ANACLITIC DEPRESSION IN AN INFANT

RAISED IN AN INSTITUTION

Robert N. Emde, M.D.) Paul R. Polak) M.D.) and

Rene A. Spitz) M.D.

Anaclitic depression was originally described as a psychiatric disturb-

ance in infancy which results from maternal deprivation in the sec-
ond half of the first year of life (Spitz, 1946). The original description
states: "If the nursing staff reports a sudden development of changed
behavior in the child without demonstrable organic disease and if
this can be correlated to a separation from the child's mother or moth-
er substitute, our suspicion as to the presence of anaclitic depression
will be confirmed."
Since the original description, other authors have questioned
whether such a syndrome could develop in the absence of a preceding
bond with a mother or mother substitute. Orlansky (1949) has stated:
"It should be noted that in the cases of anaclitic depression reported
by Spitz the children affected had been accustomed since birth to the
care and attention of their mothers. One wonders if the same reaction
would have taken place had they not been accustomed to such per-
sonal attention during their first year of life." Casler (1961), in a
later extensive review of the maternal deprivation literature, con-
tinued this line of thought by stressing the importance of differen-
tiating between cases in which there is a rupture of an existing ma-
ternal-infant bond and cases in which no such bond developed.

Dr. Emde is Chief of the Western Division, Colorado State Hospital, Pueblo, Colo-
rado. At the time of this research Dr. Emde was Chief Resident in the Department of
Psychiatry, University of Colorado Medical Center. Denver, Colorado; Dr. Polak was
Director of Research, Fort Logan Mental Health Center, Fort Logan, Colorado; Dr. Spitz
was Professor of Psychiatry, University of Colorado Medical Center, Denver, Colorado.

545
546 R. N . Emde, P. R. Polak, and R. A. Spitz

In the course of our research in a residential nursery for infants,

we had the opportunity to observe the development of one of the ma-
ternal deprivation syndromes. The syndrome of anaclitic depression
was noted to develop without the rupture of an existing mother-infant
bond and to resolve without a mother-child reunion.
The residential nursery has been described in a previous publica-
tion (Polak, Emde, and Spitz, 1964a). Prior to his developing ana-
clictic depression, the infant of this study was among many followed
in a longitudinal study of the smiling response. Because of this, a large
amount of background data and movie films were obtained before
the syndrome developed. Historical and chart information from the
professional staff of the nursery supplemented our direct observations
and movie analysis.

CASE HISTORY

George, a 6 lb., 8 oz. male infant, came to the residential nursery at

eight days of age. Of Spanish-American parentage, he had been born
at a local hospital. No abnormalities were noted in his delivery or in
his physical examination at birth. During his first month at the nurs-
ery he was noted by a nurse to exhibit a good deal of "fussy crying";
he seemed to be very demanding, and wanting more attention than
other babies his age. However, at other times, he was described as
being "shy," preferring to remain in bed rather than being held. As
was the usual nursery procedure, he was moved at age one month
from the room where he had been since his arrival to an adjacent
room with infants from one to two months of age. At age two months
he was again moved, this time to a large crib dormitory housing in-
fants from approximately two to six months of age. Each of these
moves was accomplished easily and without any noted change in be-
havior on the part of George.
During his first month in the crib dormitory, it was noted that, un-
like other infants his age, George objected to sitting in the teeter
chair. During this time, Mrs. L., one of the staff members who most
often took care of George, went away on a ten-day vacation without
any noticeable effect on him. At two months and twenty days, George
began to smile regularly to the nodding human face and was included
in weekly observations for our smiling study (1964a). He was ob-
Anaclitic Depression 547

