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Emotional deprivation in infants
Psychologic Aspects of Pediatrics EMOTIONAI~ DEPRIVATION
iN INFANTS
H:~RuY BA~WlN, M.D. N~;w YORK, N . Y. N T I L the early years of this century, when it was the custom to keep homeless infants in institutions for custodial care, the babies quickly withered and died. W h e t h e r all perished or only most of them depended principally on one f a c t o r : the duration of their stay ill the institution. The high institutional m o r t a l i t y of infants was discussed at the annual meeting of the American Pediatric Society in 1915. Dr. t t e n r y Chapin ~ reported on ten infant a s y h m s located in different cities of the United States. I n all but one institution every i n f a n t u n d e r 2 years of age died. t I a m i V of Philadelphia, in discussing C h a p i n ' s paper, said ironically: " I had the honor to be connected with an institution in this city in which the m o r t a l i t y among all the infants u n d e r one y e a r of age, when admitted to the institution and retained there for any length of time, was 100 p e r cent. T h a t is, no i n f a n t admitted u n d e r one y e a r of age lived to be two years old." Southworth, 3 speaking for conditions in New York City, said: " I can give an instance f r o m an institution t h a t no longer exists in which, on account of the v e r y considerable m o r t a l i t y among' the infants admitted, it was customary to enter the condition of every infant on the admission card as hopeless. T h a t covered all subsequent h a p p e n i n g s . " K n o x ~ described a study which he had made in Baltimore. H e followed 200 infants admitted to various institutions in the city. Of these almost 90 per cent died within a year. The 10 per cent that lived, he said, did so, apparently, because, for some reason or other, the babies were taken f r o m the institutions for short times and given into the care of foster p a r e n t s or relatives.
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SYN/PTOMATOLOG Y
I n f a n t s u n d e r 6 months of age who have been in an institution f o r some time present a well-defined picture. The outstanding features are listlessness, emaciation and pallor, relative immobility, quietness, unresponsiveness to stimuli like a smile or a coo, indifferent appetite, failure to gain weight p r o p e r l y despite the ingestion of diets which, in the home, are entirely adequate, frequent stools, poor sleep, an appearance of unhappiness, proneness to febrile episodes, absence of sucking Habits. The hospitalized infant is thin and pale but the pallor is not always associated with a reduction in the hemoglobin. The facial expression is u n h a p p y and gives all impression of misery. Muscle tone is poor and it is possible to extend the legs fully at the knees, contrasting in this way with normal young infants. There is no alteration in the deep reflexes. The i n f a n t shows no inF r o m the D e p a r t m e n t of Pediatrics, College of IVIedieine, New Y ork U n i v e r s i t y - - B e l I e v u e Medical Center. 512,
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terest in his environment, lying quietly in bed, rarely crying and moving very little. Such movements as he makes are slow and deliberate, unlike the quick movements one expects at this age. E v e n respiration seems quieter t h a n in normal infants. rl?he appetite is indifferent a.nd food is accepted without eagerness or interest. The weight m a y be stationary; there m a y be loss or slow gain. The amount of food necessary to effect a weight gain is much greater than in the home. Nevertheless growth in height continues at a rate only slightly less than average. The stools are :frequent and, in s h a r p contr'ast to the situation in the home, it is unusual for twenty-four hours to pass without an evacuation. Normal infants at 2 to 3 months of age smile and become animated in response to the smile or cooing voice of an attentive adult. Not so the baby who has been ~n a hospital for a n y length of time. Here it is difficult to elicit a smile in this way and repeated efforts are necessary. Sleep is light and :fitful even at 3 and 4 months, resembling t h a t of babies during the early weeks of life. Sucking habits are uncommon. T e m p e r a t u r e elevations, sometimes associated with mild respiratory infections, ofttimes without demonstrable cause, are frequent. We have observed babies who developed fever while in the hospital which persisted for months. We reported five infants in whom fever lasted f o r f r o m three to eight months. ~ The cause of the fever was investigated with every available laboratory test but nothing was found except an occasional red throat or running ear, infections which in the home last only a day or two. There was no response to chemotherapy. I n all instances the t e m p e r a t u r e fell to normal when the infants were iliseharged f r o m the hospital and it remained normal thereafter. In severe eases the symptoms are intensified and the baby assumes the appearance of a wizened, toothless old man. The cheeks are sunken, although in some instances the sucking pads in the cheeks remain; the skin is loose and somewhat inelastic; the whitish pallor is striking and the general impression is one of great weakness and frailness. The respirations are slow and superficial and often sighing. PREI)ISPOSING ]0'AC~I?ORS The duration of hospital stay preceding ihe appearance of symptoms varie~ considerably, some e;hildren showing definite changes within a few days after e n t r y to the hospital, others r e m a i n i n g f o r weeks without becoming' ill. Age is an i m p o r t a n t factor. We have never seen the clinical manifestations of emotional deprivation during the first two weeks of life which was the usual duration of the stay for mothers and babies in obstetrical hospitals before the war. Though most babies who are born in hospitals receive very little m a n i p u l a t i o n d u r i n g this time they a p p e a r vigorous, they have lusty cries and good color, and they gain well. However, if a newborn baby remains in the hospital, for one reason or another, a f t e r the first inonth he generally shows symptoms of hospitalism. As a :rule, i)rematurely born infants, especially the small ones, are una:ffeeted by the rigid isolation practiced in the modern p r e m a t u r e unit. Only
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when they remain in the hospital for a long time and have outgrown their prem a t u r i t y do they show the physiea.1 and behavioral manifestations generally associated with emotional deprivation. A possible predisposing factor is the nature of the illness f o r which the child enters the hospital. I t has seemed to us that children with diarrhea are more susceptible than others, possibly because this is a rather prolonged illness and one which, in itself, interferes severely with the baby's nutrition. Another factor may be the amount of emotional satisfaction which the child had received before entry to the hospital. A certain n u m b e r of babies, reared in the home, show the pallor, the quietness, and the motor retardation which are associated with emotional deprivation. Such babies are likely to be left to themselves in the hospital while the attractive, animated ones receive the affectionate attention and interest of the hospital personnel. Infants with gross cerebral damage are not affected by emotional deprivation. ()f the several hundreds of such infants who have been admitted to Bellevue Hospital in the course of years we do not recall having seen a single one who showed the clinical picture described above. Instead, they sometimes develop hyperpyrexia and die within a few days after entering a hospital. This may take place in infailts who at first appear to be in excellent nutritional condition. At home they have been cared for by attentive mothers who rome to understand their peculiar behavior and who eater to them. In the hospital the nurses find the mannerisms of these children strange and unpredictable and unattractive. Feeding is especially difficult and consequently the food and especially the :fluid intake is inadequate. In addition t h e y may contract