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Introduction to the detailed review of behavioural, psychological, and social correlates of child growth

Since the third type of finding (p. 23) concerning behavioural, psychological and social correlates of child growth is least familiar to the majority of nutrition and health professionals, the goal of this review is to acquaint them with the role of these factors so that they can collaborate more easily with social scientists and social services programmes. In part 2 (p. 86) we present a conceptual framework incorporating the full range of malnutrition correlates that must be taken into consideration in positive deviance research.

Lack of Specificity to Nutrition

As noted in the overall conclusions (p. 34), studies specifically focused only on the nutritional status of the young child have identified many of the same favourable social and behavioural characteristics found by other studies to predict cognitive development, good health, and longterm productivity and adjustment of the individual. These characteristics correspond to moral virtues taught by almost every culture in the definition of social roles. In most cases, the positive-deviant mother is recognized as a "good" mother, her husband as a "good" provider, and her community as a model community.

The fact that these social values or beneficial social conditions lead to a broad range of positive outcomes, in addition to positive deviance in nutrition, raises the question whether investment in improving the psychological and social health of families and communities might be relatively more effective for child development overall, and for nutrition, than investment in direct nutrition programmes. Obviously both approaches are important but their relative cost-effectiveness is uncertain. As recommended in the policy conclusions. fostering community-based and supported nutrition programmes promotes both goals. The community is motivated to become more cohesive and responsive to its members and nutrition services are provided.

Werner and Smith (1982) reported on an 18-year longitudinal study of the entire 1955 birth cohort of the island of Kauai, Hawaii. This study identified factors that protected high-risk infants born to poor families from developing severe psychological and social coping problems at ages 10 and 18. This was, in our terms, a positive deviance study in which the outcome was psychosocial adjustment rather than growth. Figure 5 presents a model of the findings of this study. The reader is urged to note and recall the social factors associated with good outcomes as they reappear linked to nutrition in the following pages.

A major psychological assessment instrument, the Caldwell Home Inventory (Cardwell, 1967), which was developed to assess factors in the home and in the mother child interaction that are associated with cognitive and motor development, has been found to be associated with growth (Cravioto and Delicardie, 1976; Pollitt, 1975).

Associations between Nutrition, Psychosocial Development, and Modernization

Given the fact that many of the factors predicting good developmental outcomes amidst poverty are non-specific to nutrition, it is not surprising that psychosocial and nutritional development are associated with each other. These associations exist both across and within social classes. In poor communities where food is limited and detrimental weaning practices are prevalent, the majority of children may be mildly to moderately malnourished without psychosocial abnormality. Yet, the quality of psychosocial stimulation given to these children will almost always be lower than that provided to children of higher social class and better nutritional status within the same culture. Similarly, within the low-income community, better-growing children will commonly be found to he more normal in their psychological development while male nourished children will be more seriously impaired than the group average (Masangkey et al., 1975).

Many unresolved questions remain: why some parents differ from others living in the same environment in their psychological receptivity to new concepts, new value systems, and new lifestyles. It may be that the parents of positive deviants have become more conscious than their neighbours of the need to deviate and have been able to make more efficient use of available opportunities, such as education and health services, to modernize and become upwardly mobile.

Individuals take action in any given situation within a web of driving and restraining forces that include social and economic factors. Motivation, related to past and present experiences, lies at the root of action and can be seen as an agent of change. Future expectations, perceived outcomes, and beliefs in the achievability of various goals act as motivators or demotivators. These motivators and demotivators depend on the needs, values, and personality traits of each individual.

Within the same social structure, life-styles, thought processes, and motivations appear to evolve along developmental scales that reflect the progress of individuals and subcultures towards maturity. The most famous of many scales that have been proposed to describe the developmental process is taken from the Hierarchy of Needs by Maslow and Herzeberg (1954). In this scale there are five stages, starting at the bottom with "basic needs," and progressing in sequence to "safety, belonging," and "ego-status." The top stage, achieved by only a few, is "self-actualization."

