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INFANTILE DEPRESSION IN A “NORMAL” CHILD
I N FANTILE DEPRESSIO N I N A "NO R1\ IA L" CHILD
.lOO Il
Dttuid so n, 1\1./) .
De pr ession is defined as an em otional state characteri zed by hopelessn ess, low spirits, Iat iguc, a nd leth arp;y. It occu rs in all people, goi ng in th e " no rmal" ran ge lrom mild unhappin ess to d epr essions th a t occ u r in people in reactio n to a seve re lo ss, i.e. , " reacti ve depressions." Depression is presen t as a predom inant symptom in a wide ran ge of pati en ts d iagn osed as " ne urotic" a nd "psycho tic." Psych oanal yt ic th eor y tra ces t he orig in of clinical depressions to exper iences of th e a ffected person in the first yea r of life. Thou gh m an y papers have b een wr itten a bo u t th e d yn ami cs o f ad ult d epression , few cases o f infa nti le d epression ha ve been d escr ib ed . T hose cases o f in fan tile d epression re po rted in th e Ii teratu re descri be ch ild re n wh o arc sufferi ng from ne gl ect ca used h y physical separa tio n from the mot her (Spitz, I !11Ii) or by th e mot her's wi thd ra wal du e to her feelings abo ut an abnormali ty in the in fan t ( Fngcl and R eirhsm an , I !1:;li ). ' Vh ile these auth o rs af.,JTee th a t th e et io logy o f depression lies in mil d to seve re di sturban ces in th e in-
Dr, D uui d son 1I'as a Fello w at IIII~ M I'llIl ill gl'r Foundation , T opek a, I\ //I/.\a,\ 1I. he ll II,i ,\ I/(J/'I'r 1I'as written. I 1I'o llirl lik « 10 express my de l'l' gra titude to Dr. Lois 11. Murph» f or III'r g/'II/'W IIS hd/l 10 / 1/( ' ill tr ri lin g this Imller. Sh e n ot on ly sha re d her rirh data , but a lso llt'ry kiudlv licl p rt l tn c tlt ink throug]: an tl rI a rif)' ronrcpt s. Thi s jltlj}('r is largel» b asrt! 0 11 un pub lisli cd dut a a / 1111' ,\I l'1l11 illg e r Foundation, co ll ected W Id er U SP A S G rant s Mil 27, r hir] in vrst ig% n l i rs. S. Esra lonn (llld lIf. Leitch, Gra llt lIf 6SIl all/I lIfll Ii/Il ll), ch it'! iu vcst iga tov [Jr. I .o i , II . M url'h y . Th e dat a a l l responses to th e K cnn edv a.I.I/LISilla t io ll wert: co llect ed " jw d //l tlll y liy I Jr. 0·J. M o ria rt», S. ( ;i,llj/(Jrp;. mul c. 1. ,\I orp;a II .
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Iant's affective climate during the first year of life, they describe only extreme conditions of depression. These authors do not delineate the types of mother-child interactions which cause the milder forms of adult depression. Those who have written about infantile depression and depression generally have theorized about, but have not cited, specific case material to demonstrate the milder cases. I am going to describe a state of mild, chronic depression in a twenty-eight-weekold infant. My hypothesis is that if data are available on the infancy of a person who is depressed, one ought to be able to see signs in the infant's affective state that would be the infantile counterpart of the adult's experience of depression. Such symptoms, seen in this infant, are lassitude, repeated regurgitation, poor muscle tone, and excessive sleeping. In 194G Spi tz introduced the term "affective climate" to designate the totality of forces which influence development in the infant. This is a somewhat elusive concept to define, but refers to the subtle expressions of emotion including tone of voice, facial expression, degree of muscular tension, mode of holding the baby, etc., which convey and evoke a mood within the infant. In his most recent analysis of the emotional development of the infant in his book The First Year of Life) Spitz (1965) discusses the importance of the emotional signals generated by maternal moods and what these moods convey to the infant. He states: These exchanges between mother and child go on uninterruptedly, without the mother necessarily being aware of them. This mode of communication between mother and child exerts a constant pressure which shapes the infantile psyche. I do not say that this pressure produces anything in the nature of unpleasure for the infant. I speak of "pressure" only because the words to convey these extraordinarily subtle and intangible exchanges have never been coined.... Pressure and giving way alternate and comhine to influence now one function, then another among those wh ich un fold wi th rna tura tion, retarding some, Iaci Iitating others, Spitz emphasizes the fact that traumatic events playa very small role in the infant's emotional development. He states, "what we see again and again are the cumulative results of iterative cxpcricnces and stimuli of endlessly repeated sequences of responses." In the
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same wo rk Spitz states, " I ha ve r each ed the cond usion th at the ch ild ca n ide n tify o n ly with cert a in characteristics of beh avior o n th e one hand and certa in glo ba l all 'cc ts of the ohj ect on the other." Spitz cites Anna Freud's di scussion of a child's rel ationship to a depressed m ol her. She r em a rk ed th at th e chi ld's beh avior doe s n o t rellcrt a process o f sim ple iden tification . Th e moth er 's depressive m ood ge nera tes in th e ch ild an in clin ation toward depressive tenden cies. Th e depressed m other r etreat s from the ch ild, and th e child, in Anna Fre ud's words, " fo llo ws her into th e d epressive nH)( )'I." An na Freud m ad e it d ea r th a t she considers thi s phc uo n u-no n to be in the n atu re or " in fecIion " and th at i t is n ot an im ita tion o f the mother 's ges t ur es wh ich produces thi s mood in the child. The child simply respond s to the affective climate, n ot to the cause of the affe ct : he is thus infected hy the affective dim at e. En gel a nd R ei ch sman ( I ~l:") (i) proposed that two basic processes ca n he see n in th e d evelopment of wh at they saw as a " n ucle ar psychod yna m ic rons tc lla tio u" whi ch is " de prcs soge nir :" and simi lar to th e sta te described by Bened ek ( 105(i) as a " de pressive con stellation." The fir st ba sic process is th e in di vidual's ph ysical withdraw al fr om hi s env iron men t, th e r ecogn ition of the n eed for r educed activity in th e face of actual or threaten ed ex ha us tio n or lack of what is needed from the extern al world. En gel and R ei chsrnan state that this process is at first predominantl y som atic, perh aps a basic respo nse of all cells and organ isms which in hi gh er organisms may ac h ieve psych ic r epr esentation as a basic ego sta te, a war n ing mecha n ism . Th e seco n d ba sic process, Ben edek 's "ambival ent core," also h as a bi ol ogi cal source in th e pro cess o f alim entati on . Linked with hun ger a nd sa tia tion it pro vides th e ba sis for the estab lishmen t of th e sym b io tic unit and th e format ion o f o hject re la tions hips. Its ea rl iest psychi c deri vati ons are the processes of in trojec tion and projection, whi ch mechani sm s regulate th e formation o f the "good-bad" as pects of self and object representations and thereby establish the con d itions whereb y aggr ession is tu rn ed inward. A t later stages of d evel opment aggression turn ed in ward ma y al so ac tiv a te m emory tr aces o f feelings o f helpl essn ess togeth er with corres po n d ing hi ologi cal ph enomena , characte ristic o f th e first ba sic m echanism. Enge l a nd R cirhsruan then concl ude th at th e devel opment o f d epression