infections. Presumably tile h y p e r p y r e x i a is a result of dehydration, infection, and a cerebral element ("cerebral f e v e r " ) . The absence of symptoms in p r e m a t u r e l y born infants, in newborn infants, and in infants with severe cerebral damage suggests that, though the clinical manifestations of this condition in early infancy are principally physical, a certain amount of conscious cerebral functioning is necessary in order for inj u r y to register itself. Certain physical consideraUons may contribute to t h e speed with which babies deteriorate in hospitals. They are Lmable to indicate satisfactorily when they are h u n g r y and when they have had too much, and it is h a r d l y possible for the nurses to understand the idiosyneraeies of the individual infant on short acquaintance. ~Ioreover, the prevalent custom of prescribing food in hospitals laeks the flexibility which is possible in the home. Rigid orders for :feeding are given and there is no meehanism in most hospitals whereby the infant can have more of his formula at one feeding when he is h u n g r y and not so much at another when he is satisfied with less. Food refused at one feeding' cannot be made up at another. Tile rapidity with which the symptoms of hospitalism begin to disappear when an afflicted baby is placed in a good home is amazing. I t :is convineing evidence of the etiologic relation of the emotionally arid atlnosphere of the hospital to the symptoms. The baby promptly becomes more animated and
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responsive; fever, if present in the hospital, disappears in t w e n t y - f o u r to seventy-two hours; there is a gain in weight and an i m p r o v e m e n t in the color. A striking example was that of A.S., a boy 4 months old, who had been in the hospital f o r eight weeks because of diarrhea. The diarrhea ceased soon a f t e r e n t r y but the child continued a downhill course despite all therapeutic efforts. A t 4 months of age he weighed less than at birth and his condition was critical. His a p p e a r a n c e was that of a pale, wrinkled old man. His breathing was so weak and superficial that it seemed as though he might stop breathing at any moment. W h e n seen t w e n t y - f o u r hours a f t e r he had been at home he was cooing and smiling. Though no change had been made in his diet he started to gain p r o m p t l y and by the end of the first y e a r his weight was well withiil the normal range. H e a p p e a r e d to be in every w a y a normal child. ETIOLOGY OF HOSPITALIS~I The failure of babies to thrive in hospitals, referred to as " h o s p i t a l i s m , " has been a m a t t e r of concern and speculation to the physician since babies were first confined in institutions. F o r a long time the condition was considered to be due to poor nutrition and deaths were usually attributed to m a l n u t r i t i o n or marasmus. However, when application of the newer knowledge of nutrition failed to solve the problem of hospitalism, interest shifted to infection as the cause of the difficulty and obscure deaths in hospitals were generally listed as due to nasopharyngitis and its complications. To g u a r d against cross-infections isolation methods were intensified. The wards for infants were partitioned off into separate little cubicles ~%r each baby, and nurses and physicians were expected to scrub their hands and to wear gowns and masks before handling the babies. P a r e n t s were rigidly excluded except for one or two visiting hours each week. Elaborate and expensive boxes were devised, mechanically controlled, in which the babies could be cared f o r almost untouched by h u m a n hands. Manipulation of the babies was discouraged since handling increases the o p p o r t u n i t y f o r bacterial exchange. F o r m a n y years thoughtful pediatricians have suspected that the basis for hospitalism was in some vague way related to the i n f a n t ' s psyche. Parrot, ~ who was associated with several foundling institutions ~n France, concluded that hospitalism was due to lack of adequate stimulation. Czerny, 7 felt t h a t monotony and staring at blank walls and ceilings were i m p o r t a n t factors. K a u p e 8 emphasized the role of the mothers who could not be replaced by the: most selfsacrificing nurses. The psychic and physical influence of the mother, he stated, was a v e r y i m p o r t a n t weapon against hospitalism. A similar viewpoint was expressed by P f a u n d l e r 9 who observed t h a t when the mother or some sympathetic person took over the care of the child, severe damage did not take place. E v e n when m a n y infants were crowded together without special attention to asepsis, t h a t is, u n d e r unfavorable environmental conditions, if they were taken care of by their mothers (as was the case in certain foundling institutes in Austria and F r a n c e ) , then hospitalism did not; play nearly so la,'ge a part. Birk a' held t h a t individual care, which represents a sort of psychic contact between child and nurse, is essential :for some infants, and Feer L~ believed that
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lack oil psychic stimulation exercises a, h a r m f u l effect on the vegetative functions. Brennemann, 1~ recognizing the effect of absence o~ mothering, had a rule in his hospital that every baby should be picked up, carried around, amused and " m o t h e r ' e d " several times a day. A n illuminating experience is related by l)r. F r i t z Talbot ~3 of Boston. I ) u r i n g a visit to the Children's Clinic in l)iisseldorf some f o r t y years ago Talbot noticed a very fat old lady wandering about the ward with a very measly baby on her hip. H e asked Schlossmann, the Director, who she was and he was told that, whenever they h a d a baby for whom they had done everything medically and were unsuccessful, they tm'ned the baby over to old A n n a and told her to take charge. Old A n n a was always successful. Great credit is due to Dr. H e n r y Dwigi~t Chapin ~ of New Yor'k who was responsible for introducing into America the system of boarding out babies in homes instead of leaving' t h e m in institutions. I I e was keenly aware of the need of babies for individual care and affection. Some objective evidence of the deleterious effects of institutions on the i n f a n t ' s psyche was presented by Durfee and W o l f in ~933. ~4 Using B u e h l e r ' s tests, they compared the developmental quotients (D.Q.) of infants in various institutions and correlated their findings with the amount of m a t e r n a l care which the infants received. They found t h a t the groups of infants who had the advantage of m a t e r n a l care were suI)erior to those who did not, despite the fact that several of the institutions which restricted m a t e r n a l attention were better eqnipped and staffed t h a n the others. The observations of Durfee and Wolf have been confirmed and extended by the carefully controlled studies of Spitz. ~ PATHOGENESIS The way in which emotional deprivation registers its effects on the child is largely speculative but certain rationalizations seem justifiable. According to Rapa.port, ~G the emotional process m a y be initiated in two ways. I t m a y be evoked by an incoming percept f r o m the outside or it m a y originate f r o m within as, for example, when one gets excited by a novel idea, planning a trip, an anxiety. The stimulus, whether external or internal, initiates an unconscious process which mobilizes unconscious instinctual energies. The discharge process has two components, one which is physiologic and behavioral, the "emotional expression"; the other which is psychologic, the " e m o t i o n f e l t . " These m a y occur simnltaneously or they m a y succeed one another or either m a y occur alone. Since young babies obviously lack the mental power to initiate emotionproducing situations, they are entirely dependent on their sensations in this respect. F o r the same reason the component " e m o t i o n f e l t " is a m i n o r element in the emotional process as compared with " e m o t i o n a l expression." The physL ologic and behavioral responses (ff the young babies to emotion-producing' stimuli are not unlike lhose observed at later ages. Looked a.t from lhe very reason-
