Hospitalism (or ''anaclitic depression'' in its sublethal form) was a pediatric diagnosis used in the 1930s to describe infants who wasted away while in a

hospital A hospital is a health care institution providing patient treatment with specialized Medical Science, health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically ...

. The symptoms could include decreased physical development and disruption of perceptual-motor skills and language. In the first half of the 20th century, hospitalism was discovered to be linked to social deprivation between an infant and its caregiver. The term was used by the psychotherapist

René Spitz René Árpád Spitz (January 29, 1887 in Vienna – September 11, 1974 in Denver) was an Austrian-American psychoanalyst. He is best known for his analysis of hospitalized infants in which he found links between marasmus and death with unmothere ...

in 1945, but the term can be traced back as early as 1897. It appears under adjustment disorders at F43.2, in the

World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...

's classification of diseases,

ICD-10 ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms ...

History

In 1945, the

psychoanalyst PsychoanalysisFrom Greek: + . is a set of theories and therapeutic techniques"What is psychoanalysis? Of course, one is supposed to answer that it is many things — a theory, a research method, a therapy, a body of knowledge. In what might ...

René Spitz published an article in which he explained how deprivation of social interactions can lead to a condition named "hospitalism" in

infants An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used t ...

. According to Spitz, young children who are cared for in institutions can suffer from severe impairment in their development because they are not provided with sufficient maternal care. Spitz did not coin the term "hospitalism," which can be traced back to the end of the

19th century The 19th (nineteenth) century began on 1 January 1801 ( MDCCCI), and ended on 31 December 1900 ( MCM). The 19th century was the ninth century of the 2nd millennium. The 19th century was characterized by vast social upheaval. Slavery was abolish ...

. In 1897, Floyd M. Crandall published an article in the Archive of Pediatrics in which he used the term to describe a condition in institutionalized infants characterized by loss of weight, susceptibility to various diseases, and ultimately death. According to Crandall, this high mortality rate of institutionalized children under one-year-old was suspected to be caused by a lack of

hygiene Hygiene is a series of practices performed to preserve health. According to the World Health Organization (WHO), "Hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases." Personal hygiene refer ...

, food, air, exercise and personal contact. After rapid growth in welfare centres for infants at the beginning of the

20th century The 20th (twentieth) century began on January 1, 1901 ( MCMI), and ended on December 31, 2000 ( MM). The 20th century was dominated by significant events that defined the modern era: Spanish flu pandemic, World War I and World War II, nuclea ...

, hospitalism became a more public concern. One solution that was offered was the improvement of general hygiene to avoid the spread of infections.

Breastfeeding Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that brea ...

became increasingly important since it was considered to provide sufficient

nutrition Nutrition is the biochemical and physiological process by which an organism uses food to support its life. It provides organisms with nutrients, which can be metabolized to create energy and chemical structures. Failure to obtain sufficient ...

and to improve the infants' immune systems, which helped to reduce the mortality rate. The assumption that infants had no social competence or dependence on personal interactions had developed. Nurses began to replace the mothers' role for institutionalized infants, and mothers were usually not allowed to visit their children more than once a week. This was supposed to minimize the risk of infections and was considered to be a solution to hospitalism. The

pediatrician Pediatrics ( also spelled ''paediatrics'' or ''pædiatrics'') is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until the ...

Meinhard von Pfaundler criticized this approach and argued that this rational and distant care would damage the infants’ physical and emotional well-being. He claimed that children needed more external stimulation than was provided in the environment of hospitals. In the early 1930s, researchers at the Vienna Psychological Institute started to concentrate on the development of infants. The so-called Viennese Baby Tests were created by Charlotte Bühler and could be used to assess the mental, social, and physical development of children. Katherine Wolf and Hildegard Durfee used these tests to conduct studies on infants in different institutions. They concluded that the environment influenced the development of children and that this was especially important for the development of social competence. According to them, infants needed to be in contact with their mothers to receive sufficient love and care for their development. In the 1940s, the idea that infections led to hospitalism was increasingly criticized, especially since hospitalized infants were often kept alone in small cubicles, without any contact with caregivers or external stimuli, to prevent cross-infections. In 1945, the psychoanalyst René Spitz redefined the term hospitalism by arguing that the mortality rate of infants was still high, despite the isolation in cubicles, because the lack of maternal care impaired their development. Spitz conducted research for his hypothesis by comparing infants in a foundling hospital in