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in th e indi vidual ha s n o t on ly an ac tive oral introjective b eg in n ing, hut a lso an inact ive, preobjcct origin . In co n tr ast to th e in acti ve phase, th e acti ve phase is restitu tive, an attempt to re- establish the indi vidu al' s lost o bject r elat ionship th rough introj ection . Slee p is co ncep tu alized by En gel an d Reichsman as on e way in wh ich an indi vidual can achi eve wi thd raw al from th e env iron me nt in wh at th ey de scribe as th e in acti ve, preobject phase of d epression. The ph en omen on of wi t hdra wa l into sleep as a very ea r ly d e fen se on th e part o f th e infant is d escribed by Brazelton (1962) a nd Ben jam in et al. ( I!Hj 2). In th e di scu ssion o f Brazelton 's paper, J ohn Ben jamin says that th e a ppa re n t sta tes of slee p, in cluding EEG changes, ca used by r epetition o f a stim ul us, are we ll kn own. He cites work indicating th at th e m ore intense the stimuli , th e more effect ive th ey are in producing EEG changes and sleep. If psych oanalytic theory is co rre ct , one should be able to find in infants precursors of adult d epression, although th ese precursors might not be observed in man y infants. With this a im, o ne would exa mi ne a nd look spcc ifira lly for signs of lethargy, in activity, and wi thdrawa l du rin g th e first year o f li fe. F rom th e point of view d escri bed by Sp itz and Anna Freud , o ne wo u ld st udy th e m other's m ood s an d th e kind o f emo tiona l sign al that she gives to th e infant as she cares for him . Th e case I shall d escribe is th at o f a girl wh o ha s been st ud ied inten sivel y since she was tw enty-eight weeks old (Esca lo n a and H ei d er, 1!15!1; Escal ona and Leitch , 1%2; Murph y, 19(2). She was sel ect ed alo ng with o thers as a n infant free from defect. Kate ha s show n evi de nce o f depression a t severa l periods in her d evelopment. Th ese will he d escri bed bel ow . There has been n o se pa ration from th e m other, but th e effect of the emotio na l climate on th e infant co n for med to the conc ep ts d evel oped by Anna Freud and Spitz. In thi s case, there is co ns ide ra b le evidence that th e mother's m ood s con tr ib u ted to th e infant's emotional pattern an d to respo nses which have persisted to the present, even th ough they are su ccessfully balanced by th e gi rl's vi gorous active ex plo ra tio n of the e nvi ro n me n t for many kinds o f gr a tifica tion . At seve n tee n, she is acti vel y pursuing her sch ool and soc ial career. Wh en Kate was five, she was descr ibe d by H ei der as p hys ically frail and far fro m health y m ost o f her life ( Escalo na a nd H e id er , ]!15!1). A t th e same tim e , a
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pediatrician described her as "an underweight and rather pale child who appears to l ie nervous and unhappy." She showed no signs of warmth or interest in the observer or the examiner and her full energy was spent on giving her mother "a hard time." Povl T'oussicng, the psychiatrist who interviewed her, found her play typical of a girl at the height of the oedipal period. I Iowcver, her allen ,,'.IS c ontrollcd and distant; she appeared flattened emotionally. For example, she spoke of her dead kitten very callously, but at the same time appeared to identify with the kitten who had not been cared for, and who had fallen downstairs and died. She was concerned about her looks and obviously feminine in her behavior, but played almost exclusively with the masculine-aggressive toys. She used the exammer to further her interests, but there was no warmth or spontancn.y in the interaction. The psychiatrist stated, "She meets stress by increased activity and proud self-control." He also commented on her withdrawal and avoidance and rq~ression to a more immature status when under stress. 'Vhen Kate was eight, she was a very slender girl who gave the overall impression of mastering things fairly well. The examining psychiatrist, Keith Bryant, commented that she kept her fields of interest "very narrow and constricted and took things a bit too seriously." She was very quiet and self-contained and did not chat. Povl Toussieng described her as a "lanky beanpole" at the age of twelve. The expression of her eyes was "darkened by sadness, sullenness, and bitterness." She continued to be reserved, wanting to be self-sufficient. She had a very depressed outlook on life, and her memory revolved almost exclusively around all the disappointments she had ever had. Her emotional life was dominated by intense bitterness and anger. She conveyed to the psychiatrist a feeling of misery in the past and in the present, a feeling of utter suffering. Kate still sucked her thumb, was constipated and very thin. Lois Murphy saw her two years later and described her as "a quite well-organized and cllic.ient girl who is genuinely enjoying the activities at school, at her own church and her friend's church, hunting expeditions with her father and brother, and clothes." While the psychiatrist's earlier interview focused on Kate's perception of her inner world, Murphy's interviews focused on the ways the girl was able to cope with the outer world at the later period. She
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went to weekly social gatherings at one church and monthly gatherings at a ch urch of another denomination. The validity of the psychiatrist's impression of latent troubled feelings appears in Kate's responses to the questionnaire circulated following President Kennedy's death. Kate made statements that indicated a tendency to "both a psychosomatic and a depressive response." In response to the questions about how she felt when she first heard the news she said, "I felt sick .... I also wanted to die. I felt there was no reason for living. It seemed to me life was over for everything." Since Kate showed signs of misery, unhappiness, and depression at the ages of five, twelve, and fifteen, and since psychoanalytic theory da tcs the onset of depression to the first year of life, I reviewed the extensive information about this girl in infancy. I was looking for evidence of anlage of depression in Kate herself and for a disturbance in the mother-baby climate in order to clarify the onset of her difficulty. Escalona and Leitch observed the mother and Kate together for about four hours when Kate was twenty-eight weeks old, took a movie of the mother feeding Kate, and had a follow-up visit at home. Kate was described as an attractive, delicate, rather thin, feminine-looking infant who smiled readily and responsively: a very attractive, but decidedly immature infant for her age. She was extremely sensitive to light and became very irritable when the lights were put on for taking a movie. This was because she was receiving atropine for her feeding difficulty. Her mother avoided letting Kate cry, "It gives them had habits." While she rarely cried, she Whimpered plaintively when uncomfortable. Anxiety during the examination was implied in her high sensitivity to skin stimulation, totally irregular breathing, and hy her sober and alarmed expression when she first saw the examiners. Her anxiety upon seeing them calmed after a few minutes, and although she displayed evidence of anxiety from time to time later, at no time did she fight or cry. She Whimpered a little during her mother's rough play with her. Three areas of functioning were noteworthy: her sleep was excessive, motorir development was retarded, and she regurgitated frequently so much that she did not gain weight properly.