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~d)le viewpoint pcesel~l;ed hy l?,apapoe(,, tim q(tes(.io,~ a.s to whether the emotional responses of the newborn in t!ant can be designated as " f e a r , " " r a g e , " ete., loses much of its point and the same is true for discussions regarding the ability of newborn infants to feel pleasure. 17 I n a certain sense young infants m a y be expected to show p u r e r emotional responses than later on since the p a t h w a y s for instinctual behavior at this early age are probably wide open and not modified or blocked by cultural conflicts. The senses--sight, hearing and equilibrium, taste, smell, the skin senses, the muscle senses, the internal s e n s a t i o n s - - a r e all functionally active at or shortly a f t e r birth. ~a F o r vision to be m e a n i n g f u l a certain amount of experience is necessary. Moreover, looking is an active process requiring a degree of motor eontrol of the eye and head museles which is attained only a f t e r several months. I t is not until 4 weeks of age that the baby has progressed to the point where he will regard a dangling' ring. ~9 Only later, at 2 or 3 months of age does he begin to respond to a smiling :face. This is not true, nearly to the same extent, of the other sensations. The newborn i n f a n t shows discriminating behavior toward sounds. He is disagreeably affected by a loud, a b r u p t noise and he seems pleased by a cooing voice. Sucking seems to give pleasure. Most imp o r t a n t to the young baby a p p e a r to be the skin sensations and the kinesthetic sense. Babies are readily soothed by p a t t i n g and by w a r m t h and they cry in response to p a i n f u l stiInuli and to cold. The quieting effect of keeping babies outdoors m a y well be due, in part, to the movement of air on the skin. T h a t the kinesthetie sense is m e a n i n g f u l is indicated by the soothing effect of rocking a n d the disagreeable effeet of a b r u p t change in position. I n f a n t s kept in hospitals are, as a rule, m a n i p u l a t e d as little as possible. There are two reasons for this: inadequaey of personnel and the fear of transmitting infections. I n general the more carefully run hospitals observe stricter "isolation t e c h n i q u e " than do others. As a result the infants receive a minim u m of sensory stimulation which is their only channel for initiating emotional response. I t would a p p e a r t h a t the physiologic components of tlhe emotional process are essential :for the physieal well-being of the young infant and lack of emotional stimulation in early life registers :its most profound effects in this sphere. L a t e r on psychic effeets become more apparent. A t 8 to 12 weeks of age, as the role of vision enlarges, the i n f a n t normally responds to a smile with a smile of his own and a show of animation. This is not the ease in infants who have spent some time in an institution. U n d e r these circumstances repeated attempts are necessary before the baby will smile. P r e s u m a b l y psychologic neglect leads to a blunting of the reactivity of the senses to emotion-producing stimuli. Still later, more serious and probably longer enduring psyehie effects take place, as the i n f a n t begins to distinguish between the individuals in his environment and to establish relationships with them. I t is difficult to explain on the basis of infection alone the prolonged %brile episodes in hospitals and the p r o m p t reduction in fever which takes place when the infants are r e t u r n e d to their homes. ~ One would h a r d l y expect t h a t the effects of long continued infection would disappear so p r o m p t l y and constantly.
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In this relation an experience with two babies who were admitted to the hospital a number of years ago for custodial care is interesting. During their first two or three months in the hospital these two babies had almost constant temperature elevations which were attributed to upper respiratory infections. Then they both seemed to make an adjustment. They remained free of fever, they gained weight, and they looked healthy and happy. At the time this happy change was attributed to the developmmlt of an immunity to ward infections. However, in retrospect, a much better explanation can be found in the fact that these two babies had become the ward favorites and, as such, they were showered with attention and affection by the nurses. Fever of psychogenic origin has been described in a number of conditions? ~ It may be a manifestation of hysteria, it may be induced by hypnosis, it may be associated with excitement and emotional tension in the absence of physical overactivity. Its occurrence in emotionally deprived infants evades explanation at this time. REMOTE EFFECTS ON PERSONALITY It iS not clear whether permanent damage to the psyche results if babies remain in an institution only during the first three or four months of life, but thereafter the personality distortion which takes place is, apparently, severe and long-lasting. The personality defects which result from prolonged residence in an institution during infancy have been described by Lowrey,2~ Bender, 2~ and Goldfarb. ~a According" to Bender ~ behavior remains infantile, the child using such babyish devices as screaming, kicking, and temper tantrums, in response to frustration. The motor activity is often senseless and poorly patterned. The children are constantly seeking" attention. Their relationships lack warmth and they readily shift their attentions from one person to another. They are unable to identify in their relationships to other people. Language development is defective and later on the defect concerns itself with conceptualization and social concepts. At all levels behavior is impulsive, diffusely unpatterned and unmodified by motivation, discipline, punishment, or insight therapy. There is an inability to e n t e r into and form normal relationships. According to Levy24 lack of normal emotional response is the outstanding personality defect in the emotionally deprived child. A NII~AI~
STUDIES
The ill-effects of isolation are by no means limited to the human infant. Throughout the animal world, from the minute microorganisms to the mammals, it seems to be a rule that there is safety in numbers. The deleterious influence of overcrowding has overshadowed appreciation of the protective action of companionship .25 Mice grow poorly when bred in solitude. Chickens raised in solitary confinement develop neurotic behavior. Colon bacilli fail to grow on agar containing gentian violet if singly inoculated on it. Only when thirty or more bacteria are used does steady and regular growth occur under these conditions. Recent
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studies have shown a similar protective action of numbers of bacteria ill their behavior toward media containing streptomycin. The devices which groups use to protect thelnselves are varied. They have been studied by Allee and his co-workers and are summarized in his book on the Social L i f e or A n i m a l s . ~ Certain flat worms (Procerodes) die p r o m p t l y when a few are placed in fresh water. W i t h larger grm'ps, however, the survival rate is much longer owing to the fact t h a t the few who die give off calcium which exerts a protective action on the group. Goldfish, placed in a silver solution, protect themselves by giving off a substance which precipitates the silver. Grouped D a p h n i a (water fleas) survive longer t h a n single ones when placed in an alkaline solution by excreting carbon dioxide which neutralizes the alkali. Some animals protect themselves in groups by reducing oxygen requirements. I n mice the protective action of numbers seems to reside principally in better maintenance of t e m p e r a t u r e and the consequent conservation of energy and growth. A n additionaI factor is t h a t mice with injuries about the head can only receive t r e a t m e n t by licking f r o m another individual. Isolated mice with such lesions are quickly cured by their nest mates when they are grouped. TREATiMENT