served by the authors regularly throughout the duration of his smil-

ing response.
At age three months, Mrs. L. noted that George began to demand
attention more actively. Prior to this time, it was felt that he needed
more attention because of his fussiness, but now he would actively
seek attention; when he was not picked up at such times, he would
evidence what was described by Mrs. L. as an "angry cry." George's
sensorimotor development, as observed by the authors, progressed
well within the range of normal from three to five months. In our
discrimination study comparing the moving human face and the mov-
ing photograph of the face (Polak, Emde, and Spitz, 1964b), George
evidenced clear discrimination by smiling preferentially to the hu-
man face at three months and seven days. Preferential vocalization to
the human face (as compared to the photograph of it) occurred at
four months and four days. Both discriminations took place at typical
ages for our nursery population. From three and one half months
through five months of age, George continued to smile strongly to the
nodding human face, but he did not smile at all to a similarly nodding
photograph of the same face. Within single experimental sessions,
George's smiling, by our measures, appeared more regularly than
that of other infants with little variation in magnitude on successive
stimulus presentations. He almost invariably responded to the nod-
ding human face with a quick, broad, long-lasting smile. As was typi-
cal of our sample, George's smiling response to the nodding human
face began to diminish a few weeks before he reached six months of
age. At four months, George was tested using the Buhler develop-
mental tests (Buhler and Hetzer, 1932). His developmental quotient
was 114, again within the normal range for our population.
At six months of age George was again transferred; this time, the
transfer was to a room at the other end of the nursery which contained
older children, usually from six months up to two and one half years
of age. One week after the transfer, Buhler testing was repeated. The
developmental quotient was 90. Not only was this considered below
the norm for this age of our nursery population, but it represented a
decrease of 21 per cent compared to his developmental quotient of
two months earlier. Three and one half weeks after the transfer, the
smiling response to the human face disappeared. At the age of eight
months and ten days, stranger anxiety was noted during a routine
548 R. N. Emde, P. R . Polak, and R . A. Spitz

visit to the nursery. That is, George cried and turned his head away
when approached by one of the experimenters. As in the original de-
scription of stranger anxiety (Spitz, 1946), when the experimenter
offered his back to George, making sure that his face was out of
George's line of vision, George established contact by exploring the
back of the experimenter. After establishing contact, it was possible
to interact with George face to face without the dramatic crying which
resulted from an initial face to face approach. A few days later, Mrs .
L. took note on George's chart of his display of crying in response to
strangers, which she found unusual for nursery babies. In our observa-
tions of George during the next two weeks marked stranger anxiety
persisted. Approximately three and one half weeks after the onset of
stranger anxiety, at the age of nine months, George was found in the
pathognomonic posture of anaclitic depression. He refused contact
by any of the authors, even when the gradual back approach was used.
During the following weeks our visits to the nursery would invariably
result in finding George in the same posture-lying in his crib in the
knee-chest prone position with the pathetic facial expression of ana-
clitic depression. Three months after George's anaclitic depression
began, a small experiment was performed. The purpose of this ex-
periment was to see if George responded to "friend" (i.e., nursery
staff) in the same way as he did to "stranger" (i.e., one of the experi-
menters) . George was found in his usual position, lying on the crib
mattress in the pathognomonic position. One of us approached and
George screamed and turned away as anticipated. Some time after
the intruder withdrew, George on ce again ceased crying and assumed
his original posture. At this point one of the two nursery staff mem-
bers who was largely responsible for caring for George approached
him. Not only did George not cry, but he seemed somewhat easily
comforted as N. picked him up in her arms.
In total, we estimated the period of anaclitic depression to last ap-
proximately seven and one half months. A slight change in George's
anaclitic depression began to appear when he was almost fourteen
months old, five months after the onset of the anaclitic depression. At
that time a chart notation indicated that he was beginning to crawl
again ; he had ceased to crawl after the onset of anaclitic depression,
spending much of his time in the pathognomonic position described
above. His crawling behavior occurred at the same time he began to
Anaclitic Depression 549

accept a neighbor infant of the same age, Lynne, as his playmate.