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First I shall describe Kate's sleep as observed and as reported hy the mother. The mother reported that Kate slept excessively and I infer that this was Kate's response to her mother's depressed moods. The mother did not stimulate the baby, and the baby withdrew and responded with lassitude when she was with the mother at these times. The mother reported Kate's sleep habits in terms of glowing praise and appeared to he very content to have such an inactive, agreeable baby. She said she had "never had a baby nor seen one who slept so much, was so little trouble, and was so good." The mother praised Kate's ability to take two two-and-a-half-hour naps each day and sleep twelve hours each night: a total of seventeen hours of sleep each twenty-four-hour period at twenty-eight weeks. During the four-hour observation period, Kate was quiet except when stimulated; she slept an hour and forty minutes. She moved little during her nap, stirring slightly when the group laughed loudly, hut did not awaken until stimulated hy her mother. The mother's attitude toward Kate's slow motor development and excessive sleep is shown in her comment, "She has been a little slow to try to sit up or anything because she has been asleep so much of the time and I've had so little time to train her." Her muscular development was undifferentiated and uncoordinated for her age. Objects tended to slip away from her grasp when she tried to take hold of them, hut she held on very, very firmly once she got them within her grasp. Escalona stated, "Her legs kicked gently, but she made no attempt to draw her knees under in a creeping position. The development of her coordination in her hands was far above that of her legs. She tended to go after things with both hands rather than using one, and there was no evidence of well-developed, fine motor coordination. In the standing position she did not unbend her legs and was unable to support even a fraction of her weight." I infer from this gencrally immature muscular development that Kate spent so much time in a depressed sleep that she had been unable to mature in this way. She simply had not exercised enough to develop her motor skills. For example, at this stage, she should have been practicing stiffening her legs preparatory to standing. She also should have had a better developed ability to grasp.
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The third area of disturbed functioning was Kate's nutrition. In this area Kate suffered from severe problems during this, the oral period of her life. Despite adequate food intake, she was thin and undernourished. (She weighed 8 pounds, 7% ounces at birth and at one year weighed only 17 pounds, 4 ounces. She merely doubled her birth weight instead of tripling it as infants usually do.) Constant regurgitation kept her from digesting the food she ingested. The milk frequently was regurgitated, undigested, as long as four hours after a feeding. In an analogy to the way that she was unable to hold onto her food, she was unable to keep a steady hold on pleasant fcelings and on her contact with her mother, due to her mother's alternating depression and defensive flight into activity. In contrast, perhaps as another way of coping with her constant emotional and partially physiological starvation, Kate grasped and held onto things in the environment, as well as her thumb, with tenacity. The tenacity was commented on by Escalona when Kate was seen at twcnty-eight weeks as follows: During the psychological tests, two observations were made which I do not recall having made on any other baby of similar age. One occurred in the situation where the baby holds one cube and is offered a second one. The usual pattern for the child who is not yet able to hold two objects at the same time, upon perception of the second cube, is to drop the one they have in hand and reach for the one that is being offered. Not so Kate, who while holding the first cube looked alertly at the second, seemed faintly puzzled and bothered by being offered the second, but either held onto the onc she held or dropped it only to resccurc it rather than attempting to get the proffered cube, This observation was checked upon four times in all and she reacted in precisel y the same manner Oil each occasion. It nlay be related to this that, considcring how passive and agreeable this baby is in all other aspects, it was rather difficult to remove objects from her gTasp. She did not cry at such times, hut she held onto the object tightly and it was necessary to divert her attention in order to remove the toy. Grace Heider, who analyzed the infancy data of the coping project, said that Kate's tenacity was, to her mind, a striking feature of the baby, particularly in contrast to her usual passivity and in contrast to the other in fan ts in the series.
Joan Davidson Kate could not hold onto good feelings. However, she was able coo and laugh happily when playing alone and could laugh rapturously at the moving shadows on the wall. She spent as much as seventeen hours out of twenty-lour in the depression-withdrawal state of passive apathy or sleep, hut could awaken to smile and laugh when stimulated hy the environment. The foundations of her emotional memories included chronic hunger despite adequate feeding, depression, and a tenacity of purpose to hold onto what she did have. In addition, Kate was, at twenty-eight weeks, very discriminating in her sensory development. She appeared joyful when watching the moving shadows, laughed and "jumped for joy" when she saw her brother and lather, and chuckled gleefully when naked. She perceived accurately her mother's mood and responded in a disrriminating way. For example, she laughed and cooed when her mother spoke to her smilingly, apathetically drifted 011' into sleep when her mother was depressed, and looked alarmed when her mother dropped her roughly into her c.r ib. Difficulties with feeding, nutrition, and oral gratification began shortly alter birth when Kate hegan spitting up. Kate started to suck her thumb at one month of age and screamed all night when her mother put mittens on her to stop her. The mother gave in somewhat reluctant! y and rational izcd the th urn h sucking on the grounds that the pediatrician had said the hahy needed it. '\Then Kate was five months old, the mother was ohliged to wean her. The mother was having "hot flashes" and her physician started to give her cstrogcn injections which stopped lactation. The mother gave Kate milk from a cup and stated that "she liked it, hut it was hard to keep her awake for the cup feedings." Kate refused the bottle at first so the mother would take Kate's thumb out of the sleeping baby's mouth and insert the nipple. Kate then accepted the rubber nipple, hut at twenty-eight weeks was still "fussing" every time she was given the bottle. Escalona recorded: to
Then as the mother oilers the bottle to the baby, the baby whines and docs not accept the nipple into her mouth. Now the mother inserts the nipple into her open mouth and she spits it out. The bahy whimpers, then as mother presents the nipple to her mouth, she closes her mouth on it, sucks momentarily and then whimpers
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again and spits the nipple out. The mother says, "She never gets over complain ing about the rubber nipples for a little while at the beginning." The mother offers it again, and again the baby rejects it. The mother says, "Well, don't you want it?" and then decides to discontinue offering the bottle. The mother felt that the only problems she had had with Kate were the regurgitation beginning at birth with consequent slowness to gain weight and the thumb sucking which began at three months. The regurgitation, often almost projectile vomiting, was seen as a problem but was accepted calmly by the mother. She said, "All my babies vomited and I did, too, the whole nine months I carried them." Kate's mother rigidly and conscientiously followed the pediatrician's advice for dealing with this problem and gave Kate atropine regularly. In contrast to the conscious acceptance of Kate and her need, the mother presented a somewhat different picture to the observer. Escalona described the movie of the feeding as follows: Solid feeding: The baby is held in a half-sitting posItIOn, the mother's grasp on her shoulder and arm is not overly tight but very confining. The entire feeding struck us as somehow "mechanical." The mother shovels the food into the baby's mouth, frequently scraping her chin to collect food which has run out of the baby's mouth and refeeding it. The baby throughout shows a remarkable lassitude. The mother does not wait for signs of readiness on the baby's part. Frequently, the spoon is pushed between the baby's closed lips. At first the baby allows this to happen and swallows a portion of each spoonful, but toward the end therc arc definite movements of avoidance which appear to lack encrgy and push, however. Throughout, communication between mother and baby appears to be minimal. The baby moves very little. Because Spitz and Anna Freud have emphasized the importance of the infant's response to the mother's depressive moods, the data about the mother were also studied. The mother poured out a torrent of information during the four hours the baby was being studied; all this was volunteered under the stress of her situation. No attempt was made at a psychiatric interview with her. Kate's mother was in her early forties at the time of Kate's (the fifth child) birth. She was an intelligent and attractive woman, well gToomed,