I n 1941, when the thesis that tile f a i h r e of babies to thrive in hospitals is due to emotional deprivation was presented before the American Pediatric Society, 2G babies were no longer d y i n g ill large numbers in institutions, as had previously been the case. The reason was t h a t most institutions h a d closed their doors and were boarding their babies out in private homes instead. The problem of institutional mortality had not been solved; it had been by-passed. The clinical picture of hospitalization, however, was still frequently seen in general hospitals when babies, for one reason or another, were retained in the wards over an extended period; and in the few remaining custodial institutions. While p r e p a r i n g this report it seemed a p p r o p r i a t e to again examine emotionally deprived infants to see whether any clinical features had been overlooked. W i t h this thought in mind I visited, together with Dr. Joseph Di Leo, a large foundling hospital which houses some 250 children, more t h a n one-half of whom are u n d e r one y e a r of age. I was unable to find a single b a b y who showed the clinical features which have come to be associated with emotional deprivation in young infants. The babies showed the motor activity and the r e a d y response to a smile which were so rarely seen in hospitalized babies only a few y e a r s ago. The principal reason for this favorable change is the large corps of women volunteers who devote the m a j o r p a r t of their time in the hospital to m a n i p u l a t i n g and playing with the babies. D u r i n g the last few years a wholesome change has taken place in the attitude toward the hospital care of infants in the direction o~ a general relaxation of the rules governing asepsis. I n most institutions nurses and interns are encouraged to pick up and c a r r y infants, and m a n y hospitals have volunteers whose principal task it is to play with the babies. This policy has been carried out actively on the Children's Medical Services at Bellevue ttos-
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pital for the past twenty years. In addition, it has been the custom to assign infants who are doing poorly or who seem u n h a p p y to p a r t i c u l a r interns f o r " t e n d e r loving c a r e . " This device has been well received in most instances and it has often proved as beneficial for the intern as for the baby. An i m p o r t a n t measure for p r e v e n t i n g hospitalism is the presenee of the mother. Where it is necessary to keep a child in the hospital for any length of time as for example, in the case of subdural hematoma, the m o t h e r is invited to remain with her baby all day, if possible, and to minister to his wants. This has worked very well. The mother, instead of being a hindrance, relieves the nurses of the eare of one patient and she ellen helps out in the care of other babies. C o n t r a r y to what might have been expected the free m a n i p u l a t i o n of babies and the presence of parents in the ward has not increased the incidence of infections among the babies. Indeed, there has been a decrease in cross-infections. Since 1930, when a,n active campaign directed toward satisfying the psychologic needs of babies in the i n f a n t ' s w a r d at Bellew~e Itospital was instituted, the ease f a t a l i t y for infants u n d e r one y e a r fell steadily ~'rom 30 to 35 per cent to less t h a n 10 per cent in 1938 where it has remained ever since. I t is interesting to note t h a t most of the fall in m o r t a l i t y had taken place before the introduction of the chemotherapeutic and antibiotic agents. Re]evant at this point is the experience at the Bassam Clinic, a surgiea] hospital in New Zealand, where it has been the custom to admit the mothers along with their babies requiring operations, e.g., harelip and cleft palate. ~7 Each mother and child is provided with a small bed-sitting room where the mother can look a f t e r her child exactly as though she were at home. She has the companionship of other mothers in neighboring rooms and she can enjoy the garden where the babies take the air in their carriages. Surgical dressings are done aseptically, generally u n d e r light anesthesia to reduce emotional shock. The mother does all the routine work for the b a b y such as feeding, dressing, changing diapers, therel-~y saving much time for the nurses. The clinic has been r u n n i n g f o r five years and d u r i n g t h a t time there has not been a single ease of cross-infection, local or general, and not a single slough or ease of dehiscence. SU~IMAP~u
1. The failure os infants to thrive in institutions is due to emotional deprivation. 2. I n young infants emotional reactions arise principally, if not entirely, in response to sensory stimuli. These stimuli set in motion processes t h a t ap-, pear to be essential for the child's well-being. 3. To offset the adverse effects of residence in an institution, babies who require hospital care should receive manipulation, attention a n d affection. W h e n e v e r possible, tile mother should be at the b a b y ' s bedside during the greater p a r t of the day. 4. There is no reason to believe t h a t more handling of the b a b y and the presence of the mother inerea.se the incidence of infections; indeed, the evidence would indicate the reverse,
I',RYC,I[OLO(II() ASI'ECTS OF I'EI)IATI~IC..%
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R EFJ2;I~EN (~'ld~ L Chapin~ H. D.: A -Plea for A(;eurate Statistics in i n f a n t s ' InstRations, Tr. Anl. Pediat. Sot. 27: 180, 1915, 2. HamJ]~ ~ . : ]Discussion of paper by Chapin. 1 3. S o a t h w o r t h , T. S.: Diseussion of paper by Chapin.[ 4. Knox, J. H . M . : Discussion of paper by 0hapin.~ 5. Bakwin, H.: Psychogenic J~'ever ia I n f a n t s , Am. J. Dis. Chihl. 67: 176, 21944. 6. Parrot, M.: Quoted by Czerny.7 7. Czerny, A.: Der A r t z t als Erzieher des Iiindes, ed. 6, Leipzig, 1922, ]~'ranz Deutieke, p. 5. 8. Kaupe, W.: tIospitalismus der in Sguglingsheimen nntergebraehten I(indern, IvIiinehen reed. Wehnsehr., No. 8, 1920. 9. Pfaundler, N . : Ueber nat~irliehe und neber rationelle Siiuglingspflege, Vortrag ]909, Sonderabdruck, a.d. Siiddeutschen IVlonutsheften. 10. Birk, W.: Ueber den Einfluss psyehiseher Vorg~inge au~f den Erniihrungserfolg bei S~.uglingen, Mionatssehr. f. Kinderheilk. 12: (Orig.), 1, 1919. 11. Feer, E.: Die Ern~hrungsstLrungen im Si~tlglingsalter und ihre Behandlung, Beihefte z. med. ;Klinik 1: 25, 1909. 12. Brennemann, J.: The I n f a n t Ward, Am. J. Dis. Child. 43: 577, 1932. 13. Talbot, IP.: Transactions of the A m e r i c a n P e d i a t r i c Society, 1941, discussion of paper b y Bakwln,2~ Am. J. ;Dis. Child. 62: 469, ]941. 14. Durfee, H., and Wolf, K.: Anstaltspflege und Entwick[ung im ersteit Lebensjahr, Ztschr. f. Kinderforseh. 42: ]933. 15. Spitz, R. A.: Hospitalism, an Inquiry Into the Genesis of Psyehiatrie Conditions in /Early Childhood. ~'tae Psy(~hoa~ "lyric Study of ~he Ctdld, A Year Book, New York, 1945, N. Y . International Pre~s. 10. Rapaport~ :D.: Emotions and l-Vfemory, Baltimore, ]942, Williams & Wilkins Co, Chap. 2. 17. Spitz, 1~.: Emotional Growtk in the ~'irst Year, Child Study~ Spring, 1947. 18. Carmiehael, L.: Manual of Child Psychology, New York, 1946, John Wiley & Sons, Inc., pp. 203-226. 19. Gesell, A., and Ilg, F. L.: The Infan~ and Child in the Culture of Today, New York, 1943, t t a r p e r & Brothers, p. 19. 20. Wolf, S., and Wolff, H. G.: I n t e r m i t t e n t ~'ever of Unknown 0rigin~ Arch. Int. iged. 70: 293, 1942. 21. Lowrey, L. G.: Personality Distortion in Early [nstltutionaI Care, Am. J. Orthopsyehiat. 10: 576~ 1940. 22. Bender, L.: There Is No Substitute for :~amily IAfe, Child Study, Spring~ 1946. 23. Goldfarb, W.: a. I n f a n t Rearing and Problem Behavior, Am. J. Orthopsyehiat. 13: 2, 1943. b. Effects of E a r l y I n s t i t u t i o n a l Care on Adolescent P e r s o n a l i t y : Rorsehaeh Dat% Ibid. 14: 441, 1944. 24. Levy, D . M . : Primary Affect tIunger, Am. J. Psychiat. 94: 643, 1937. 25. Allee, W . C . : The Social Life of Animals, New York, 1938, W. W. Norton & Co., Inc. 26. Bakwin, Ill.: Loneliness in Infants, Am. J. 1)is. Child. 63: 33, 1942. 27. Pickerill, C.: Nursing Mirror, Aug. 16~ 1947, Supplement II, quoted by Lancet 2: 588, 1947.