Lynne had been in the nursery since birth but was not depressed as
she was walking and interested in adult contact. Although we could
not approach George directly at this time, we observed that he would
play with Lynne, engaging in such activities as give and take of soft
toys. We also noted that if we engaged Lynne in play, George's in-
terest could be attracted. At these times he did not actively avoid
looking into our faces, although he still resisted any advances by us.
At the age of sixteen and one half months, George began to make in-
creasingly successful attempts at walking. Coincident with this, his
anaclitic depression resolved. George once again appeared to enjoy
human adult contact.
Subsequently, George progressively increased his mobility, walk-
ing through the nursery whenever he was allowed. He made more
friends among the other children his age in the nursery and we would
frequently find him actively playing with them when we arrived. He
continued to welcome adult contact and began to seek it actively by
giggling and jumping up and down in his crib when we entered the
crib room. Incidental observations, however, revealed that he showed
some abnormal distress at times, by crying, when one's approach to
him was sudden and when it involved physical contact. He made some
successful trial week-end visits to the homes of some volunteer work-
ers, and at the age of twenty months was adopted. Our initial reports
from his adoptive home indicate that he is doing well.
At first we were quite puzzled by the development of this case of
anaclitic depression. A biological mother seemed not to be involved,
as George had been separated from her since birth. George was taken
care of by many different people, but two of them, L. and N., were
most consistently involved with him. Both women were employed
full time by the nursery and were responsible for twenty or more chil-
dren at any given time. As a first step we checked the vacation sched-
ules of these two mother surrogates in order to ascertain the time cor-
relation with George's anaclitic depression.
Although the actual anaclitic depression did not begin until age
nine months, we began to observe behavioral changes in George short-
ly after his transfer to the crib room at age six months. Approximate-
ly one week after this transfer the Developmental Quotient of 90 was
obtained, and two months later stranger anxiety was noted. It was
550 R. N. Emde, P. R. Polak, and R. A. Spitz

found that shortly after the event of transfer, N. went on vacation for
one week and, following this, L. went on vacation for ten days. While
some relationship between their temporary absence from the nursery
and George's state seemed possible, it was not a satisfactory explana-
tion of George's behavior. The anaclitic depression had its onset after
their return, and was not resolved by their presence. Further investi-
gation of changes at the time of transfer was therefore undertaken.
Before transfer, George resided in a dormitory with sixteen other
infants, under the care of four regular nursery staff members. After
transfer, he was in another room containing seventeen infants, but
with only two regular staff members in attendance. Thus the trans-
fer resulted in a 50 percent decrease in regular staff members taking
care of the infants. In addition, it was discovered that teen-age sum-
mer volunteers visited the infants of the two- to six-month age group
much more frequently than they visited the older infants. In the for-
mer room, there were many regular volunteers who came on specific
days to play with, cuddle, and feed the babies. According to L., George
seemed to get to "know" some of the teen-age volunteers who came
regularly. He sought their attention, and his "fussy crying" often sub-
sided when one of them picked him up. When he was moved to the
room with older infants, George found far fewer volunteers coming
to see him, and they came less regularly. To add to his loss, when
school resumed four weeks after George's transfer, teen-age volun-
teers' visits decreased further.
Another change occurred in the way feeding took place before and
after transfer. In the two- to six-month nursery, infants were routine-
ly held by a staff person or volunteer during feeding, and meals were
given four times a day. In the six-month-and-over nursery, the infants
were suddenly graduated to high chairs and meals of junior foods
three times a day. This clearly involved a good deal less physical con-
tact with the feeder. The importance of skin contacts in the feeding
and mothering of infants has been emphasized (Spitz, 1950).
A detailed consideration of the time during which George's anaclit-
ic depression resolved was equally revealing. When he was sixteen
months old, two weeks before we considered the depression to have
resolved, the end of the school year brought another influx of enthusi-
astic teen-age volunteers. Initially, according to L., George sat in his
crib and cried on approach of the volunteers, but they persisted, Ire-
Anaclitic Depression 551

quently picking him up and giving him much attention. Their per-
sistence bore fruit, and L. stated that eventually George no longer
cried at their approach and began to show that he enjoyed them.