Fig. 5. Model of interrelations between risk, stress, sources of support, and coping (based on data from the Kauai Longitudinal Study, after Werner and Smith, 1982). Part 1

Fig. 5. Model of interrelations between risk, stress, sources of support, and coping (based on data from the Kauai Longitudinal Study, after Werner and Smith, 1982). Part 2

According to this hierarchy, basic needs for food and shelter precede needs for physical safety and belonging, which in turn must be met before individuals are motivated to act to enhance ego status and achieve self-actualization. Once each phase has been experienced fully, with values internalized and skills acquired, the individual is able to move from simple and least developed phases to complex and more developed ones. A person in need of food is not likely to place a high value on belonging, independence or synergy, and will not be motivated to move on through the phases.

In this document we presuppose that hierachies of this sort exist in developing country communities and help to explain why parents of positive deviants somehow "make it," although they apparently have the same life chances as their peers. However, we cannot document such developmental stages in our review of the literature. Most of the typologies that exist have been postulated without scientific research and with primary reference to males rather than females. To the authors' knowledge, all were constructed in industrialized rather than developing countries.

The Values and Lifestyles Program of the Stanford Research Institute in the United States recently developed a typology of nine developmental life-style stages based on a nationally representative sample of males (Mitchell, 1983). The methods used in this study could usefully be applied in developing countries. One of the insights it yields is that individuals at the bottom of the hierarchy may be too preoccupied with their own personal survival to focus on the needs of their children.

One typology of women's thinking, which was developed by means of a sample survey in the United States (Belenky et al., 1986) ranks women from lowest to highest in five positions. First is "silence," or the silence of women who live in a world in which they perceive words as weapons to which the response may be physical violence. Second is "received knowledge," or the unquestioning acceptance of the authority of patriarchs and experts. Third is "subjective," where women's thoughts and actions are based on their "guts," intuitions, and experience. Fourth comes "procedural" thought, where women accept logical methods and institutional channels. Fifth and last is "constructed knowledge," in which women apply their intuitive gifts to the experience of others and apply the tools of science to their own experience. Women falling in the first and second stages of such a hierachy would be severely limited in their abilities to make use of opportunities to modernize their own lives and the lives of their infants.

The Child Development Context

Since infants cannot survive without constant attention from the mother or another caretaker for the first two to four years of life, someone must be able and motivated to provide this care 24 hours a day, 365 days a year. The infant's physical and emotional needs must be met, and responded to appropriately. Frequently physical contact, and a warm and reciprocal interaction, are necessary for the good growth and development of the infant. It is needless to emphasize that, depending on the culture, feeding and non-feeding interactions will be expressed differently, and hence must be understood within a culturally relative framework.

Table 3. Stage-specific tasks and capacities

Source: Adapted from Greenspan, 1981.

It is known, for example, that institutionalized infants who receive insufficient stimulation may fall into a state of depression in which they lose weight, become increasingly apathetic and immobile, and eventually die (Smith and Berenberg, 1970). Between two and seven months, infants develop strong emotional attachments or bonds to their mothers and others with whom they interact warmly and regularly. Multiple caretakers appear to serve the infant's needs as well as a single caretaker, so long as the environment remains stable and emotionally nurturing. If an infant bonded to a single individual is separated from this person before the age of three or four years, depression similar to that of hospitalized infants is likely to occur.

Greenspan (1981) describes the psychological developmental agenda of the infant between birth and about two-and-a-half years. This agenda is discussed below and linked to the nutritional agenda over the same period. Although the psychological milestones probably are somewhat retarded by, and affected in quality by, malnutrition, it has been assumed that human development follows a species-typical path and that most of these stages are not culturespecific (although their expression may be culturally determined.)

The evidence on which Greenspan bases his conception of early development, however, comes largely from Western populations, and its universality should be reyarded as an empirical question rather than a settled issue. Research conducted in non-Western populations reveals parents with different agendas for infant development (e.g. with respect to the auto-regulation of the sleep-wake cycle), different concepts and standards of maternal attachment, and (following their cultures' models) different styles of communicative interaction (Konner, 1977; Super and Harkness, 1981; Richman, 1983; Caudill and Weinstein, 1969).