Joan Davidson dficien t, ani ve in many afl'airs. She was under acu tc strcss because of a move and change in the family's circumstances. She had begun to sutler from estrogen deficiency due to the onset of the mcnopa use as we II as from periods of severe depression. She deseri bed periods or severe despondency after Kate's birth together with headaches and weight gain. She stated that she managed her "hlue spells" hy IJeing extremely arr ive and busy. For instance, she said, "If I want something for the house, I don't ask for it, I just get busy and earn the money." She had painted and redecorated a dcrrcpit old house and had converted it into pleasant living quarters. In addition to caring for the house and sewing for her daughters, she was very active in the family business and in her church. During the observation this mother dung with voice and eye contact to at least one of the team members and talked incessantly in a poorly modulated and high-pitched voice. For example, one observer commented, "My question precipitated an avalanche of material." The mother's overactivity as shown by incessant movement and talking as well as her accounts of her heroic feats of work at home further contributed to a partial withdrawal from Kate and threw Kate back on her own resources. This overactivity was necessary for the mother to repair her self-esteem, but prevented her from giving adequate stimulation to her baby. However, once the mother's self-esteem was restored, she began to be able to stimulate Kate more pleasantly. The mother's conscientious and experienced care was obvious to the observer as well as her rigidity and trial-and-error method of dealing with the baby's needs. Her play was described as nagging, teasing. She played very roughly with the baby, throwing her down repeatedly on a toy that squawked and failing to observe the baby's anxious, apprehensive expression. The mother showed little sensitivity to Kate's subtler cues, hut, when Kate fussed, the mother responded instantly with a process of elimination of possibilities. The mother's insensitivity was further illustrated hy her behavior when she wanted the baby to sleep. As one observer put it, "She seemed to IJe determined that the baby should sleep." She slapped the hahy on the hack and said repeatedly and firmly, "Go to sleep," until the baby finally slept. The mother expressed no open hostility to the baby, but prohablv was defending against unconscious hostility when she told
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many horrendous tales of mothers who neglected their infants and added, "Wasn't that terrihle?" She cited as an example how many mothers let their children cry without trying to take care of them and how many mothers left their babies feeling thirsty. She naively praised herself, her infant, her other four children and their many accomplishments, It was noted that as the mother talked constantly about someone else, she watched her baby with interest and smiled warmly at her from time to time during the test. Although she saw herself as a very good mother, there were lengthy periods in which the mother sat talking and did not watch the baby or interact with her. As one can correlate Kate's later difficulties with disturbances in the mother-in Iant rclationshi p, the infantile affective climate, one can also correlate her later strengths with the positive aspects of this same relationship. There were a number of periods during the observation when the mother perceived the hahy's needs dearly. She held the baby supportivcly, though not caressingly, and was sensitive to and tolerant of the baby's movements. She picked up a toy for the baby over and over with perfect cheerfulness in spite of her own obvious fatigue. When she was diapering the baby, she smiled and cooed back to the baby as the baby cooed at her. In the same way at the age of twenty-eight weeks, Kate experienced alternating states of cheerful wakefulness and states of depression-withdrawal such as those described hy Engel and Reichsman. She had periods in which she was awake and happy, either entertaining herself or responding appropriately to her mother, and periods in which she was quite awake, but lethargic and passive. These states of passivity could either go toward wakefulness and cheerfulness depending upon the stimulus, or toward depressionwithdrawal state. The depression-withdrawal state was seen in her excessive sleep, her lassitude, her passivity, and her inability to retain her food. She was an extremely undemanding baby and apparently, according to one observer, seemed to shift for herself. The early psychological and hiological models of the afTective state felt hy the adult as depression can be seen in Kate's withdrawal into sleep and inactivity as a response to her mother's depressed moods and aggTessive overstimulating play. Her motor development
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was slow, in part, because of the need to sleep in order to withdraw from and perhaps cope with a particular kind of unsatisfying environment. At the same time, Kate's withdrawal gave mother time to do the extraordinary amount of work she seemed to require in order to repair her self-esteem. Restored, the mother could then stimulate Kate happily and take care of her, though even then somewhat rigidly and insensitively. 'Ve found that tendencies toward a depressed ou tlook on 1iIe and toward insatiable longings could he seen in Kate when she was five, twelve, and fifteen. These same tendencies can he observed in their earliest form in the material recorded when she was twenty-eight weeks of age. The depressed tendencies are apparent at that age in her lassitude, apathy, and feeding difficulties. It is also relevant to the continuation of Kate's difficulties that her mother has continued to react wi th depression to her problems through the past eighteen years. She has com hatted her depressions with constant hard physical labor that preoccupied her, thereby continuing and reinforcing the emotional climate of her relationship with her daughter as well as the climate of the girl's inner life.
SUMl\IARY
The psychoanalytic literature about the affective state of depression locates the origin of this state, in its varying degrees, in the first year of lilc. The cases of infantile depression reponed previously were those of severe depression in response to the absence of the mother; no cases of less severe d isu nhaurcs have been examined. This paper is an attempt to document the theoretical assumption of the etiology of depression hy examining the occurrence of depression in a "normal" twenty-eight-week-old infant who lived in an intact family. The precursors of the depression noted later in life were evidenced at that age hy excessive sleep, lassitude, delayed motor development, and regurgitation with concomitant malnutrition. Kate's depressive outlook was observed at ages five, twelve, and fifteen. I Icr problems were rooted in her response to her mother's handling of her. The mother was sufrcring from symptoms of estrogen clcficiency, and fighting to stave off her own depressed moods hy extreme activity. Her constant productive activity
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restored her self-esteem so that she could stimulate her baby very happily at times, hut it also required a gTeat deal of time and energy which made her too content with Kate's inactivity and withdrawal. This well-documented case illustrates the psychoanalytic theory regarding the time of origin of depression, and the way that the infant follows the mother into a depressed mood.
REFERENCES BE:>;EIlEK, T. F. (19:'6), Toward the biology of the depressive constellation, j. ArneI'. Psychoanal. Assn" 4:389-427. BE;o.;.JA~ll:>;,.J, D., ET Al.. (1!l62), Panel discussion, This [ournal, 1:59-66. BRAZEl.TON, T. II, (I!lG2), Obscrvat ions of the neonate, This journal, 1:38-58. EN(;El., G. 1.. & REICII,~fAN, F, (1!l:,G), Spontaneous and experimentally induced depressions in an infant with a Rastric fistula. l- All/a, Psvrhoanul, A.lsn., 4:428-4:'2. Esc.\ r.ox A, S. K. & HEIDER, G. M. (1959), Prediction and Outcome: A Study ill Child Deoclopment, New York: Basic Books, - - I.EITCII, M., ET AL. (1952). Early phases of personality development: a non-normative study of infant behavior. Monogr. Soc, Res, ill Child Drurlpnt., XVII, Serial 1\:0. 5·1,1\:0. 1. GINSI'AR(;, S., i\[oRIARTY, A.. & MI'RI'IIY, 1.. B. (196:», Young teenagers' responses to the assassination of President Kcnnedy: relation to previous life experiences. In: Children alld till' Death of a President: Multi-Disciplinary Studies, cd. M. 'Vo!fenstein & G. Kl iman, Garden City, N.Y.: Doubleday, pp.I-33. MURI'HY, 1.. B. (I!lG2). The Il'idellillg Il'orld of Childhood: Paths Toward Must crv, New York: Basic Books. SI'ITZ, R. A. (194G), Anaclitic depression, The Psychoanalytic Study of the Child, 2:3133-12. :'\"w York: International Universities Press. - - (l~lij5), The First Year of Lilc. New York: Int ernat ionnl Universities Press.
