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# Bathing routines in different infant placement settings: an ethological study

Edwige Ducreux, Guadalupe Puentes-Neuman

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Edwige Ducreux, Guadalupe Puentes-Neuman. Bathing routines in different infant placement settings: an ethological study. Early Child Development and Care, 2020, 192 (1), pp.83-94. 10.1080/03004430.2020.1739027. hal-04475977

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# Bathing routines in different infant placement settings: an ethological study

Edwige Ducreux & Guadalupe Puentes-Neuman

To cite this article: Edwige Ducreux & Guadalupe Puentes-Neuman (2020): Bathing routines in different infant placement settings: an ethological study, Early Child Development and Care, DOI: 10.1080/03004430.2020.1739027

To link to this article: https://doi.org/10.1080/03004430.2020.1739027

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Published online: 13 Mar 2020.

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# Bathing routines in different infant placement settings: an ethological study

Edwige Ducreux a, b, c and Guadalupe Puentes-Neuman a

aDépartement de psychologie, Université de Sherbrooke, Sherbrooke, QC, Canada; bInstitut National Supérieur du Professorat et de l'Éducation (INSPE), Académie de Lille – Haut de France; cPSITEC Lab (Université de Lille)

## ABSTRACT

This study used an ethological approach to explore the behavioural adaptation of nineteen infants during their first six weeks in Residential Care (RC), or a Foster Family (FF) or an Infant-Mother Centre (IMC). Direct observations were conducted once a week at bath time. Observed behaviours were: sleep-wake states, visual exploration, motor activity, facial and vocal expressions. Non-parametric analyses showed that, in RC, the duration of bathing was the shortest and babies expressed more crying and withdrawal and less locomotor abilities and vocalizations. By contrast, in IMC, the bathing time was the longest and babies spent the least time in crying and showed the most locomotor abilities and vocalizations. The placement in FF showed intermediate results. This study showed sleep-wake states and behaviours that found variable expression depending on the placement environment and therefore could be considered as markers of the baby's adaptation to his placement milieu in follow-up quantitative studies.

## ARTICLE HISTORY

Received 27 November 2019
Accepted 3 March 2020

## KEYWORDS

Baby; adaptation;
institutionalization; foster
family; observation; bath

## Introduction

### Consequences of placement for the infant's development

Numerous studies agree in showing the negative influence of an institutional or foster home placement during the child's earliest years. When compared with control groups, babies having experienced institutional or foster care present more behavioural problems (Dubois-Comtois et al., 2015; Hoksbergen, ter Laak, van Dijkum, Rijk, & Stoutjesdijk, 2003; Jacobsen, Moe, Ivarsson, Wentzel-Larsen, & Smith, 2013; McGoron et al., 2012; Tan & Marfo, 2016; Torres, Maia, Veríssimo, Fernandes, & Silva, 2012) attachment problems (Gabler et al., 2014; Katsurada, 2007; Torres et al., 2012; Vorria et al., 2003) and delayed psychomotor development (Hanson, Jawad, Ryan, & Silver, 2011; Kroupina et al., 2015).

Studies done in institutions show that certain of their characteristics augur poorly for the child's development (Groark & McCall, 2011). Across countries, institutions are generally characterized by a high children-to-caregivers ratio (Groark & McCall, 2011) that induces the establishment of rigid routines aimed at maintaining efficient personnel with little regard for the needs of the child (Bakermans-Kranenburg et al., 2011). Notably, a high children-to-caregivers ratio precludes acting in a sensitive manner (Vorria et al., 2003) and therefore limits the child's opportunities to form secure and selective attachments (Bakermans-Kranenburg et al., 2011; Zeanah, Smyke, Koga, & Carlson, 2005).

In foster care, several studies emphasize the link between the expression of problem behaviours in foster children and a past marked by maltreatment, the number of previous placements, and the age

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at which they were placed in foster care (Oosterman, Schuengel, Slot, Bullens, & Doreleijers, 2007; Taussig, 2002). However, the foster family's own behaviour plays a crucial role in these children's development (Stovall & Dozier, 2000). Notably, the foster parents' sensitivity in the family is a predictor of the quality of the attachments and the development of problem behaviours (De Schipper, Oosterman, & Schuengel, 2012; Gabler et al., 2014).

