Anaclitic Depression and
Infant Development
Timothy J. Kowalski, DO, FACN, DFAPA
Objectives
• 1. Identify anaclitic depression, its early description, and animal
models of maternal deprivation
• 2. Identify those factors contributing to normal infant development,
temperament and attachment
• 3. Identify normal age progression in Gross and Fine Motor
Development
• 4. Identify the developmental lines and theoreticians of
Psychosexual, Psychosocial, and Cognitive Development
• 5. Describe the importance of touch in development of the doctor
patient relationship
I have no financial interest in
anything presented in this
lecture.
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Diagnostic Classification
ZERO TO THREE
Published in 1994
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a systematic, developmentally based approach
to classify mental health and developmental disorders
in the first four years of life;
to complement, but not replace,
existing medical and developmental frameworks.
such as the DSM-III-R and the ICD 9
(International Classification of Diseases of the World Health Organization)
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DC:0-3 has been published in 8 additional languages
The DC:0-3R Multi-Axial System
Axis I: Primary Diagnosis
100 Traumatic Stress Disorder
200 Disorders of Affect
300 Adjustment Disorder
400 Regulatory Disorder
500 Sleep Behavior Disorder
600 Eating Behavior Disorder
700 Disorders of Relating and
Communication
Axis II: Relationship
Classification
901 Overinvolved
902 Underinvolved
903 Anxious/Tense
904 Angry/Hostile
905 Mixed Relationship Disorder
906 Abusive (verbal, physical,
sexual)
Child Temperament (Chess and Thomas)
Nine temperament characteristics (1970s New York)
assessed--Cary Infant Temperament Questionnaire
– Described differences in infant temperament 20-60% genetically influenced
categorized into one of three groups:
easy(40%), difficult(10%), and slow-to-warm-up(15%)
through first 5 years that remain stable through life:
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Activity level (verbal/nonverbal)
Rhythmicity (regularity--sleeping, eating, bowel)
Approaching/withdrawing (resist/accept--new people/environments)
Adaptability (adjust to change over time—goal directed or not)
Responsiveness (intense or calm)
Mood (happy/unhappy demeanor)
Distractibility (do stimuli alter behavior)
Attention span (persistence)
Intensity (energy level—active/passive)
Anaclitic Depression
• Impairment of an infant's
physical, social, and intellectual development
resulting from absence of mothering.
• First introduced in 1946 by René Spitz
referring to the reaction of children
after being separated from their mothers
for a period of three months or longer
during the second six months of life.
• The process can be reversed with reintroduction to their mother.
Rene Spitz, MD—Anaclitic Depression
Harry Harlow Monkey Experiment Contact Comfort
Infant Deprivation
• Supportive and caring relationships are essential
for normal psychological development of infants.
• Infants need to be physically close to their caregivers
and build an emotional bond.
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Infant Stimulation
• Infants need
– Skin to skin contact
– Breastfeeding
– Being held
– Movement
– Affectionate play
– Face to face time
These multi-sensory experiences feed development and
are weaved together in the limbic system.
Still Face Experiment
Depressed Infants of Depressed Moms
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Clinical presentation in birth to 3 yrs of age:
– Sad or expressionless face
– Feeding and sleep problems
– Restricted social play, slow movements
– Tantrums/ irritability
– Lethargy
– Lack of responsiveness or interest in peer activity
– Separation anxiety or attachment problems.
– Developmental regression
– Failure to Thrive
• Postpartum Depression: infants Failure to thrive (BMJ. 2004 April 3; 328(7443): 820–823)
Failure to Thrive
. Contributing factors to failure to thrive:
• Maternal deprivation/Absence of a father
• Unwanted pregnancy
• Lack of family support /poverty
• Young mother (improper feeding -- juice)
• Maternal mental illness
• Malabsorption syndrome/other illness
Romanian Orphans: A Healing Touch - Physical
Therapy for Romania's Abandoned Children
The Touch Research Institute University of Miami School of Medicine
established in 1992 by Director Tiffany Field, Ph.D.
• First center in the world devoted
solely to the study of touch and its
application in science and medicine.
• Includes distinguished researchers,
from Duke, Harvard, Maryland, and
others.