iN INFANTS
H:~RuY BA~WlN, M.D. N~;w YORK, N . Y. N T I L the early years of this century, when it was the custom to keep homeless infants in institutions for custodial care, the babies quickly withered and died. W h e t h e r all perished or only most of them depended principally on one f a c t o r : the duration of their stay ill the institution. The high institutional m o r t a l i t y of infants was discussed at the annual meeting of the American Pediatric Society in 1915. Dr. t t e n r y Chapin ~ reported on ten infant a s y h m s located in different cities of the United States. I n all but one institution every i n f a n t u n d e r 2 years of age died. t I a m i V of Philadelphia, in discussing C h a p i n ' s paper, said ironically: " I had the honor to be connected with an institution in this city in which the m o r t a l i t y among all the infants u n d e r one y e a r of age, when admitted to the institution and retained there for any length of time, was 100 p e r cent. T h a t is, no i n f a n t admitted u n d e r one y e a r of age lived to be two years old." Southworth, 3 speaking for conditions in New York City, said: " I can give an instance f r o m an institution t h a t no longer exists in which, on account of the v e r y considerable m o r t a l i t y among' the infants admitted, it was customary to enter the condition of every infant on the admission card as hopeless. T h a t covered all subsequent h a p p e n i n g s . " K n o x ~ described a study which he had made in Baltimore. H e followed 200 infants admitted to various institutions in the city. Of these almost 90 per cent died within a year. The 10 per cent that lived, he said, did so, apparently, because, for some reason or other, the babies were taken f r o m the institutions for short times and given into the care of foster p a r e n t s or relatives.
U
SYN/PTOMATOLOG Y
I n f a n t s u n d e r 6 months of age who have been in an institution f o r some time present a well-defined picture. The outstanding features are listlessness, emaciation and pallor, relative immobility, quietness, unresponsiveness to stimuli like a smile or a coo, indifferent appetite, failure to gain weight p r o p e r l y despite the ingestion of diets which, in the home, are entirely adequate, frequent stools, poor sleep, an appearance of unhappiness, proneness to febrile episodes, absence of sucking Habits. The hospitalized infant is thin and pale but the pallor is not always associated with a reduction in the hemoglobin. The facial expression is u n h a p p y and gives all impression of misery. Muscle tone is poor and it is possible to extend the legs fully at the knees, contrasting in this way with normal young infants. There is no alteration in the deep reflexes. The i n f a n t shows no inF r o m the D e p a r t m e n t of Pediatrics, College of IVIedieine, New Y ork U n i v e r s i t y - - B e l I e v u e Medical Center. 512,
I'SYCIlOI~()GIC
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[)1',~
terest in his environment, lying quietly in bed, rarely crying and moving very little. Such movements as he makes are slow and deliberate, unlike the quick movements one expects at this age. E v e n respiration seems quieter t h a n in normal infants. rl?he appetite is indifferent a.nd food is accepted without eagerness or interest. The weight m a y be stationary; there m a y be loss or slow gain. The amount of food necessary to effect a weight gain is much greater than in the home. Nevertheless growth in height continues at a rate only slightly less than average. The stools are :frequent and, in s h a r p contr'ast to the situation in the home, it is unusual for twenty-four hours to pass without an evacuation. Normal infants at 2 to 3 months of age smile and become animated in response to the smile or cooing voice of an attentive adult. Not so the baby who has been ~n a hospital for a n y length of time. Here it is difficult to elicit a smile in this way and repeated efforts are necessary. Sleep is light and :fitful even at 3 and 4 months, resembling t h a t of babies during the early weeks of life. Sucking habits are uncommon. T e m p e r a t u r e elevations, sometimes associated with mild respiratory infections, ofttimes without demonstrable cause, are frequent. We have observed babies who developed fever while in the hospital which persisted for months. We reported five infants in whom fever lasted f o r f r o m three to eight months. ~ The cause of the fever was investigated with every available laboratory test but nothing was found except an occasional red throat or running ear, infections which in the home last only a day or two. There was no response to chemotherapy. I n all instances the t e m p e r a t u r e fell to normal when the infants were iliseharged f r o m the hospital and it remained normal thereafter. In severe eases the symptoms are intensified and the baby assumes the appearance of a wizened, toothless old man. The cheeks are sunken, although in some instances the sucking pads in the cheeks remain; the skin is loose and somewhat inelastic; the whitish pallor is striking and the general impression is one of great weakness and frailness. The respirations are slow and superficial and often sighing. PREI)ISPOSING ]0'AC~I?ORS The duration of hospital stay preceding ihe appearance of symptoms varie~ considerably, some e;hildren showing definite changes within a few days after e n t r y to the hospital, others r e m a i n i n g f o r weeks without becoming' ill. Age is an i m p o r t a n t factor. We have never seen the clinical manifestations of emotional deprivation during the first two weeks of life which was the usual duration of the stay for mothers and babies in obstetrical hospitals before the war. Though most babies who are born in hospitals receive very little m a n i p u l a t i o n d u r i n g this time they a p p e a r vigorous, they have lusty cries and good color, and they gain well. However, if a newborn baby remains in the hospital, for one reason or another, a f t e r the first inonth he generally shows symptoms of hospitalism. As a :rule, i)rematurely born infants, especially the small ones, are una:ffeeted by the rigid isolation practiced in the modern p r e m a t u r e unit. Only
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T I I F JOURNAI~ OF PEDIATRICS
when they remain in the hospital for a long time and have outgrown their prem a t u r i t y do they show the physiea.1 and behavioral manifestations generally associated with emotional deprivation. A possible predisposing factor is the nature of the illness f o r which the child enters the hospital. I t has seemed to us that children with diarrhea are more susceptible than others, possibly because this is a rather prolonged illness and one which, in itself, interferes severely with the baby's nutrition. Another factor may be the amount of emotional satisfaction which the child had received before entry to the hospital. A certain n u m b e r of babies, reared in the home, show the pallor, the quietness, and the motor retardation which are associated with emotional deprivation. Such babies are likely to be left to themselves in the hospital while the attractive, animated ones receive the affectionate attention and interest of the hospital personnel. Infants with gross cerebral damage are not affected by emotional deprivation. ()f the several hundreds of such infants who have been admitted to Bellevue Hospital in the course of years we do not recall having seen a single one who showed the clinical picture described above. Instead, they sometimes develop hyperpyrexia and die within a few days after entering a hospital. This may take place in infailts who at first appear to be in excellent nutritional condition. At home they have been cared for by attentive mothers who rome to understand their peculiar behavior and who eater to them. In the hospital the nurses find the mannerisms of these children strange and unpredictable and unattractive. Feeding is especially difficult and consequently the food and especially the :fluid intake is inadequate. In addition t h e y may contract infections. Presumably tile h y p e r p y r e x i a is a result of dehydration, infection, and a cerebral