Finally, an alternative placement solution has been tested in countries like Europe, USA, Canada and Australia (Kohlhoff & Barnett, 2013; Savonlahti et al., 2005) whereby residential intervention is offered for mothers and their babies. Most of these initiatives aim at treating specific maternal problems, such as psychiatric symptoms (Phillips, Sharpe, & Nemeth, 2010) or substance abuse (Savonlahti et al., 2005), and studies have shown positive outcomes in maternal psychopathology and infant behaviour (a decrease in sleep disturbances and attachment problems) (Phillips et al., 2010; Savonlahti et al., 2005). However, even if this option can possibly prevent potential removal and placement of the child, these residential care programmes do not constitute a placement setting where the parental capacities of the mother are evaluated in order to determine placement of the child or termination of parental rights. In Québec, an Infant-Mother Centre carry out the mandate of intervention and evaluation of the mother's parental capacities. However, no published data exists to assess the adaptation of infants to this specific placement, nor do we know how it compares to alternative placement options.

The placement of a child implies an adaptation to a new life. However, most studies are either retrospective or centred only on the presence of behavioural and attachment problems. Moreover, the babies' behaviour is not recorded prior to age 11 months in studies of residential or foster care. Thus, to study the newborn's behavioural adaptation to various types of placement in the first few months of life, we must turn to the general literature on infant development as a comparison standard.

## Baby's development

Developmentally, babies come equipped with a variety of behavioural and regulatory mechanisms that facilitate their transactions with the environment. They are capable of regulating their sleep-wake states to adjust themselves to environmental stimuli (Brazelton & Nugent, 2001). The newborn can work his state into a protest when assailed by stimuli exceeding his tolerance threshold. Moreover, alert attention, useful for exploring his environment, is distinguished from withdrawal (shifting glances, little facial mimicry), which constitutes a state of protection expressed by the baby when facing an environment perceived as aggressive (Brazelton & Nugent, 2001).

Concerning visual exploration, at birth, babies can explore their environment thanks to a functional and well-organized visual system (Schlesinger, Johnson, & Amso, 2014). The neonate can recognize the general characteristics of a stimulus and can show visual preferences, notably for faces (Valenza et al., 2015). Visual exploration requires physical maturation as well as learning by experience (Fogel, Garvey, Hsu, & West-Stroming, 2006).

From birth, the baby is also armed with reflexes and global rhythmic movements that will become more complex motor activities depending on both maturation and environmental stimulation (Lima-Alvarez, Tudella, van der Kamp, & Savelsbergh, 2014). Concerning locomotor abilities, pedalling movements of the legs appear in the first weeks of life and happen increasingly within the first months as precursors to crawling at 4-6 months (Thelen, 1981). As for postural abilities, the tonic neck reflex develops into raising of the head to 90° at 2 or 3 months (Lima-Alvarez et al., 2014). Regarding manipulative abilities, the grasping reflex, present at birth, progressively develops into fine motor skills within 6 months (Molina & Jouen, 2004).

Smiles and vocalizations are present at birth and increase in frequency over the first months largely as the result of parental reactions (Keller, Otto, Lamm, Yovsi, & Kärtner, 2008; Mendes & Seidl-de-Moura, 2014). Babies also manifest mouth movements (opening or puckering, tongue protrusion) from birth in response to similar movements by the adult, which shows the neonate's precocious imitative abilities (Nagy, Pilling, Orvos, & Molnar, 2013). Like vocalizations, from the second
month, mouth movements are accompanied by adult-directed attention and motor excitation (Mendes, Seidl-de-Moura, & de Oliveira Siqueira, 2009). By 3 months, mouth movements diminish (Kugiumutzakis, 1999), before integrating a 'call structure', which is a combination of facial and vocal expressions with associated motor excitation functioning to gain attention from social surroundings (Rouchouse, 1978).

## Current study

The current study observed babies' adaptation in three placement settings: Residential Care (RC, France), Foster Families (FF, Québec) and Infant-Mother Centre (IMC, Québec). The approach taken here is exploratory and ethological. Characterized by naturalistic and observational methods, ethology is concerned with ontogenesis and the adaptive character of behaviours and therefore is particularly relevant for the study of the earliest mutual adult-newborn adaptations (Bowlby, 1969; Sloman, 2016). This paper presents portions of a larger study which includes feeding times and caregiver-infant social interaction as unique windows into the newborn's adaptive and social behaviours (Paul, Dittrichova, & Papousek, 1996). Bathing was targeted as an observational context common to all placement settings, while reflecting the routines characteristic of each environment. Bathing offers the baby an opportunity to discover his physical environment and the extent of his motor abilities, in a social context (Karl, 1999). In the present paper, only bathing routines are considered.

