Hospitalism came first, before autism. Studies of the former during the 1930s made it possible to see the latter in the decades that followed. Hospitalism ultimately became shorthand for the harm that long-term institutional care did to children. The people who documented that harm helped to forge a new consensus about human development. Particular emotional attachments early in life were critical to making children normal.
In orphanages and infant asylums, hospital-like institutions that gave hospitalism its name, researchers and clinicians observed a host of autistic-like behaviors in young children, from listlessness and indifference to wasting and rocking. These dangers, often revealed in the earliest weeks and months of life, were unrelated to poor sanitation, malnutrition, or epidemic disease, menaces clearly linked to high rates of infant and child mortality. Children suffering from hospitalism could be well nourished, clean, and free from infection. They might even have access to the most advanced technologies available in neonatal and pediatric hospital care. Yet they displayed disturbing signs. Hospitalism encouraged researchers to interpret development as an uneven process that combined normal and abnormal. That made it possible for infants with healthy bodies to face significant cognitive risks and inspired the earliest sustained attention to emotional development in infancy. Hospitalism made conditions like autism and developmental disability imaginable.
Hospitalism was not new in the twentieth century. Suspicions that hospital buildings might actually spread rather than contain or cure disease date to late eighteenth-century Europe and many nineteenth-century health reformers constructed buildings they hoped would minimize or eliminate early versions of “sick building syndrome.” By 1900, however, hospitalism had shifted attention from the spatial design of hospitals to their social organization. In 1897, pediatrician Floyd Crandall described hospitalism as “a very definite and grave condition,” “more deadly than pneumonia or diphtheria.” Hospitalism caused babies in modern and comfortable institutional surroundings to pine away. During the first three decades of the twentieth century, the term remained in constant use. Other terms were also used: “affect hunger,” “anaclitic depression,” “failure to thrive.” “Loneliness in infants” was the most poignantly descriptive phrase of all.
Photos of children before and after institutional residence were often used by reformers and researchers as evidence of hospitalism’s harm. These pictures were published in a 1942 article by Bellevue Hospital’s Harry Bakwin titled “Loneliness in Infants.” Drawn from an article originally published by physician Henry Dwight Chapin in 1908, they illustrated how much weight and happiness this child had gained after just four months in a home environment.
Influential studies of hospitalism were conducted by David Levy, William Goldfarb, Margaret Ribble, and René Spitz, along with other psychologists and physicians. Some of the earliest investigations were conducted in the 1920s and 1930s by Jewish child welfare organizations in New York. They found that institutionalized children lacked the drive to grow seen in normal children, along with the “degree of contact with or relatedness to the external world.” This led to the alarming conclusion that institutional residence itself caused “generalized retardation and impoverishment in all aspects of personality.” Worst of all was that the damage could be permanent, even after children were removed from institutions. Research on hospitalism was embraced by reformers who, beginning in the late nineteenth-century, set out to dismantle institutional child care and champion family homes as the only environments conducive to healthy development. After 1945, the hospitalism literature strengthened a psychoanalytically-inflected developmental paradigm focused on the significance of attachment and loss (or “deprivation”) early in life.
David Levy was a pioneering orthopsychiatrist (a branch of psychiatry geared simultaneously toward prevention and childhood) at the New York Institute for Child Guidance in the late 1920s and early 1930s. His description of “primary affect hunger” was based on four children whose “emotional hunger for maternal love” had gone unsatisfied early in life, leaving them solitary, sometimes cruelly oblivious to others’ feelings, and disconnected from their human surroundings. All four subjects were adopted between the ages of two and nine and displayed outcomes ranging from severe pathology to milder, more treatable conditions. His study led Levy to ask, “Is it possible that there results a deficiency disease of the emotional life, comparable to a deficiency of vital nutritional elements within the developing organism?”
The comparison between fuel for the body and fuel for the personality was significant. Levy’s use of the word hunger made explicit the analogical thinking that helped hospitalism (and developmental risk generally) gain legitimacy. If inadequate emotional inputs could compromise human development as surely as inadequate food stunted bodily growth, then hospitalism might be as serious as starvation and love as essential as calories and cleanliness.
Of all the hospitalism researchers who energized the idea that mother love was indispensable to normal development, few were better known in the United States than René Spitz. An émigré psychiatrist and psychoanalyst at Mount Sinai Hospital in the early 1940s, Spitz used moving pictures to document infants damaged by hospitalism. One film showed babies, some expressionless, others crying inconsolably, still others displaying peculiar body and hand movements. The film’s tragic lesson was delivered bluntly: “It is the emotional climate created by the mother which enables the child’s mind to develop normally. Where this emotional climate is lacking the baby’s mind cannot develop properly. If it grows up it may become mentally impaired, asocial, criminal or insane.”
This image from Spitz’s 1952 film, “Psychogenic Diseases in Infancy,” illustrated the emotional damage caused by institutional care, which deprived infants and toddlers of their mothers.
This 9-month-old, also featured in Spitz’s 1952 film, was deprived of its mother for six months.
The drama of Spitz’s message masked the methodological weaknesses of his research. A study published in 1945, for instance, compared 164 children under the age of one in two institutions. Spitz never identified where or when his studies took place. He simply called one location “Nursery” and the other “Foundling Home.” According to Spitz, both offered comparable material conditions: good hygiene, decent food, warm temperatures, clean clothing, and adequate medical care.
Spitz tested infants before they reached four months of age and again between the ages of eight and twelve months, revealing that the unlucky babies who lived in Foundling Home showed all the telltale symptoms of hospitalism. Spitz coined the term “anaclitic depression” to describe what he saw: eczema, eating disorders, disproportionate vulnerability to epidemic disease and, in older children, significantly del ayed walking, talking, and toileting. This is what depression looked like between the ages of six and twelve months. Even untrained observers, Spitz insisted, could identify this syndrome easily. After enough time in an institution, children would display “stuporous deteriorated catatonia” or “agitated idiocy.”
Spitz, like Levy, theorized that maternal absence sterilized institutional child-caring environments. Motherlessness pushed infants toward the cliff of developmental risk by depriving them of the emotional sustenance necessary for normal development. Life without mother denied them critical interaction, causing them to grieve and withdraw from the social world and making it extremely difficult and time-consuming for caretakers to regain contact with them as time passed.
The distance between lamenting absent mothers and blaming bad ones turned out to be short, so studies like those by Levy and Spitz helped to eventually make the case that autism originated with maternal resentment or indifference, an idea central to psychogenesis. Hospitalism fueled the attachment paradigm, closely associated with the work of British psychoanalyst John Bowlby and popularized after 1945.
Hospitalism faded from view after 1945, but studies of institutionalized children and their perplexing developmental delays and strange behaviors were historically influential. They showed how mental and emotional development could go off the rails very early in life. By World War II, the social deficits that would become autism’s trademarks were firmly lodged at the heart of hospitalism. Hospitalism therefore linked autism and developmental disability to a period in history before those words existed.