• Research efforts ongoing since1982
have shown that touch therapy
has numerous beneficial effects
on health and well-being.
http://www6.miami.edu/touchresearch/InfantMassage.html
Developmental Lines
Comprehensive Textbook of Psychiatry
Sadock et al, 2009
http://www.childhealth-explanation.com/milestones.html accessed 10-15-14
Fine Motor assessment
Two year old can: copy a line
• Use two words
• Favorite word “NO”
• Points to body parts
Three year old can: copy a circle
say three word sentence
ride tricycle
gender identity formed
Four year old can: draw a cross
hop on one foot
knows colors
Five year old can copy a square:
counts
skips
Six year old can:
copy a triangle
Draws person with
six parts
Seven year old can copy a diamond;
Attachment Theory
Comprehensive Textbook of Psychiatry Sadock et al 2009
Attachment theory describes the dynamics of long-term relationships between humans
Its most important tenet is that an
Infant needs to develop a relationship
with at least one primary caregiver
for social, emotional and physical development to occur normally.
Attachment theory explains how much
the caretaker's relationship with the child influences development.
Infants become attached to individuals who are
sensitive and responsive in social interactions with them,
and who remain as consistent caregivers for some months.
Attachment Theory
John Bowlby, MD (1907-1990)
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World War II created homeless and orphaned children
British psychiatrist and psychoanalyst John Bowlby was asked by the UN to explore the
resulting problems of orphaned children -- maternal deprivation and attachment
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Attachment describes the child’s affective relationship with the parents
– Attachment occurs when the infant has a warm intimate
and continuous relationship with mother
where both find satisfaction and pleasure
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Bonding describes the parents affective relationship with the child.
– It concerns mother’s feelings for the infant,
but unlike the infant, the mother does not rely on infant for security
It is critical to facilitate the Bonding of the mother
to allow for a health Attachment of the infant
Attachment Theory: Separation-Individuation
Margaret Mahler, MD (1897-1985)
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Hungarian Pediatrician who described early development as a sequential process
of separation of the child from the mother or primary caretaker
– Beginning with the autistic phase of the infant (self absorbed)
– Evolving to symbiosis with the caregiver
(beginning differentiation of the self from mother)
– Progressing to Rapprochement
the moving away and then returning to the mother for reassurance (age 2)
– Finally reaching a point of Individuation
(achieving a level of comfort at being separated from mother)
Attachment Theory
Mary Ainsworth, PhD
When an infant begins to crawl and walk
they begin to use attachment figures (familiar people)
as a secure base to explore from and return to.
Ainsworth, a developmental psychologist and researcher in the 1960s and 70s,
introduced the concept of the "secure base“; and
developed a theory of a number of attachment patterns in infants:
secure, avoidant, anxious and disorganized attachment.
Caregivers' responses lead to the development of patterns of attachment;
these, in turn, lead to internal working models
which will guide the individual's perceptions, emotions, thoughts
and expectations in later relationships.
Ainsworth Stranger Situation—
Donald Winnicott, MD
British Pediatrician and Psychoanalyst (1896-1971)
Recreating the Holding Environment-Physical/emotional care (Loving touch) between
two imperfect people (mother infant dyad)--
He saw as a prerequisite for healthy
development, the continuation of reliable
holding, in terms of the ever-widening circle
of family, school and social life.