element ("cerebral f e v e r " ) . The absence of symptoms in p r e m a t u r e l y born infants, in newborn infants, and in infants with severe cerebral damage suggests that, though the clinical manifestations of this condition in early infancy are principally physical, a certain amount of conscious cerebral functioning is necessary in order for inj u r y to register itself. Certain physical consideraUons may contribute to t h e speed with which babies deteriorate in hospitals. They are Lmable to indicate satisfactorily when they are h u n g r y and when they have had too much, and it is h a r d l y possible for the nurses to understand the idiosyneraeies of the individual infant on short acquaintance. ~Ioreover, the prevalent custom of prescribing food in hospitals laeks the flexibility which is possible in the home. Rigid orders for :feeding are given and there is no meehanism in most hospitals whereby the infant can have more of his formula at one feeding when he is h u n g r y and not so much at another when he is satisfied with less. Food refused at one feeding' cannot be made up at another. Tile rapidity with which the symptoms of hospitalism begin to disappear when an afflicted baby is placed in a good home is amazing. I t :is convineing evidence of the etiologic relation of the emotionally arid atlnosphere of the hospital to the symptoms. The baby promptly becomes more animated and
PSYCHOLOGIC ASPECTS
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responsive; fever, if present in the hospital, disappears in t w e n t y - f o u r to seventy-two hours; there is a gain in weight and an i m p r o v e m e n t in the color. A striking example was that of A.S., a boy 4 months old, who had been in the hospital f o r eight weeks because of diarrhea. The diarrhea ceased soon a f t e r e n t r y but the child continued a downhill course despite all therapeutic efforts. A t 4 months of age he weighed less than at birth and his condition was critical. His a p p e a r a n c e was that of a pale, wrinkled old man. His breathing was so weak and superficial that it seemed as though he might stop breathing at any moment. W h e n seen t w e n t y - f o u r hours a f t e r he had been at home he was cooing and smiling. Though no change had been made in his diet he started to gain p r o m p t l y and by the end of the first y e a r his weight was well withiil the normal range. H e a p p e a r e d to be in every w a y a normal child. ETIOLOGY OF HOSPITALIS~I The failure of babies to thrive in hospitals, referred to as " h o s p i t a l i s m , " has been a m a t t e r of concern and speculation to the physician since babies were first confined in institutions. F o r a long time the condition was considered to be due to poor nutrition and deaths were usually attributed to m a l n u t r i t i o n or marasmus. However, when application of the newer knowledge of nutrition failed to solve the problem of hospitalism, interest shifted to infection as the cause of the difficulty and obscure deaths in hospitals were generally listed as due to nasopharyngitis and its complications. To g u a r d against cross-infections isolation methods were intensified. The wards for infants were partitioned off into separate little cubicles ~%r each baby, and nurses and physicians were expected to scrub their hands and to wear gowns and masks before handling the babies. P a r e n t s were rigidly excluded except for one or two visiting hours each week. Elaborate and expensive boxes were devised, mechanically controlled, in which the babies could be cared f o r almost untouched by h u m a n hands. Manipulation of the babies was discouraged since handling increases the o p p o r t u n i t y f o r bacterial exchange. F o r m a n y years thoughtful pediatricians have suspected that the basis for hospitalism was in some vague way related to the i n f a n t ' s psyche. Parrot, ~ who was associated with several foundling institutions ~n France, concluded that hospitalism was due to lack of adequate stimulation. Czerny, 7 felt t h a t monotony and staring at blank walls and ceilings were i m p o r t a n t factors. K a u p e 8 emphasized the role of the mothers who could not be replaced by the: most selfsacrificing nurses. The psychic and physical influence of the mother, he stated, was a v e r y i m p o r t a n t weapon against hospitalism. A similar viewpoint was expressed by P f a u n d l e r 9 who observed t h a t when the mother or some sympathetic person took over the care of the child, severe damage did not take place. E v e n when m a n y infants were crowded together without special attention to asepsis, t h a t is, u n d e r unfavorable environmental conditions, if they were taken care of by their mothers (as was the case in certain foundling institutes in Austria and F r a n c e ) , then hospitalism did not; play nearly so la,'ge a part. Birk a' held t h a t individual care, which represents a sort of psychic contact between child and nurse, is essential :for some infants, and Feer L~ believed that
516
TkIE J O U R N A I ~ OF }'EDIATIgICS
lack oil psychic stimulation exercises a, h a r m f u l effect on the vegetative functions. Brennemann, 1~ recognizing the effect of absence o~ mothering, had a rule in his hospital that every baby should be picked up, carried around, amused and " m o t h e r ' e d " several times a day. A n illuminating experience is related by l)r. F r i t z Talbot ~3 of Boston. I ) u r i n g a visit to the Children's Clinic in l)iisseldorf some f o r t y years ago Talbot noticed a very fat old lady wandering about the ward with a very measly baby on her hip. H e asked Schlossmann, the Director, who she was and he was told that, whenever they h a d a baby for whom they had done everything medically and were unsuccessful, they tm'ned the baby over to old A n n a and told her to take charge. Old A n n a was always successful. Great credit is due to Dr. H e n r y Dwigi~t Chapin ~ of New Yor'k who was responsible for introducing into America the system of boarding out babies in homes instead of leaving' t h e m in institutions. I I e was keenly aware of the need of babies for individual care and affection. Some objective evidence of the deleterious effects of institutions on the i n f a n t ' s psyche was presented by Durfee and W o l f in ~933. ~4 Using B u e h l e r ' s tests, they compared the developmental quotients (D.Q.) of infants in various institutions and correlated their findings with the amount of m a t e r n a l care which the infants received. They found t h a t the groups of infants who had the advantage of m a t e r n a l care were suI)erior to those who did not, despite the fact that several of the institutions which restricted m a t e r n a l attention were better eqnipped and staffed t h a n the others. The observations of Durfee and Wolf have been confirmed and extended by the carefully controlled studies of Spitz. ~ PATHOGENESIS The way in which emotional deprivation registers its effects on the child is largely speculative but certain rationalizations seem justifiable. According to Rapa.port, ~G the emotional process m a y be initiated in two ways. I t m a y be evoked by an incoming percept f r o m the outside or it m a y originate f r o m within as, for example, when one gets excited by a novel idea, planning a trip, an anxiety. The stimulus, whether external or internal, initiates an unconscious process which mobilizes unconscious instinctual energies. The discharge process has two components, one which is physiologic and behavioral, the "emotional expression"; the other which is psychologic, the " e m o t i o n f e l t . " These m a y occur simnltaneously or they m a y succeed one another or either m a y occur alone. Since young babies obviously lack the mental power to initiate emotionproducing situations, they are entirely dependent on their sensations in this respect. F o r the same reason the component " e m o t i o n f e l t " is a m i n o r element in the emotional process as compared with " e m o t i o n a l expression." The physL ologic and behavioral responses (ff the young babies to emotion-producing' stimuli are not unlike lhose observed at later ages. Looked a.t from lhe very reason-
I)SYCIIOI,O(II(?