Objective 1: To describe the ways in which newborns adapt to their placement environment, by observing their behaviours during the first six weeks of their placement and assessing associations among behaviours as well as the effect of growth. The development of these behaviours is then compared with developmental milestones as generally described in the literature. The differences noted are discussed in terms of newborns' means of adapting.

Objective 2: To determine whether the newborns' behavioural adaptations differ according to the type of placement.

## Method

### Participants

Babies were recruited as they entered their placement. For each participant, informed consent was obtained from the child's biological parent or legal guardian, and from the foster family if applicable. The high participation rate (95%) minimized selection bias because participation was voluntary. Babies were included in the study if they were between 0 and 3 months old at placement. Nineteen babies were selected, including 8 babies placed in a French RC, 5 placed in FF and 6 placed in the IMC (Table 1). At the beginning of data collection, babies in the younger group (Age-1, *n* = 13) ranged in age from 1 to 2 weeks (M = 1.30 weeks, S.D. = 0.48); the older group (Age-2, *n* = 6) ranged in age from 5 to 12 weeks (M = 7.83 weeks, S.D. = 2.4). Case records indicated that babies were placed for the following reasons: pending adoption (8), maltreatment (3), at-risk situation (8). All babies were in their first placement.

### Characteristics of the placements

The RC sample were recruited in the nursery of a residential care operated by the French Child Welfare Service. The nursery staff – six childcare workers, an educator and three night workers – can accommodate up to 7 children aged 0–3 years. For each baby, two childcare workers are assigned as primary caregivers, prioritizing his care to increase the chances of establishing specific attachment figures. The recruitment of FF was conducted through child protective services in Québec. Three families participated in the study. One of them received each of the three youngest babies on separate occasions (babies I, J and K). The IMC is an intensive intervention boarding facility serving
<figure><img src="image_12.png" /><figcaption>**Table 1.** Sample characteristics.</figcaption></figure>

<table><thead><tr><th>Babies</th><th>Age group</th><th>Sexe</th><th>Reason for placement</th></tr></thead><tbody><tr><td>RC</td><td></td><td></td><td></td></tr><tr><td>A</td><td>1</td><td>Girl</td><td>PA</td></tr><tr><td>B</td><td>1</td><td>Boy</td><td>PA</td></tr><tr><td>C</td><td>1</td><td>Girl</td><td>PA</td></tr><tr><td>D</td><td>1</td><td>Boy</td><td>PA</td></tr><tr><td>E</td><td>1</td><td>Girl</td><td>PA</td></tr><tr><td>F</td><td>1</td><td>Girl</td><td>M</td></tr><tr><td>G</td><td>1</td><td>Boy</td><td>ARS</td></tr><tr><td>H</td><td>2</td><td>Boy</td><td>ARS</td></tr><tr><td>FF</td><td></td><td></td><td></td></tr><tr><td>I</td><td>1</td><td>Boy</td><td>PA</td></tr><tr><td>J</td><td>1</td><td>Boy</td><td>PA</td></tr><tr><td>K</td><td>1</td><td>Girl</td><td>PA</td></tr><tr><td>L</td><td>2</td><td>Girl</td><td>M</td></tr><tr><td>M</td><td>2</td><td>Boy</td><td>ARS</td></tr><tr><td>IMC</td><td></td><td></td><td></td></tr><tr><td>N</td><td>1</td><td>Boy</td><td>ARS</td></tr><tr><td>O</td><td>1</td><td>Boy</td><td>ARS</td></tr><tr><td>P</td><td>1</td><td>Girl</td><td>ARS</td></tr><tr><td>Q</td><td>2</td><td>Girl</td><td>ARS</td></tr><tr><td>R</td><td>2</td><td>Boy</td><td>M</td></tr><tr><td>S</td><td>2</td><td>Boy</td><td>ARS</td></tr></tbody></table>

Abbreviations: RC: Residential care; FF: Foster Family; IMC: Infant-Mother Centre; PA: pending adoption; M: maltreatment; ARS: at-risk situation; Age-1: 1–2 weeks old; Age-2: 5–12 weeks old.

mothers who experience significant difficulties adjusting to parenthood. Each mother receives daily assistance by specialized psychoeducators who oversee and provide guidance about the physical and emotional care she gives to her child. The assessment of parenting skills is then taken into account in judicial placement decisions. This centre is unique in its mandate in the whole of Quebec.