.lOO Il
Dttuid so n, 1\1./) .
De pr ession is defined as an em otional state characteri zed by hopelessn ess, low spirits, Iat iguc, a nd leth arp;y. It occu rs in all people, goi ng in th e " no rmal" ran ge lrom mild unhappin ess to d epr essions th a t occ u r in people in reactio n to a seve re lo ss, i.e. , " reacti ve depressions." Depression is presen t as a predom inant symptom in a wide ran ge of pati en ts d iagn osed as " ne urotic" a nd "psycho tic." Psych oanal yt ic th eor y tra ces t he orig in of clinical depressions to exper iences of th e a ffected person in the first yea r of life. Thou gh m an y papers have b een wr itten a bo u t th e d yn ami cs o f ad ult d epression , few cases o f infa nti le d epression ha ve been d escr ib ed . T hose cases o f in fan tile d epression re po rted in th e Ii teratu re descri be ch ild re n wh o arc sufferi ng from ne gl ect ca used h y physical separa tio n from the mot her (Spitz, I !11Ii) or by th e mot her's wi thd ra wal du e to her feelings abo ut an abnormali ty in the in fan t ( Fngcl and R eirhsm an , I !1:;li ). ' Vh ile these auth o rs af.,JTee th a t th e et io logy o f depression lies in mil d to seve re di sturban ces in th e in-
Dr, D uui d son 1I'as a Fello w at IIII~ M I'llIl ill gl'r Foundation , T opek a, I\ //I/.\a,\ 1I. he ll II,i ,\ I/(J/'I'r 1I'as written. I 1I'o llirl lik « 10 express my de l'l' gra titude to Dr. Lois 11. Murph» f or III'r g/'II/'W IIS hd/l 10 / 1/( ' ill tr ri lin g this Imller. Sh e n ot on ly sha re d her rirh data , but a lso llt'ry kiudlv licl p rt l tn c tlt ink throug]: an tl rI a rif)' ronrcpt s. Thi s jltlj}('r is largel» b asrt! 0 11 un pub lisli cd dut a a / 1111' ,\I l'1l11 illg e r Foundation, co ll ected W Id er U SP A S G rant s Mil 27, r hir] in vrst ig% n l i rs. S. Esra lonn (llld lIf. Leitch, Gra llt lIf 6SIl all/I lIfll Ii/Il ll), ch it'! iu vcst iga tov [Jr. I .o i , II . M url'h y . Th e dat a a l l responses to th e K cnn edv a.I.I/LISilla t io ll wert: co llect ed " jw d //l tlll y liy I Jr. 0·J. M o ria rt», S. ( ;i,llj/(Jrp;. mul c. 1. ,\I orp;a II .
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Iant's affective climate during the first year of life, they describe only extreme conditions of depression. These authors do not delineate the types of mother-child interactions which cause the milder forms of adult depression. Those who have written about infantile depression and depression generally have theorized about, but have not cited, specific case material to demonstrate the milder cases. I am going to describe a state of mild, chronic depression in a twenty-eight-weekold infant. My hypothesis is that if data are available on the infancy of a person who is depressed, one ought to be able to see signs in the infant's affective state that would be the infantile counterpart of the adult's experience of depression. Such symptoms, seen in this infant, are lassitude, repeated regurgitation, poor muscle tone, and excessive sleeping. In 194G Spi tz introduced the term "affective climate" to designate the totality of forces which influence development in the infant. This is a somewhat elusive concept to define, but refers to the subtle expressions of emotion including tone of voice, facial expression, degree of muscular tension, mode of holding the baby, etc., which convey and evoke a mood within the infant. In his most recent analysis of the emotional development of the infant in his book The First Year of Life) Spitz (1965) discusses the importance of the emotional signals generated by maternal moods and what these moods convey to the infant. He states: These exchanges between mother and child go on uninterruptedly, without the mother necessarily being aware of them. This mode of communication between mother and child exerts a constant pressure which shapes the infantile psyche. I do not say that this pressure produces anything in the nature of unpleasure for the infant. I speak of "pressure" only because the words to convey these extraordinarily subtle and intangible exchanges have never been coined.... Pressure and giving way alternate and comhine to influence now one function, then another among those wh ich un fold wi th rna tura tion, retarding some, Iaci Iitating others, Spitz emphasizes the fact that traumatic events playa very small role in the infant's emotional development. He states, "what we see again and again are the cumulative results of iterative cxpcricnces and stimuli of endlessly repeated sequences of responses." In the
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same wo rk Spitz states, " I ha ve r each ed the cond usion th at the ch ild ca n ide n tify o n ly with cert a in characteristics of beh avior o n th e one hand and certa in glo ba l all 'cc ts of the ohj ect on the other." Spitz cites Anna Freud's di scussion of a child's rel ationship to a depressed m ol her. She r em a rk ed th at th e chi ld's beh avior doe s n o t rellcrt a process o f sim ple iden tification . Th e moth er 's depressive m ood ge nera tes in th e ch ild an in clin ation toward depressive tenden cies. Th e depressed m other r etreat s from the ch ild, and th e child, in Anna Fre ud's words, " fo llo ws her into th e d epressive nH)( )'I." An na Freud m ad e it d ea r th a t she considers thi s phc uo n u-no n to be in the n atu re or " in fecIion " and th at i t is n ot an im ita tion o f the mother 's ges t ur es wh ich produces thi s mood in the child. The child simply respond s to the affective climate, n ot to the cause of the affe ct : he is thus infected hy the affective dim at e. En gel a nd R ei ch sman ( I ~l:") (i) proposed that two basic processes ca n he see n in th e d evelopment of wh at they saw as a " n ucle ar psychod yna m ic rons tc lla tio u" whi ch is " de prcs soge nir :" and simi lar to th e sta te described by Bened ek ( 105(i) as a " de pressive con stellation." The fir st ba sic process is th e in di vidual's ph ysical withdraw al fr om hi s env iron men t, th e r ecogn ition of the n eed for r educed activity in th e face of actual or threaten ed ex ha us tio n or lack of what is needed from the extern al world. En gel and R ei chsrnan state that this process is at first predominantl y som atic, perh aps a basic respo nse of all cells and organ isms which in hi gh er organisms may ac h ieve psych ic r epr esentation as a basic ego sta te, a war n ing mecha n ism . Th e seco n d ba sic process, Ben edek 's "ambival ent core," also h as a bi ol ogi cal source in th e pro cess o f alim entati on . Linked with hun ger a nd sa tia tion it pro vides th e ba sis for the estab lishmen t of th e sym b io tic unit and th e format ion o f o hject re la tions hips. Its ea rl iest psychi c deri vati ons are the processes of in trojec tion and projection, whi ch mechani sm s regulate th e formation o f the "good-bad" as pects of self and object representations and thereby establish the con d itions whereb y aggr ession is tu rn ed inward. A t later stages of d evel opment aggression turn ed in ward ma y al so ac tiv a te m emory tr aces o f feelings o f helpl essn ess togeth er with corres po n d ing hi ologi cal ph enomena , characte ristic o f th e first ba sic m echanism. Enge l a nd R cirhsruan then concl ude th at th e devel opment o f d epression
Dep ression in a "Normal" Chi ld