DISCUSSION

The case of George appears to extend the clinical picture of ana-

clitic depression. This syndrome is known to occur after separation
interferes with an existing mother-infant bond. However, it does not
occur after each such instance. The original description (Spitz, 1946)
emphasized that maternal separation should be considered a neces-
sary but not a sufficient cause of the syndrome, because not all infants
with maternal separation develop anaclitic depression. The case of
George reveals a classical clinical picture of this syndrome developing
in an infant who had never established a relationship with a mother,
or a single mother surrogate. George was cared for by a large number
of people, and it was apparently a sudden decrease in the amount and
quality of this mothering from many people that was associated with
the onset of anaclitic depression, and an increase in this mothering
from many sources that was followed by his restoration to health.
The role of a peer infant in the recovery from anaclitic depression
may have been more important than we at first thought. There is a
correspondence of George's beginning to crawl again and of his be-
ginning to play with Lynne, an infant placed next to him. More recent
experiments by H. and M. Harlow (1964) have shown that the moth-
er-infant relationship in the Rhesus monkey could, to a large extent,
be substituted by permitting the infant monkeys to play with other
age-matched infant peers. These peer monkeys could be equally de-
prived or nondeprived infants. However, caution must be used in
applying these findings to the human infant. In terms of maturation
the Rhesus monkey is born with a physical and mental development
which corresponds to the human infant of one to one and one half
years. It would seem the human infant is much more vulnerable. If an
analogy from Harlow's work is useful, it may be that in humans peer
interaction can substitute for mothering only when such play is pos-
sible-Le., after the first year of life (see Spitz's discussion of Harlow,
1964).
The importance of locomotion in the treatment of anaclitic depres-
552 R. N. Emile, P. R. Polak, and R. A. Spitz

sion has been pointed out (Spitz, 1946), and in this case there is a cor-
relation between increasing locomotion and George's improvement.
It is uncertain whether this was an added factor in his improvement
or a natural concomitant of it, but it is likely that both were involved.
During the time of his initial improvement, George was often placed
on the floor and allowed more opportunity for crawling and, later,
walking.
George's anaclitic depression followed what we diagnosed as a classi-
cal case of eight-month anxiety. With time, one syndrome fused into
the other. This was recorded dramatically on film and serves again to
underscore Spitz's original statement that the difference between
eight-month anxiety and anaclitic depression is basically a quantita-
tive rather than a qualitative one.
An unexpected finding was the duration of George's anaclitic de-
pression. Originally, a period of three months was considered critical,
after which the process of depression appeared to be irreversible
(Spitz, 1950). George does provide an exception to this, as his anaclitic
depression lasted seven and one half months.
There remains an intriguing question. Why should George develop
anaclitic depression in a situation of a relative decrease in mothering
when most of the infants in the institution experienced the same rela-
tive decrease with no visible problems? A partial answer may lie in
George's personality before the age of six months. He was described
as shy, withdrawn, fussy, and at the same time demanding. Another
consideration arises from the finding that all of the cases of severe de-
pression occurred in situations where there was an estimate of a "good
mothering" relationship (Spitz, 1946). In this study, the majority of
infants with no depression, and maternal separation, were found to
have an estimate of "bad mothering." This led Spitz to comment:
"Evidently it is more difficult to replace a satisfactory love object than
an unsatisfactory one," Was it because of the "good mothering"
George had at the nursery that he became susceptible where others
did not? Or is it possible that by some combination of heredity and
environmental factors, he was more vulnerable to decreases in moth-
ering than other infants? Unfortunately, at our present state of knowl-
edge we feel it is not possible to answer these questions.
Anaclitic Depression 553

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