## Procedure

During the first six weeks of their placement, babies were observed with a focal sampling method once a week in the context of a bathing session (114 sessions observed). The session included undressing, soaping, immersing, routine care (e.g. wiping nose), dressing and finally settling baby down. Caregivers were asked to proceed as usual in order to maximize the study's ecological validity. As videography was forbidden in all of the placements, inter-observer reliability was established from video tapes recorded in a French nursery involving 9 babies (5 in Age 1 and 4 in Age 2) with each baby observed three times using the same measures as in the main study (sleep-wake states recorded in duration, behaviours recorded in frequency). Reliability was thus based on 27 recorded sessions, which is 23.7% of the 114 sessions observed live in the main study. Independent coding by the principal investigator and a research assistant yielded inter-rater agreements from 90.4% (sleep-wake states) to 93.9% (other behaviours)

## Measures

Observed behaviours were: sleep-wake state (alert, asleep, drowsy, crying, withdrawn), visual exploration, motor activity (postural abilities: maintaining/straightening the neck; manipulation abilities: grasping/manipulating; locomotor abilities: moving, pedalling), smile, mouth movements, vocalization. Duration and frequency measures were expressed relative to the length of the bathing session. Participants were grouped by age (Age-1 or Age-2), and the factor of time was tested within-subjects by comparing the results from the first three weeks of observation (Time 1: T1) vs the second three weeks (Time 2: T2).
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## Statistical analysis

Given the small sample size and non-normality of the data, non-parametric statistical tests were used. Preliminary analyses were conducted to determine baseline means and to assess correlations (Spearman) among study variables (Objective 1). Then, to describe the babies' modes of adaptation (Objective 1), non-parametric tests targeted the potential effects of age and time on the baby's development. Finally, to determine the influence of placement modality on babies' adaptation (Objective 2), a Kruskal-Wallis (K-W) test with post-hoc Mann-Whitney signed rank tests was conducted. Alpha = .05. However, as this is an exploratory study, certain highly pertinent although marginally significant differences (p < .10) were flagged for discussion.

## Results

### Preliminary analyses

Descriptive analysis and correlations were conducted across variables for the total sample (N = 19) to determine baseline means and to assess potential associations among the study variables.

The strong correlation obtained between the mean percentage of time spent asleep and drowsy ($r_{(17)} = .725; p < .01$) led to the grouping of these two states under the category 'sleepy'. The mean percentage of time spent crying was negatively correlated with the mean duration of bath times ($r_{(17)} = -.519; p < .05$) and positively correlated with the time spent in withdrawal ($r_{(17)} = .700; p < .01$). Additionally, the mean frequency of vocalizations was positively correlated with that of mouth movements ($r_{(17)} = .547; p < .05$) and the mean duration of bath times ($r_{(17)} = .806; p < .01$), and negatively correlated with the mean time spent crying ($r_{(17)} = -.617; p < .01$). Together, these results suggest that the time allotted to bathing may contribute to whether it is experienced as a stressful or a stimulating activity. Finally, positive correlations were noted between the mean frequency of locomotor abilities and that of mouth movements ($r_{(17)} = .493; p < .05$) and of vocalizations ($r_{(17)} = .793; p < .01$), which seems to confirm the appearance of a 'call structure' combining facial and vocal expressions with motor excitation (Mendes et al., 2009; Rouchouse, 1978).

### The effects of age and time on the expression of babies' behaviours

Mann-Whitney and Wilcoxon tests determined respectively the effect of age and time on the development of the babies' activities/behaviours. Table 2 presents the means and S.E.s for each age group