Mexico Mexico ( Spanish: México), officially the United Mexican States, is a country in the southern portion of North America. It is bordered to the north by the United States; to the south and west by the Pacific Ocean; to the southeast by Gua ...

and in a prison nursery in

New York New York most commonly refers to: * New York City, the most populous city in the United States, located in the state of New York * New York (state), a state in the northeastern United States New York may also refer to: Film and television * ...

with two control groups of children growing up with their families. With the help of Katherine Wolf, he assessed the development of the infants using the Viennese Baby Tests. Spitz concluded that the decline in development and the high susceptibility to diseases he discovered in institutionalized babies were not due to a lack of environmental stimuli, since the prison nursery infants actually had access to toys, but mostly due to emotional and social deprivation. According to Spitz, a stable and intimate mother-child relationship is critical for the healthy development of the child. In his short film, Grief: A Peril in Infancy, he demonstrated the consequences of hospitalism. This idea had a strong influence on other researchers, and in 1951, the British psychoanalyst

John Bowlby Edward John Mostyn Bowlby, CBE, FBA, FRCP, FRCPsych (; 26 February 1907 – 2 September 1990) was a British psychologist, psychiatrist, and psychoanalyst, notable for his interest in child development and for his pioneering work in attachm ...

published a report on homeless children in the

USA The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territo ...

. This report, which was titled ''Maternal Care and Mental Health'', was commissioned by the WHO and supported his theory of

maternal deprivation Maternal deprivation is a scientific term summarising the early work of psychiatrist and psychoanalyst John Bowlby on the effects of separating infants and young children from their mother (or primary caregiver). Although the effect of loss of the ...

. According to Bowlby, a child needs to have a loving and continuous relationship with the mother to avoid permanent developmental damage and hospitalism.

Causes

There are three conditions which determine the likelihood of hospitalism in a patient: * How healthy the person is before the admission into the hospital * How well the operation or appointment gets done * How the patient is taken care of after the operation or appointment, including the number of patients in the hospital in general and the hygiene of the hospital The most investigated causes which have been observed are those from infants and children in hospitals or nursery homes. The main cause of hospitalism in children and infants is the separation of the child from the mother. They experience a massive desperation and distress due to the isolation from their mother. An example is children or infants in a nursery home when they are only held in cribs, depriving them of the opportunity to interact with their environment and other people. This deprivation might happen since the nurse has to take care of multiple children at once. A lot of causes, as well as assumptions of causes, still have to get scientifically proved and investigated.

Symptoms

Symptoms of hospitalism are numerous. Symptoms are largely observable in behaviour, but a patient's psychological or physical impairments are largely driven by the cause of their condition, and as such not all patients experience the same suite of problems. Physical impairments include physical underdevelopment, reduced motor speed, and increased risk of rapid-onset

muscle atrophy Muscle atrophy is the loss of skeletal muscle mass. It can be caused by immobility, aging, malnutrition, medications, or a wide range of injuries or diseases that impact the musculoskeletal or nervous system. Muscle atrophy leads to muscle weakness ...

. Patients commonly suffer from maladaptive or disruptive eating behaviour, which results in a general decrease in stamina. This has been linked to

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues ...

, extreme weight loss, and

food addiction A food or eating addiction is any behavioral addiction that is primarily characterized by the compulsive consumption of palatable (e.g., high fat and high sugar) food items which markedly activate the reward system in humans and other anima ...

. Patients tend to have a strong predisposition to

marasmus Marasmus is a form of severe malnutrition characterized by energy deficiency. It can occur in anyone with severe malnutrition but usually occurs in children. Body weight is reduced to less than 62% of the normal (expected) body weight for the a ...