"good-enough mother" - the foundations
of health are laid down by the ordinary
mother in her ordinary loving care of her
own baby
• Transitional Object
Helps to cope with separation
Cognitive Development
Jean Piaget, PhD (1896-1980)
Genetic Epistemologist
• Explained cognitive maturation focusing on schemes
• Two complimentary fixed (invariant) processes:
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Assimilation: Objects can be assimilated into an experience they have already encountered
A top spins, a mobile makes music, apple juice tastes sweet, hot food burns
They begin to practice skills with games such as peek-a-boo
But each experience does not assimilate with the same function
Accommodation adjusts to this newer function
Infants and children internally construct new schemes to fit old and new experiences
into a universally uniform reality
Stages of Cognitive Development of Jean Piaget
Sensorimotor Stage
birth to 2yrs
• Uses body senses and activity to explore the environment
• Learn to anticipate an experience by internally constructing a model of each
experience—stranger anxiety develops at this stage
• Cognitive growth results in forming new skills such as object permanencethe ability to remember an object once it is out of sight
• This is the time children develop stranger anxiety
Preoperational Stage
ages 2-7
• Children become intuitive, anticipating experiences with consequences,
thinking symbolically, but illogically and with egocentricity
and a distinct inability to perceive self from others in their environment;
• Create an inner world populated with the creations of
magical thinking and animism
– A stuffed kitty becomes a ferocious tiger;
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A darkened room a dungeon
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The shadow of a swaying tree bough conjures up monsters with unlimited power
Concrete Operational Stage
ages 7-11
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Involves the ability to think logically and in an organized fashion
The magical thinking of old is replaced by a more realistic set of concerns
Conservation of number, length, weight and volume
Stimulated by a new-found conception of cause and effect
– Children often worry about school success,
– health and dying and
– social relationships
Formal Operations
age 11 and up
• Abstraction and Reason
• Can think of all possibilities
• Imaginary Audience
• everybody is looking at them
• (where egocentrism meets abstraction)
• Hypothetical-deductive reasoning
– Adolescent quick thinking or excuses
Stages are Critical Periods for the Achievement of Social Goals
Stages not successfully completed
may be expected to reappear
as problems in the future.
However, mastery of a stage
is not required to advance
to the next stage
Each stage is characterized by
a psycho social crisis of
two conflicting forces
Touch—More than a Basic Science
Elkiss and Jerome
JAOA August 2012
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Osteopathic Physicians touch their patients with purposeful attention and thoughtful care,
communicating reciprocity, unconditional positive regard,
empathic understanding, and the intent to help.
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For the patient, touch communicates a sense of being examined comprehensively,
being cared for, and being treated directly by the physicians touch.
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For the osteopathic physician, touch is an expression of compassion, skill, and expertise,
a method for having a direct, therapeutic influence on the patient’s well being.
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For both the patient and physician, it is an intensely meaningful,
heartfelt, therapeutic interaction with touch as the interface.
Biopsychosocial Dynamics– Being Touched
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Touch begins with the feeling of contact.
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With higher levels of processing, the touch may be imbued with affective and
evaluative qualities, as well as interpreted in terms of past experience and learning.
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If there is a sense of trust, the brain is primed to release oxytocin while being touched.
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As affect is engaged, the limbic system is recruited to lend autonomic, endocrine, and
immune elements to the person’s global physiologic and psychological state.
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This affect is largely experienced, executed, and communicated through the actions of
the autonomic nervous system, the circulatory system, and the musculoskeletal system,
creating a systems network in which healing may be promoted.
Biopsychosocial Dynamics– Being Touched
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In its own way, touching our patients—both diagnostically and therapeutically—
can be seen in direct juxtaposition to the technical and impersonal aspects
of annexing the body to the virtual world of images and data.
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One can put the patient at ease when talking to and touching him or her
by including an explanation of intent and nature of the touching,
its purpose, and what the patient is likely to experience.
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As the physician touches and explains why and what he or she is doing,
as well as what is being found during the palpatory examination,
he or she is enhancing confidence and trust.
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Trust and dialogue can then center on the patient’s ultimate questions of
what is wrong and what can be done.
Additional References
Spitz RA , Wolf KM . Anaclitic depression: an inquiry into the genesis of
psychiatric conditions in early childhood . In: The Psychoanalytic Study of
the Child . 2: New York: International Universities Press; 1946;p. 313–342
Elkiss ML1, Jerome JA. Touch--more than a basic science.
J Am Osteopath Assoc. 2012 Aug;112(8):514-7.
Kaplan and Sadock’s Comprehensive Textbook of Psychiatry 9th edition,
2009
Stella Chess, Alexander Thomas, Temperament: Theory and Practice Psychology Press, 1996
Zero to Three
http://www.zerotothree.org/child-development/early-childhood-mental-health/diagnostic-classification-of-mentalhealth-and-developmental-disorders-of-infancy-and-early-childhood-revised.html accessed 10/15/2014
Harry Harlow Monkey Experiment Contact Comfort
https://www.youtube.com/watch?v=vbEdNJ-e-Yc
YouTube Video Clips
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