Table 3 combines Greenspan's developmental stage-specific tasks and capacities on the left with the infant's nutritional tasks and capacities on the right. This scheme is presented in order to illustrate the types of links between developmental and nutritional stages that should be sought empirically through interdisciplinary research in nutrition and development.

In the first stage in table 3, the infant should learn to regulate sleep/wake states and hunger cycles without becoming excessively irritable or colicky at the same time that he ingests very large amounts of food relative to his body size and gains between 0.5 and 1.5 kg per month. The baby's capacity to engage with the outside world, form affectionate attachment with his or her caretaker, and obtain sufficient milk from an abundant milk supply depends on the ability of the dyed to achieve a steady relationship that satisfies both of them.

In the second stage, mother and baby "fall in love" with each other in a pleasurable involvement. Breast-feeding is an expression of the bond that exists between the two, and helps reinforce this attachment.

In stage three, the infant and mother become more able to interpret each other's non-verbal signals. On the mother's side, the timing of introducing supplementary foods, the amounts fed, and the frequency of offering the breast or bottle and supplements depend on her interpretation of her baby's needs and desires. The baby's ability to make his desires known, and to respond to feeding opportunities offered by the mother in a manner that is not apathetic. excessively distracted, or self-assertively rejecting, may affect his growth.

Gradually, between 9 and 24 months, the emerging toddler takes increasing responsibility for seeking out and obtaining his share of the food that is available in the household. At the same time, he becomes more active and goal-directed in play and exploration. His excursions must be supervised and limited for his own safety without destroying his urge and capacity to be goaldirected. In the early part of this period, when he is able to crawl but not to walk, his exposure to infection will be very high if he is allowed to crawl in dirty surroundings shared with domestic animals (Zeitlin et al., 1985) and to put everything into his mouth.

Between 18 and 30 months, the child starts to talk and learn by imitation. He is able to evoke mental images of people and events, and to participate in social rituals. Since he is capable of visualizing the clear mental image of "mother giving me food," his vocalizations become more goal-directed. The use of the words "please" and "thank you" helps him obtain food, and the way he handles the food contributes to his ability to get "seconds."

The stage of assertiveness, known in the United States as the "terrible twos," may also enable children to persist in their attempt to obtain food from indifferent or inadequate caretakers. F. C. Johnson in Mexico (personal communication, 1986) observed that a child that had long been marasmic began by two-and-a-half to scream so loudly and persistently for food that her mentally retarded mother fed her more and the child improved.

Disruption of any stage in the developmental process retards the infant's ability to proceed to the next stage. Mild to moderate post-natal malnutrition appears to delay the emergence of developmental stages but does not make them abnormal in quality when they do emerge (Chavez and Martinez, 1982). One major exception to this general finding is that the amount of initiative and exploratory behaviour of the young malnourished child is greatly reduced when compared with that of well-nourished children.

Pre-natal malnutrition appears more likely to produce a behaviourally abnormal newborn who fails to engage properly in the post-natal developmental cycle. A breakdown of the maternalinfant relationship early, in the first year of life, indicates more severe pathology than interactional problems that emerge during the second year (Greenspan, 1981).

In affluent societies. where an abundance of nutrient-dense food is available, psychosocial dysfunction may occur without malnutrition. Psychologically healthy children are, however, almost invariably well nourished, whereas children classified as suffering from failure-to-thrive (FTT: a name for malnutrition when food availability is not a constraint) almost invariably have a pathological relationship with their primary caretaker.

Non-feeding interactions between the mother and child are significantly related to growth. Pollitt and Wirtz (1981) associated micro-behaviours of bottle-feeding mothers and infants in Massachusetts with the weight gain of the child during the first month of life. They found that infant communication (crying, whimpering, opening eyes) and mother's proximal nurturing (adjusting blankets, caressing infant) accounted for about 20 per cent of the variance in weight gain, compared with about 10 per cent associated with nutritional activity of the mother (putting nipple in mouth, rotating, tilting bottle, grooming/cleaning baby's body).