<table><caption>Table 2. Activity, sleep-wake states and behaviours of babies as a function of Age.</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Age 1 (n = 13)</th><th colspan="2">Age 2 (n = 6)</th><th rowspan="2">Mann-Whitney<br/>p Value</th></tr><tr><th>M</th><th>SE</th><th>M</th><th>SE</th></tr></thead><tbody><tr><td><strong>Activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Bath period</td><td>18.85</td><td>1.33</td><td>16.97</td><td>2.40</td><td>0.335</td></tr><tr><td><em>Sleep-wake states</em></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Alert</td><td>72.59</td><td>3.66</td><td>80.27</td><td>8.14</td><td>0.293</td></tr><tr><td>Crying</td><td>16.31</td><td>2.61</td><td>16.47</td><td>7.20</td><td>0.599</td></tr><tr><td>Sleepy</td><td>8.30</td><td>2.34</td><td>0.65</td><td>0.34</td><td>0.009**</td></tr><tr><td>Withdrawn</td><td>2.80</td><td>0.70</td><td>2.61</td><td>0.95</td><td>0.792</td></tr><tr><td><em>Behaviours</em></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Visual exploration</td><td>76.82</td><td>8.06</td><td>74.10</td><td>13.03</td><td>0.999</td></tr><tr><td>Postural abilities</td><td>3.58</td><td>0.98</td><td>2.47</td><td>0.61</td><td>0.930</td></tr><tr><td>Manipulation</td><td>1.38</td><td>0.46</td><td>2.45</td><td>1.10</td><td>0.265</td></tr><tr><td>Locomotor abilities</td><td>1.58</td><td>0.52</td><td>10.67</td><td>6.07</td><td>0.280</td></tr><tr><td>Vocalization</td><td>13.80</td><td>3.99</td><td>34.09</td><td>19.04</td><td>0.629</td></tr><tr><td>Smile</td><td>1.72</td><td>0.78</td><td>15.00</td><td>6.34</td><td>0.036*</td></tr><tr><td>Mouth movement</td><td>11.32</td><td>1.97</td><td>7.20</td><td>1.55</td><td>0.483</td></tr></tbody></table>

Measurement units: Bath time: mean duration (min); Sleep-wake states: mean percentage of time (%); Behaviours: mean frequency (behaviours per hour).

<footnote>*p < .05; **p < .01; ***p < .001.</footnote>
<figure><img src="image_14.png" /><figcaption>**Table 3.** Activity, sleep-wake states and behaviours of Age-1 group as function of Time.</figcaption></figure>

<table><thead><tr><th rowspan="2">Variable</th><th colspan="2">Time 1 (n = 13)</th><th colspan="2">Time 2 (n = 6)</th><th rowspan="2">Wilcoxon<br>p Value</th></tr><tr><th>M</th><th>SE</th><th>M</th><th>SE</th></tr></thead><tbody><tr><td><strong>Activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Bath period</td><td>19.68</td><td>1.24</td><td>18.08</td><td>1.50</td><td>0.055</td></tr><tr><td><em>Sleep-wake states</em></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Alert</td><td>67.00</td><td>4.69</td><td>78.13</td><td>3.50</td><td>0.019*</td></tr><tr><td>Crying</td><td>15.98</td><td>2.92</td><td>16.50</td><td>3.20</td><td>0.600</td></tr><tr><td>Sleepy</td><td>13.79</td><td>3.55</td><td>2.94</td><td>1.25</td><td>0.002**</td></tr><tr><td>Withdrawn</td><td>3.23</td><td>0.81</td><td>2.44</td><td>0.72</td><td>0.116</td></tr><tr><td><em>Behaviours</em></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Visual exploration</td><td>64.79</td><td>8.97</td><td>88.58</td><td>10.39</td><td>0.039*</td></tr><tr><td>Postural abilities</td><td>3.21</td><td>0.89</td><td>4.02</td><td>1.22</td><td>0.530</td></tr><tr><td>Manipulation</td><td>1.18</td><td>0.46</td><td>1.57</td><td>0.56</td><td>0.263</td></tr><tr><td>Locomotor abilities</td><td>0.96</td><td>0.60</td><td>2.06</td><td>0.70</td><td>0.123</td></tr><tr><td>Vocalization</td><td>9.58</td><td>2.17</td><td>17.75</td><td>6.04</td><td>0.099</td></tr><tr><td>Smile</td><td>1.96</td><td>1.28</td><td>1.79</td><td>1.18</td><td>0.575</td></tr><tr><td>Mouth movement</td><td>13.45</td><td>3.50</td><td>9.81</td><td>2.26</td><td>0.701</td></tr></tbody></table>

Measurement units: Bath time: mean duration (min); Sleep-wake states: mean percentage of time (%); Behaviours: mean frequency (behaviours per hour).

and the Mann-Whitney test results for the entire data set. Tables 3 and 4 present the means and S.E.s for each time (T1, T2) and the Wilcoxon test results respectively for the younger (Age-1) and the older (Age-2) groups.

The percentage of time spent sleepy was significantly less in Age-2 than in Age-1 (see Table 2). In Age-1, the percentage of time spent sleepy was significantly greater, and time spent in alert wakefulness significantly less in T1 than in T2 (see Table 3). In Age-2, the percentage of time spent in alert increased significantly over time (see Table 4). We note too that the percentage of time spent crying decreased in T2, although no significant differences were found (see Table 4).