ANPE(YI?,~, OF
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517
~d)le viewpoint pcesel~l;ed hy l?,apapoe(,, tim q(tes(.io,~ a.s to whether the emotional responses of the newborn in t!ant can be designated as " f e a r , " " r a g e , " ete., loses much of its point and the same is true for discussions regarding the ability of newborn infants to feel pleasure. 17 I n a certain sense young infants m a y be expected to show p u r e r emotional responses than later on since the p a t h w a y s for instinctual behavior at this early age are probably wide open and not modified or blocked by cultural conflicts. The senses--sight, hearing and equilibrium, taste, smell, the skin senses, the muscle senses, the internal s e n s a t i o n s - - a r e all functionally active at or shortly a f t e r birth. ~a F o r vision to be m e a n i n g f u l a certain amount of experience is necessary. Moreover, looking is an active process requiring a degree of motor eontrol of the eye and head museles which is attained only a f t e r several months. I t is not until 4 weeks of age that the baby has progressed to the point where he will regard a dangling' ring. ~9 Only later, at 2 or 3 months of age does he begin to respond to a smiling :face. This is not true, nearly to the same extent, of the other sensations. The newborn i n f a n t shows discriminating behavior toward sounds. He is disagreeably affected by a loud, a b r u p t noise and he seems pleased by a cooing voice. Sucking seems to give pleasure. Most imp o r t a n t to the young baby a p p e a r to be the skin sensations and the kinesthetic sense. Babies are readily soothed by p a t t i n g and by w a r m t h and they cry in response to p a i n f u l stiInuli and to cold. The quieting effect of keeping babies outdoors m a y well be due, in part, to the movement of air on the skin. T h a t the kinesthetie sense is m e a n i n g f u l is indicated by the soothing effect of rocking a n d the disagreeable effeet of a b r u p t change in position. I n f a n t s kept in hospitals are, as a rule, m a n i p u l a t e d as little as possible. There are two reasons for this: inadequaey of personnel and the fear of transmitting infections. I n general the more carefully run hospitals observe stricter "isolation t e c h n i q u e " than do others. As a result the infants receive a minim u m of sensory stimulation which is their only channel for initiating emotional response. I t would a p p e a r t h a t the physiologic components of tlhe emotional process are essential :for the physieal well-being of the young infant and lack of emotional stimulation in early life registers :its most profound effects in this sphere. L a t e r on psychic effeets become more apparent. A t 8 to 12 weeks of age, as the role of vision enlarges, the i n f a n t normally responds to a smile with a smile of his own and a show of animation. This is not the ease in infants who have spent some time in an institution. U n d e r these circumstances repeated attempts are necessary before the baby will smile. P r e s u m a b l y psychologic neglect leads to a blunting of the reactivity of the senses to emotion-producing stimuli. Still later, more serious and probably longer enduring psyehie effects take place, as the i n f a n t begins to distinguish between the individuals in his environment and to establish relationships with them. I t is difficult to explain on the basis of infection alone the prolonged %brile episodes in hospitals and the p r o m p t reduction in fever which takes place when the infants are r e t u r n e d to their homes. ~ One would h a r d l y expect t h a t the effects of long continued infection would disappear so p r o m p t l y and constantly.
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THE
JOURNAIj
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In this relation an experience with two babies who were admitted to the hospital a number of years ago for custodial care is interesting. During their first two or three months in the hospital these two babies had almost constant temperature elevations which were attributed to upper respiratory infections. Then they both seemed to make an adjustment. They remained free of fever, they gained weight, and they looked healthy and happy. At the time this happy change was attributed to the developmmlt of an immunity to ward infections. However, in retrospect, a much better explanation can be found in the fact that these two babies had become the ward favorites and, as such, they were showered with attention and affection by the nurses. Fever of psychogenic origin has been described in a number of conditions? ~ It may be a manifestation of hysteria, it may be induced by hypnosis, it may be associated with excitement and emotional tension in the absence of physical overactivity. Its occurrence in emotionally deprived infants evades explanation at this time. REMOTE EFFECTS ON PERSONALITY It iS not clear whether permanent damage to the psyche results if babies remain in an institution only during the first three or four months of life, but thereafter the personality distortion which takes place is, apparently, severe and long-lasting. The personality defects which result from prolonged residence in an institution during infancy have been described by Lowrey,2~ Bender, 2~ and Goldfarb. ~a According" to Bender ~ behavior remains infantile, the child using such babyish devices as screaming, kicking, and temper tantrums, in response to frustration. The motor activity is often senseless and poorly patterned. The children are constantly seeking" attention. Their relationships lack warmth and they readily shift their attentions from one person to another. They are unable to identify in their relationships to other people. Language development is defective and later on the defect concerns itself with conceptualization and social concepts. At all levels behavior is impulsive, diffusely unpatterned and unmodified by motivation, discipline, punishment, or insight therapy. There is an inability to e n t e r into and form normal relationships. According to Levy24 lack of normal emotional response is the outstanding personality defect in the emotionally deprived child. A NII~AI~
STUDIES
The ill-effects of isolation are by no means limited to the human infant. Throughout the animal world, from the minute microorganisms to the mammals, it seems to be a rule that there is safety in numbers. The deleterious influence of overcrowding has overshadowed appreciation of the protective action of companionship .25 Mice grow poorly when bred in solitude. Chickens raised in solitary confinement develop neurotic behavior. Colon bacilli fail to grow on agar containing gentian violet if singly inoculated on it. Only when thirty or more bacteria are used does steady and regular growth occur under these conditions. Recent
P S Y C H O L O G I C A S P E C T S OF P E D I A T R I C S
519
studies have shown a similar protective action of numbers of bacteria ill their behavior toward media containing streptomycin. The devices which groups use to protect thelnselves are varied. They have been studied by Allee and his co-workers and are summarized in his book on the Social L i f e or A n i m a l s . ~ Certain flat worms (Procerodes) die p r o m p t l y when a few are placed in fresh water. W i t h larger grm'ps, however, the survival rate is much longer owing to the fact t h a t the few who die give off calcium which exerts a protective action on the group. Goldfish, placed in a silver solution, protect themselves by giving off a substance which precipitates the silver. Grouped D a p h n i a (water fleas) survive longer t h a n single ones when placed in an alkaline solution by excreting carbon dioxide which neutralizes the alkali. Some animals protect themselves in groups by reducing oxygen requirements. I n mice the protective action of numbers seems to reside principally in better maintenance of t e m p e r a t u r e and the consequent conservation of energy and growth. A n additionaI factor is t h a t mice with injuries about the head can only receive t r e a t m e n t by licking f r o m another individual. Isolated mice with such lesions are quickly cured by their nest mates when they are grouped. TREATiMENT