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in th e indi vidual ha s n o t on ly an ac tive oral introjective b eg in n ing, hut a lso an inact ive, preobjcct origin . In co n tr ast to th e in acti ve phase, th e acti ve phase is restitu tive, an attempt to re- establish the indi vidu al' s lost o bject r elat ionship th rough introj ection . Slee p is co ncep tu alized by En gel an d Reichsman as on e way in wh ich an indi vidual can achi eve wi thd raw al from th e env iron me nt in wh at th ey de scribe as th e in acti ve, preobject phase of d epression. The ph en omen on of wi t hdra wa l into sleep as a very ea r ly d e fen se on th e part o f th e infant is d escribed by Brazelton (1962) a nd Ben jam in et al. ( I!Hj 2). In th e di scu ssion o f Brazelton 's paper, J ohn Ben jamin says that th e a ppa re n t sta tes of slee p, in cluding EEG changes, ca used by r epetition o f a stim ul us, are we ll kn own. He cites work indicating th at th e m ore intense the stimuli , th e more effect ive th ey are in producing EEG changes and sleep. If psych oanalytic theory is co rre ct , one should be able to find in infants precursors of adult d epression, although th ese precursors might not be observed in man y infants. With this a im, o ne would exa mi ne a nd look spcc ifira lly for signs of lethargy, in activity, and wi thdrawa l du rin g th e first year o f li fe. F rom th e point of view d escri bed by Sp itz and Anna Freud , o ne wo u ld st udy th e m other's m ood s an d th e kind o f emo tiona l sign al that she gives to th e infant as she cares for him . Th e case I shall d escribe is th at o f a girl wh o ha s been st ud ied inten sivel y since she was tw enty-eight weeks old (Esca lo n a and H ei d er, 1!15!1; Escal ona and Leitch , 1%2; Murph y, 19(2). She was sel ect ed alo ng with o thers as a n infant free from defect. Kate ha s show n evi de nce o f depression a t severa l periods in her d evelopment. Th ese will he d escri bed bel ow . There has been n o se pa ration from th e m other, but th e effect of the emotio na l climate on th e infant co n for med to the conc ep ts d evel oped by Anna Freud and Spitz. In thi s case, there is co ns ide ra b le evidence that th e mother's m ood s con tr ib u ted to th e infant's emotional pattern an d to respo nses which have persisted to the present, even th ough they are su ccessfully balanced by th e gi rl's vi gorous active ex plo ra tio n of the e nvi ro n me n t for many kinds o f gr a tifica tion . At seve n tee n, she is acti vel y pursuing her sch ool and soc ial career. Wh en Kate was five, she was descr ibe d by H ei der as p hys ically frail and far fro m health y m ost o f her life ( Escalo na a nd H e id er , ]!15!1). A t th e same tim e , a
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pediatrician described her as "an underweight and rather pale child who appears to l ie nervous and unhappy." She showed no signs of warmth or interest in the observer or the examiner and her full energy was spent on giving her mother "a hard time." Povl T'oussicng, the psychiatrist who interviewed her, found her play typical of a girl at the height of the oedipal period. I Iowcver, her allen ,,'.IS c ontrollcd and distant; she appeared flattened emotionally. For example, she spoke of her dead kitten very callously, but at the same time appeared to identify with the kitten who had not been cared for, and who had fallen downstairs and died. She was concerned about her looks and obviously feminine in her behavior, but played almost exclusively with the masculine-aggressive toys. She used the exammer to further her interests, but there was no warmth or spontancn.y in the interaction. The psychiatrist stated, "She meets stress by increased activity and proud self-control." He also commented on her withdrawal and avoidance and rq~ression to a more immature status when under stress. 'Vhen Kate was eight, she was a very slender girl who gave the overall impression of mastering things fairly well. The examining psychiatrist, Keith Bryant, commented that she kept her fields of interest "very narrow and constricted and took things a bit too seriously." She was very quiet and self-contained and did not chat. Povl Toussieng described her as a "lanky beanpole" at the age of twelve. The expression of her eyes was "darkened by sadness, sullenness, and bitterness." She continued to be reserved, wanting to be self-sufficient. She had a very depressed outlook on life, and her memory revolved almost exclusively around all the disappointments she had ever had. Her emotional life was dominated by intense bitterness and anger. She conveyed to the psychiatrist a feeling of misery in the past and in the present, a feeling of utter suffering. Kate still sucked her thumb, was constipated and very thin. Lois Murphy saw her two years later and described her as "a quite well-organized and cllic.ient girl who is genuinely enjoying the activities at school, at her own church and her friend's church, hunting expeditions with her father and brother, and clothes." While the psychiatrist's earlier interview focused on Kate's perception of her inner world, Murphy's interviews focused on the ways the girl was able to cope with the outer world at the later period. She
Depression in a "Normal" Child
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went to weekly social gatherings at one church and monthly gatherings at a ch urch of another denomination. The validity of the psychiatrist's impression of latent troubled feelings appears in Kate's responses to the questionnaire circulated following President Kennedy's death. Kate made statements that indicated a tendency to "both a psychosomatic and a depressive response." In response to the questions about how she felt when she first heard the news she said, "I felt sick .... I also wanted to die. I felt there was no reason for living. It seemed to me life was over for everything." Since Kate showed signs of misery, unhappiness, and depression at the ages of five, twelve, and fifteen, and since psychoanalytic theory da tcs the onset of depression to the first year of life, I reviewed the extensive information about this girl in infancy. I was looking for evidence of anlage of depression in Kate herself and for a disturbance in the mother-baby climate in order to clarify the onset of her difficulty. Escalona and Leitch observed the mother and Kate together for about four hours when Kate was twenty-eight weeks old, took a movie of the mother feeding Kate, and had a follow-up visit at home. Kate was described as an attractive, delicate, rather thin, feminine-looking infant who smiled readily and responsively: a very attractive, but decidedly immature infant for her age. She was extremely sensitive to light and became very irritable when the lights were put on for taking a movie. This was because she was receiving atropine for her feeding difficulty. Her mother avoided letting Kate cry, "It gives them had habits." While she rarely cried, she Whimpered plaintively when uncomfortable. Anxiety during the examination was implied in her high sensitivity to skin stimulation, totally irregular breathing, and hy her sober and alarmed expression when she first saw the examiners. Her anxiety upon seeing them calmed after a few minutes, and although she displayed evidence of anxiety from time to time later, at no time did she fight or cry. She Whimpered a little during her mother's rough play with her. Three areas of functioning were noteworthy: her sleep was excessive, motorir development was retarded, and she regurgitated frequently so much that she did not gain weight properly.