, which increases mental and physical fragility, alongside an impairment of their immune system, leading them to be at higher risk for infections and viral diseases. Infants also experience a higher mortality rate. The psychological circumstances fit this image. Especially in children that stayed in orphanages for a long time and suffer from deprivation syndrome – the sensory withdrawal before adulthood resulting in physical and psychological damages – one can observe a reduction of activities due to a lack of motivation and suppression of feelings. Sleeplessness, loss of weight and apathy are additional symptoms of depression that can also play a role. Another effect of withdrawal of sensory desires in an early age are personality disorders as for example borderline and attachment and adjustment disorders that are especially seen in behavioral abnormalities. These abnormalities can consist of

stereotypes In social psychology, a stereotype is a generalized belief about a particular category of people. It is an expectation that people might have about every person of a particular group. The type of expectation can vary; it can be, for example ...

– a motor restlessness that results in showing repetitive and consistent motor processes and spoken utterances that do not have any goal or function and occur in absolutely unfitting situations. Stereotypic movement might also result in self harm. Behavioral abnormalities can also hinder social relations effectively. Affected individuals tend to become apathetic and withdrawn. Antisocial behavior might manifest as lying or stealing. Disrupted social functions related to a lack of socialization and integration can lead to further isolation. Hygiene and appearance may also be negatively impacted.

Consequences and complication

The consequences of hospitalism can be detrimental for the people affected and reveal themselves in different ways. It is noteworthy that the symptoms can vary across different individuals, and several factors, such as age, play a significant role. Patients are also at higher risk for various mental disorders and anti-social behaviors: *

anxiety disorder Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...

s * depression * borderline-personality disorder * suicidal tendencies *

apathy Apathy is a lack of feeling, emotion, interest, or concern about something. It is a state of indifference, or the suppression of emotions such as concern, excitement, motivation, or passion. An apathetic individual has an absence of intere ...

* low self-esteem * autoaggressive behaviour * attachment anxiety * adjustment and communication disorders * tendencies towards aggressive behaviour * lack of personal hygiene Individuals suffering from hospitalism are also at risk for sensory perception problems: * altered or delayed pain perception * fear of touch *

hypersensitivity Hypersensitivity (also called hypersensitivity reaction or intolerance) refers to undesirable reactions produced by the normal immune system, including allergies and autoimmunity. They are usually referred to as an over-reaction of the immune s ...

Other common consequences relate to cognitive disorders, such as: *

learning disabilities Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficult ...

* rarely memory lapses or even loss of long- or short-term memory * motor disorders such as monotonous and stereotyped movements (for example, banging the head against the wall) or a severely reduced ability to react Long-term consequences, which is causally related to traumatic experiences, can be expressed in different ways. People showing signs of hospitalism might express an extreme aversion towards showing or accepting emotional or physical affection, effectively shutting themselves off from others. A different response could be promiscuity, whereas people strive for love and affection.

Prevention and solutions

Prevention and solutions of hospitalism largely focuses on efforts that seek to counter-act deprivation. During their stay, skin-to-skin contact between mother and child has shown to beneficial. Also, conducting various types of play activities with children, which will meet their need for physical activity can provide an opportunity to establish an intimate emotional relationship with the mother or a substitute. Therapeutic interventions should be carried out by specially trained professionals, psychotherapists, psychologists, social workers, teachers, and a network of non-professionals for people who are physically, mentally, or emotionally handicapped. Efforts are made to place parentless children in suitable accommodations, such as children's villages and

foster care Foster care is a system in which a minor has been placed into a ward, group home (residential child care community, treatment center, etc.), or private home of a state- certified caregiver, referred to as a "foster parent" or with a family me ...

. Special attention should focus on the suitability of the environment for the child. These institutions should provide the necessary support and the right environment so that children can develop normally. For the care of elderly and sick people assisted living and community houses are used for prevention. Accessibility and affordability are to continuously be improved. High-quality accommodation is also important for the proper treatment of existing illnesses and disorders. A very unique approach is lived in the Belgium city

Geel Geel () is a city located in the Belgian province of Antwerp, which acquired city status in the 1980s. It comprises Central-Geel which is constituted of 4 old parishes a/o towns: Sint-Amand, Sint-Dimpna, Holven and Elsum. Further on around the ce ...

, where it is common for people with mental illnesses to live with local families.

References