I n 1941, when the thesis that tile f a i h r e of babies to thrive in hospitals is due to emotional deprivation was presented before the American Pediatric Society, 2G babies were no longer d y i n g ill large numbers in institutions, as had previously been the case. The reason was t h a t most institutions h a d closed their doors and were boarding their babies out in private homes instead. The problem of institutional mortality had not been solved; it had been by-passed. The clinical picture of hospitalization, however, was still frequently seen in general hospitals when babies, for one reason or another, were retained in the wards over an extended period; and in the few remaining custodial institutions. While p r e p a r i n g this report it seemed a p p r o p r i a t e to again examine emotionally deprived infants to see whether any clinical features had been overlooked. W i t h this thought in mind I visited, together with Dr. Joseph Di Leo, a large foundling hospital which houses some 250 children, more t h a n one-half of whom are u n d e r one y e a r of age. I was unable to find a single b a b y who showed the clinical features which have come to be associated with emotional deprivation in young infants. The babies showed the motor activity and the r e a d y response to a smile which were so rarely seen in hospitalized babies only a few y e a r s ago. The principal reason for this favorable change is the large corps of women volunteers who devote the m a j o r p a r t of their time in the hospital to m a n i p u l a t i n g and playing with the babies. D u r i n g the last few years a wholesome change has taken place in the attitude toward the hospital care of infants in the direction o~ a general relaxation of the rules governing asepsis. I n most institutions nurses and interns are encouraged to pick up and c a r r y infants, and m a n y hospitals have volunteers whose principal task it is to play with the babies. This policy has been carried out actively on the Children's Medical Services at Bellevue ttos-
D~0
!I?tlE ,IOURN AL OF I't~;1)IATRIC8
pital for the past twenty years. In addition, it has been the custom to assign infants who are doing poorly or who seem u n h a p p y to p a r t i c u l a r interns f o r " t e n d e r loving c a r e . " This device has been well received in most instances and it has often proved as beneficial for the intern as for the baby. An i m p o r t a n t measure for p r e v e n t i n g hospitalism is the presenee of the mother. Where it is necessary to keep a child in the hospital for any length of time as for example, in the case of subdural hematoma, the m o t h e r is invited to remain with her baby all day, if possible, and to minister to his wants. This has worked very well. The mother, instead of being a hindrance, relieves the nurses of the eare of one patient and she ellen helps out in the care of other babies. C o n t r a r y to what might have been expected the free m a n i p u l a t i o n of babies and the presence of parents in the ward has not increased the incidence of infections among the babies. Indeed, there has been a decrease in cross-infections. Since 1930, when a,n active campaign directed toward satisfying the psychologic needs of babies in the i n f a n t ' s w a r d at Bellew~e Itospital was instituted, the ease f a t a l i t y for infants u n d e r one y e a r fell steadily ~'rom 30 to 35 per cent to less t h a n 10 per cent in 1938 where it has remained ever since. I t is interesting to note t h a t most of the fall in m o r t a l i t y had taken place before the introduction of the chemotherapeutic and antibiotic agents. Re]evant at this point is the experience at the Bassam Clinic, a surgiea] hospital in New Zealand, where it has been the custom to admit the mothers along with their babies requiring operations, e.g., harelip and cleft palate. ~7 Each mother and child is provided with a small bed-sitting room where the mother can look a f t e r her child exactly as though she were at home. She has the companionship of other mothers in neighboring rooms and she can enjoy the garden where the babies take the air in their carriages. Surgical dressings are done aseptically, generally u n d e r light anesthesia to reduce emotional shock. The mother does all the routine work for the b a b y such as feeding, dressing, changing diapers, therel-~y saving much time for the nurses. The clinic has been r u n n i n g f o r five years and d u r i n g t h a t time there has not been a single ease of cross-infection, local or general, and not a single slough or ease of dehiscence. SU~IMAP~u
1. The failure os infants to thrive in institutions is due to emotional deprivation. 2. I n young infants emotional reactions arise principally, if not entirely, in response to sensory stimuli. These stimuli set in motion processes t h a t ap-, pear to be essential for the child's well-being. 3. To offset the adverse effects of residence in an institution, babies who require hospital care should receive manipulation, attention a n d affection. W h e n e v e r possible, tile mother should be at the b a b y ' s bedside during the greater p a r t of the day. 4. There is no reason to believe t h a t more handling of the b a b y and the presence of the mother inerea.se the incidence of infections; indeed, the evidence would indicate the reverse,
I',RYC,I[OLO(II() ASI'ECTS OF I'EI)IATI~IC..%
7)~1
R EFJ2;I~EN (~'ld~ L Chapin~ H. D.: A -Plea for A(;eurate Statistics in i n f a n t s ' InstRations, Tr. Anl. Pediat. Sot. 27: 180, 1915, 2. HamJ]~ ~ . : ]Discussion of paper by Chapin. 1 3. S o a t h w o r t h , T. S.: Diseussion of paper by Chapin.[ 4. Knox, J. H . M . : Discussion of paper by 0hapin.~ 5. Bakwin, H.: Psychogenic J~'ever ia I n f a n t s , Am. J. Dis. Chihl. 67: 176, 21944. 6. Parrot, M.: Quoted by Czerny.7 7. Czerny, A.: Der A r t z t als Erzieher des Iiindes, ed. 6, Leipzig, 1922, ]~'ranz Deutieke, p. 5. 8. Kaupe, W.: tIospitalismus der in Sguglingsheimen nntergebraehten I(indern, IvIiinehen reed. Wehnsehr., No. 8, 1920. 9. Pfaundler, N . : Ueber nat~irliehe und neber rationelle Siiuglingspflege, Vortrag ]909, Sonderabdruck, a.d. Siiddeutschen IVlonutsheften. 10. Birk, W.: Ueber den Einfluss psyehiseher Vorg~inge au~f den Erniihrungserfolg bei S~.uglingen, Mionatssehr. f. Kinderheilk. 12: (Orig.), 1, 1919. 11. Feer, E.: Die Ern~hrungsstLrungen im Si~tlglingsalter und ihre Behandlung, Beihefte z. med. ;Klinik 1: 25, 1909. 12. Brennemann, J.: The I n f a n t Ward, Am. J. Dis. Child. 43: 577, 1932. 13. Talbot, IP.: Transactions of the A m e r i c a n P e d i a t r i c Society, 1941, discussion of paper b y Bakwln,2~ Am. J. ;Dis. Child. 62: 469, ]941. 14. Durfee, H., and Wolf, K.: Anstaltspflege und Entwick[ung im ersteit Lebensjahr, Ztschr. f. Kinderforseh. 42: ]933. 15. Spitz, R. A.: Hospitalism, an Inquiry Into the Genesis of Psyehiatrie Conditions in /Early Childhood. ~'tae Psy(~hoa~ "lyric Study of ~he Ctdld, A Year Book, New York, 1945, N. Y . International Pre~s. 10. Rapaport~ :D.: Emotions and l-Vfemory, Baltimore, ]942, Williams & Wilkins Co, Chap. 2. 17. Spitz, 1~.: Emotional Growtk in the ~'irst Year, Child Study~ Spring, 1947. 18. Carmiehael, L.: Manual of Child Psychology, New York, 1946, John Wiley & Sons, Inc., pp. 203-226. 19. Gesell, A., and Ilg, F. L.: The Infan~ and Child in the Culture of Today, New York, 1943, t t a r p e r & Brothers, p. 19. 20. Wolf, S., and Wolff, H. G.: I n t e r m i t t e n t ~'ever of Unknown 0rigin~ Arch. Int. iged. 70: 293, 1942. 21. Lowrey, L. G.: Personality Distortion in Early [nstltutionaI Care, Am. J. Orthopsyehiat. 10: 576~ 1940. 22. Bender, L.: There Is No Substitute for :~amily IAfe, Child Study, Spring~ 1946. 23. Goldfarb, W.: a. I n f a n t Rearing and Problem Behavior, Am. J. Orthopsyehiat. 13: 2, 1943. b. Effects of E a r l y I n s t i t u t i o n a l Care on Adolescent P e r s o n a l i t y : Rorsehaeh Dat% Ibid. 14: 441, 1944. 24. Levy, D . M . : Primary Affect tIunger, Am. J. Psychiat. 94: 643, 1937. 25. Allee, W . C . : The Social Life of Animals, New York, 1938, W. W. Norton & Co., Inc. 26. Bakwin, Ill.: Loneliness in Infants, Am. J. 1)is. Child. 63: 33, 1942. 27. Pickerill, C.: Nursing Mirror, Aug. 16~ 1947, Supplement II, quoted by Lancet 2: 588, 1947.