As noted by Pollitt and Wirtz, such micro-behaviours have not been explored in depth. Given the large gaps in our knowledge of how these behaviours are linked to child growth, it is probably not useful to make a rigid distinction at this time between feeding and non-feeding aspects of caretaker-child interactions. Accordingly, this document will place them in separate categories where there appears to be good reason to do so, but will not compartmentalize them rigidly.

Quality of care as a continuum

The literature linking young-child nutrition to psychosocial and behavioural correlates suggests that quality of caretaking is a continuum. ranging from absent or very poor at the low end to highly competent at the top. In homogeneous communities where socio-economic level and infant-feeding practices are relatively uniform, growth parameters during the first two to three years of life are more or less normally distributed. If weaning practices are poor and food supply restricted, the averages for the community will be low. It is known that many of the infants who fall in the bottom 5 to 10 per cent of any given local distribution will have caretakers who lack in competence; those in the middle range will have caretakers of moderate competence; and those at the top will probably be benefiting from superior "maternal technology" or the constellation of factors determining positive deviance.

Figure 6 shows both maternal and infant contributions to the outcomes of failuret o-thrive (by local standards) below the lower curve to the left and positive deviance above the upper curve to the right. To the far left of the horizontal axis are caretakers who are either absent or suffer from overt psychopathology and to the far right are those who have extreme maternal competence and joy in living. At the bottom of the vertical axis are infants who are organically damaged to a degree that precludes normal growth, and at the top are exceptionally mature and adaptable babies. Individual mothers vary in their skills over time. Under stress, they become less competent. Their infants may temporarily suffer, and recover when the mother's situation improves.

Discrete physiological syndromes and behavioural clusters emerge at different levels of the continuum. Scholl and associates (1980) show, for example, that clinical male nutrition in Mexico was preceded by a gradual progressive decline in growth status over several months. Failure-to-thrive infants exhibit abnormal behaviour, such as posturing and a fixed stare referred to as "radar gaze." Kwashiorkor infants appear to be in misery. These manifestations disappear as their health and nutritional status improve.

Fig. 6. Maternal and infant contributions to failure-to-thrive and positive deviance.

Positive-deviant behaviours, attitudes, and social-support structures are expected to emerge as discrete entities towards the top of the continuum. The configurations characterizing both top and bottom may differ by culture. The father's role is an example; in some cultures the father's presence in the home is critical to the well-being of the mother-infant dyed. In others, he may remain in contact with the dyed, but live elsewhere. In still other cases a real or surrogate grandmother may provide emotional support to the mother-child pair.

Some of the factors that characterize the top of any given culture-specific continuum will be transferable by intervention to members operating at lower levels, while other factors will not. Hence, there is a need for "transfer trials" before an attempt is made to incorporate these factors into programmes.

Levels of Approach

Mother-child (or caretaker-child) interactions and the technology used in weaning and health care have the most proximal effects on food intake, stress levels, child morbidity, and child growth. These interactions are affected by maternal and child characteristics, as well as by the social network surrounding and supporting the dyed. Figure 7 illustrates these relationships on the left, and shows the intervention types that may be developed to improve them on the right.

Nutrition education through growth monitoring and social marketing can be a major channel for improving these interactions (box 1). Maternal and child characteristics and the socialsupport structure, although increasingly indirect, are no less important. Early childhood interventions provide another more comprehensive approach (Pollitt, 1984). Improved pre-natal nutrition, via education and supplementation programmes, may have the greatest impact on child characteristics (box 2). Improved nutritional status across the weaning age also enhances the child's contribution to interactions with his caretakers. Social welfare, formal education, health, and particularly family planning services are needed to improve the psychological and attitudinal characteristics of mothers (box 3).

Finally, the social-support system surrounding the dyed (box 4) has a major influence on the mother's ability to provide high-quality care for her baby. Socioeconomic and socialdevelopment policies affecting the availability of employment for male heads of household and migration patterns, for example, tend to have a large impact on family-support networks. The mother's own employment prospects and the child-care facilities available to her may be equally, if not more, important.

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