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First I shall describe Kate's sleep as observed and as reported hy the mother. The mother reported that Kate slept excessively and I infer that this was Kate's response to her mother's depressed moods. The mother did not stimulate the baby, and the baby withdrew and responded with lassitude when she was with the mother at these times. The mother reported Kate's sleep habits in terms of glowing praise and appeared to he very content to have such an inactive, agreeable baby. She said she had "never had a baby nor seen one who slept so much, was so little trouble, and was so good." The mother praised Kate's ability to take two two-and-a-half-hour naps each day and sleep twelve hours each night: a total of seventeen hours of sleep each twenty-four-hour period at twenty-eight weeks. During the four-hour observation period, Kate was quiet except when stimulated; she slept an hour and forty minutes. She moved little during her nap, stirring slightly when the group laughed loudly, hut did not awaken until stimulated hy her mother. The mother's attitude toward Kate's slow motor development and excessive sleep is shown in her comment, "She has been a little slow to try to sit up or anything because she has been asleep so much of the time and I've had so little time to train her." Her muscular development was undifferentiated and uncoordinated for her age. Objects tended to slip away from her grasp when she tried to take hold of them, hut she held on very, very firmly once she got them within her grasp. Escalona stated, "Her legs kicked gently, but she made no attempt to draw her knees under in a creeping position. The development of her coordination in her hands was far above that of her legs. She tended to go after things with both hands rather than using one, and there was no evidence of well-developed, fine motor coordination. In the standing position she did not unbend her legs and was unable to support even a fraction of her weight." I infer from this gencrally immature muscular development that Kate spent so much time in a depressed sleep that she had been unable to mature in this way. She simply had not exercised enough to develop her motor skills. For example, at this stage, she should have been practicing stiffening her legs preparatory to standing. She also should have had a better developed ability to grasp.
Depression in a "Normal" Child
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The third area of disturbed functioning was Kate's nutrition. In this area Kate suffered from severe problems during this, the oral period of her life. Despite adequate food intake, she was thin and undernourished. (She weighed 8 pounds, 7% ounces at birth and at one year weighed only 17 pounds, 4 ounces. She merely doubled her birth weight instead of tripling it as infants usually do.) Constant regurgitation kept her from digesting the food she ingested. The milk frequently was regurgitated, undigested, as long as four hours after a feeding. In an analogy to the way that she was unable to hold onto her food, she was unable to keep a steady hold on pleasant fcelings and on her contact with her mother, due to her mother's alternating depression and defensive flight into activity. In contrast, perhaps as another way of coping with her constant emotional and partially physiological starvation, Kate grasped and held onto things in the environment, as well as her thumb, with tenacity. The tenacity was commented on by Escalona when Kate was seen at twcnty-eight weeks as follows: During the psychological tests, two observations were made which I do not recall having made on any other baby of similar age. One occurred in the situation where the baby holds one cube and is offered a second one. The usual pattern for the child who is not yet able to hold two objects at the same time, upon perception of the second cube, is to drop the one they have in hand and reach for the one that is being offered. Not so Kate, who while holding the first cube looked alertly at the second, seemed faintly puzzled and bothered by being offered the second, but either held onto the onc she held or dropped it only to resccurc it rather than attempting to get the proffered cube, This observation was checked upon four times in all and she reacted in precisel y the same manner Oil each occasion. It nlay be related to this that, considcring how passive and agreeable this baby is in all other aspects, it was rather difficult to remove objects from her gTasp. She did not cry at such times, hut she held onto the object tightly and it was necessary to divert her attention in order to remove the toy. Grace Heider, who analyzed the infancy data of the coping project, said that Kate's tenacity was, to her mind, a striking feature of the baby, particularly in contrast to her usual passivity and in contrast to the other in fan ts in the series.
Joan Davidson Kate could not hold onto good feelings. However, she was able coo and laugh happily when playing alone and could laugh rapturously at the moving shadows on the wall. She spent as much as seventeen hours out of twenty-lour in the depression-withdrawal state of passive apathy or sleep, hut could awaken to smile and laugh when stimulated hy the environment. The foundations of her emotional memories included chronic hunger despite adequate feeding, depression, and a tenacity of purpose to hold onto what she did have. In addition, Kate was, at twenty-eight weeks, very discriminating in her sensory development. She appeared joyful when watching the moving shadows, laughed and "jumped for joy" when she saw her brother and lather, and chuckled gleefully when naked. She perceived accurately her mother's mood and responded in a disrriminating way. For example, she laughed and cooed when her mother spoke to her smilingly, apathetically drifted 011' into sleep when her mother was depressed, and looked alarmed when her mother dropped her roughly into her c.r ib. Difficulties with feeding, nutrition, and oral gratification began shortly alter birth when Kate hegan spitting up. Kate started to suck her thumb at one month of age and screamed all night when her mother put mittens on her to stop her. The mother gave in somewhat reluctant! y and rational izcd the th urn h sucking on the grounds that the pediatrician had said the hahy needed it. '\Then Kate was five months old, the mother was ohliged to wean her. The mother was having "hot flashes" and her physician started to give her cstrogcn injections which stopped lactation. The mother gave Kate milk from a cup and stated that "she liked it, hut it was hard to keep her awake for the cup feedings." Kate refused the bottle at first so the mother would take Kate's thumb out of the sleeping baby's mouth and insert the nipple. Kate then accepted the rubber nipple, hut at twenty-eight weeks was still "fussing" every time she was given the bottle. Escalona recorded: to
Then as the mother oilers the bottle to the baby, the baby whines and docs not accept the nipple into her mouth. Now the mother inserts the nipple into her open mouth and she spits it out. The bahy whimpers, then as mother presents the nipple to her mouth, she closes her mouth on it, sucks momentarily and then whimpers
Depression in a "Normal" Child
531
again and spits the nipple out. The mother says, "She never gets over complain ing about the rubber nipples for a little while at the beginning." The mother offers it again, and again the baby rejects it. The mother says, "Well, don't you want it?" and then decides to discontinue offering the bottle. The mother felt that the only problems she had had with Kate were the regurgitation beginning at birth with consequent slowness to gain weight and the thumb sucking which began at three months. The regurgitation, often almost projectile vomiting, was seen as a problem but was accepted calmly by the mother. She said, "All my babies vomited and I did, too, the whole nine months I carried them." Kate's mother rigidly and conscientiously followed the pediatrician's advice for dealing with this problem and gave Kate atropine regularly. In contrast to the conscious acceptance of Kate and her need, the mother presented a somewhat different picture to the observer. Escalona described the movie of the feeding as follows: Solid feeding: The baby is held in a half-sitting posItIOn, the mother's grasp on her shoulder and arm is not overly tight but very confining. The entire feeding struck us as somehow "mechanical." The mother shovels the food into the baby's mouth, frequently scraping her chin to collect food which has run out of the baby's mouth and refeeding it. The baby throughout shows a remarkable lassitude. The mother does not wait for signs of readiness on the baby's part. Frequently, the spoon is pushed between the baby's closed lips. At first the baby allows this to happen and swallows a portion of each spoonful, but toward the end therc arc definite movements of avoidance which appear to lack encrgy and push, however. Throughout, communication between mother and baby appears to be minimal. The baby moves very little. Because Spitz and Anna Freud have emphasized the importance of the infant's response to the mother's depressive moods, the data about the mother were also studied. The mother poured out a torrent of information during the four hours the baby was being studied; all this was volunteered under the stress of her situation. No attempt was made at a psychiatric interview with her. Kate's mother was in her early forties at the time of Kate's (the fifth child) birth. She was an intelligent and attractive woman, well gToomed,
