasmic children. Journalof Pediatrics, 74, 774.

Correspondence to Professor P. M. Smythe, Depart-ment of Paediatrics and Child Health, University ofNatal Medical School, P.O. Box 39, Congella 4013.Natal, South Africa.



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