Joan Davidson dficien t, ani ve in many afl'airs. She was under acu tc strcss because of a move and change in the family's circumstances. She had begun to sutler from estrogen deficiency due to the onset of the mcnopa use as we II as from periods of severe depression. She deseri bed periods or severe despondency after Kate's birth together with headaches and weight gain. She stated that she managed her "hlue spells" hy IJeing extremely arr ive and busy. For instance, she said, "If I want something for the house, I don't ask for it, I just get busy and earn the money." She had painted and redecorated a dcrrcpit old house and had converted it into pleasant living quarters. In addition to caring for the house and sewing for her daughters, she was very active in the family business and in her church. During the observation this mother dung with voice and eye contact to at least one of the team members and talked incessantly in a poorly modulated and high-pitched voice. For example, one observer commented, "My question precipitated an avalanche of material." The mother's overactivity as shown by incessant movement and talking as well as her accounts of her heroic feats of work at home further contributed to a partial withdrawal from Kate and threw Kate back on her own resources. This overactivity was necessary for the mother to repair her self-esteem, but prevented her from giving adequate stimulation to her baby. However, once the mother's self-esteem was restored, she began to be able to stimulate Kate more pleasantly. The mother's conscientious and experienced care was obvious to the observer as well as her rigidity and trial-and-error method of dealing with the baby's needs. Her play was described as nagging, teasing. She played very roughly with the baby, throwing her down repeatedly on a toy that squawked and failing to observe the baby's anxious, apprehensive expression. The mother showed little sensitivity to Kate's subtler cues, hut, when Kate fussed, the mother responded instantly with a process of elimination of possibilities. The mother's insensitivity was further illustrated hy her behavior when she wanted the baby to sleep. As one observer put it, "She seemed to IJe determined that the baby should sleep." She slapped the hahy on the hack and said repeatedly and firmly, "Go to sleep," until the baby finally slept. The mother expressed no open hostility to the baby, but prohablv was defending against unconscious hostility when she told
Depression in a "Normal" Child
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many horrendous tales of mothers who neglected their infants and added, "Wasn't that terrihle?" She cited as an example how many mothers let their children cry without trying to take care of them and how many mothers left their babies feeling thirsty. She naively praised herself, her infant, her other four children and their many accomplishments, It was noted that as the mother talked constantly about someone else, she watched her baby with interest and smiled warmly at her from time to time during the test. Although she saw herself as a very good mother, there were lengthy periods in which the mother sat talking and did not watch the baby or interact with her. As one can correlate Kate's later difficulties with disturbances in the mother-in Iant rclationshi p, the infantile affective climate, one can also correlate her later strengths with the positive aspects of this same relationship. There were a number of periods during the observation when the mother perceived the hahy's needs dearly. She held the baby supportivcly, though not caressingly, and was sensitive to and tolerant of the baby's movements. She picked up a toy for the baby over and over with perfect cheerfulness in spite of her own obvious fatigue. When she was diapering the baby, she smiled and cooed back to the baby as the baby cooed at her. In the same way at the age of twenty-eight weeks, Kate experienced alternating states of cheerful wakefulness and states of depression-withdrawal such as those described hy Engel and Reichsman. She had periods in which she was awake and happy, either entertaining herself or responding appropriately to her mother, and periods in which she was quite awake, but lethargic and passive. These states of passivity could either go toward wakefulness and cheerfulness depending upon the stimulus, or toward depressionwithdrawal state. The depression-withdrawal state was seen in her excessive sleep, her lassitude, her passivity, and her inability to retain her food. She was an extremely undemanding baby and apparently, according to one observer, seemed to shift for herself. The early psychological and hiological models of the afTective state felt hy the adult as depression can be seen in Kate's withdrawal into sleep and inactivity as a response to her mother's depressed moods and aggTessive overstimulating play. Her motor development
Joan Davidson
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was slow, in part, because of the need to sleep in order to withdraw from and perhaps cope with a particular kind of unsatisfying environment. At the same time, Kate's withdrawal gave mother time to do the extraordinary amount of work she seemed to require in order to repair her self-esteem. Restored, the mother could then stimulate Kate happily and take care of her, though even then somewhat rigidly and insensitively. 'Ve found that tendencies toward a depressed ou tlook on 1iIe and toward insatiable longings could he seen in Kate when she was five, twelve, and fifteen. These same tendencies can he observed in their earliest form in the material recorded when she was twenty-eight weeks of age. The depressed tendencies are apparent at that age in her lassitude, apathy, and feeding difficulties. It is also relevant to the continuation of Kate's difficulties that her mother has continued to react wi th depression to her problems through the past eighteen years. She has com hatted her depressions with constant hard physical labor that preoccupied her, thereby continuing and reinforcing the emotional climate of her relationship with her daughter as well as the climate of the girl's inner life.
SUMl\IARY
The psychoanalytic literature about the affective state of depression locates the origin of this state, in its varying degrees, in the first year of lilc. The cases of infantile depression reponed previously were those of severe depression in response to the absence of the mother; no cases of less severe d isu nhaurcs have been examined. This paper is an attempt to document the theoretical assumption of the etiology of depression hy examining the occurrence of depression in a "normal" twenty-eight-week-old infant who lived in an intact family. The precursors of the depression noted later in life were evidenced at that age hy excessive sleep, lassitude, delayed motor development, and regurgitation with concomitant malnutrition. Kate's depressive outlook was observed at ages five, twelve, and fifteen. I Icr problems were rooted in her response to her mother's handling of her. The mother was sufrcring from symptoms of estrogen clcficiency, and fighting to stave off her own depressed moods hy extreme activity. Her constant productive activity
Depression in a "Normal" Child
535
restored her self-esteem so that she could stimulate her baby very happily at times, hut it also required a gTeat deal of time and energy which made her too content with Kate's inactivity and withdrawal. This well-documented case illustrates the psychoanalytic theory regarding the time of origin of depression, and the way that the infant follows the mother into a depressed mood.
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