Contrary to expectations, the frequency of visual exploration did not vary as a function of babies' age (see Table 2). The very high expression of visual exploration manifested by the youngest babies in RC and in FF, in comparison with IMC's babies might partly explain why no effect of age was found (RC(Age-1): *M* = 83.89bph, *SE* = 7.64; FF(Age-1): *M* = 96.85bph, *SE* = 18.21; IMC(Age-1): *M* = 40.34bph, *SE* = 4.95). Nevertheless, we note an effect of time on visual exploration among the youngest

<table><caption>**Table 4.** Activity, sleep-wake states and behaviours of Age-2 group as function of Time.</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Time 1 (n = 13)</th><th colspan="2">Time 2 (n = 6)</th><th rowspan="2">Wilcoxon<br>p Value</th></tr><tr><th>M</th><th>SE</th><th>M</th><th>SE</th></tr></thead><tbody><tr><td><strong>Activity</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Bath period</td><td>16.21</td><td>2.35</td><td>17.74</td><td>2.43</td><td>0.028*</td></tr><tr><td><em>Sleep-wake states</em></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Alert</td><td>76.90</td><td>8.65</td><td>83.93</td><td>7.71</td><td>0.046*</td></tr><tr><td>Crying</td><td>19.20</td><td>7.91</td><td>13.43</td><td>6.60</td><td>0.116</td></tr><tr><td>Sleepy</td><td>1.14</td><td>0.64</td><td>0.13</td><td>0.13</td><td>0.109</td></tr><tr><td>Withdrawn</td><td>2.76</td><td>0.80</td><td>2.52</td><td>1.18</td><td>0.753</td></tr><tr><td><em>Behaviours</em></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Visual exploration</td><td>66.12</td><td>10.74</td><td>82.10</td><td>18.45</td><td>0.249</td></tr><tr><td>Postural abilities</td><td>1.36</td><td>0.46</td><td>3.67</td><td>1.38</td><td>0.116</td></tr><tr><td>Manipulation</td><td>1.10</td><td>0.53</td><td>4.00</td><td>1.92</td><td>0.138</td></tr><tr><td>Locomotor abilities</td><td>7.21</td><td>4.09</td><td>14.26</td><td>8.18</td><td>0.144</td></tr><tr><td>Vocalization</td><td>27.69</td><td>18.38</td><td>40.09</td><td>20.08</td><td>0.043*</td></tr><tr><td>Smile</td><td>15.48</td><td>7.60</td><td>15.24</td><td>6.34</td><td>0.893</td></tr><tr><td>Mouth movement</td><td>6.34</td><td>2.93</td><td>7.70</td><td>2.52</td><td>0.893</td></tr></tbody></table>

Measurement units: Bath time: mean duration (min); Sleep-wake states: mean percentage of time (%); Behaviours: mean frequency (behaviours per hour).

<footnote>*p < .05; **p < .01; ***p < .001.</footnote>

<footnote>*p < .05; **p < .01; ***p < .001.</footnote>
<figure><img src="image_15.png" /><figcaption>**Table 5.** Activities, sleep-wake states and behaviours of babies as function of type of placement.</figcaption></figure>

<table><thead><tr><th rowspan="2">Variable</th><th colspan="2">RC (n = 8)</th><th colspan="2">FF (n = 5)</th><th colspan="2">IMC (n = 6)</th><th rowspan="2">Kruskal-Wallis<br>p Value</th></tr><tr><th>M</th><th>SE</th><th>M</th><th>SE</th><th>M</th><th>SE</th></tr></thead><tbody><tr><td><strong>Activity</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Bath time</td><td>15.04</td><td>0.42</td><td>16.98</td><td>2.14</td><td>23.61</td><td>1.80</td><td>0.007**</td></tr><tr><td><strong>Sleep-wake states</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Alert</td><td>67.50</td><td>3.39</td><td>80.20</td><td>9.29</td><td>80.70</td><td>6.23</td><td>0.162</td></tr><tr><td>Crying</td><td>23.07</td><td>2.37</td><td>15.47</td><td>8.19</td><td>8.18</td><td>2.56</td><td>0.021*</td></tr><tr><td>Sleepy</td><td>5.38</td><td>1.67</td><td>2.30</td><td>1.27</td><td>9.54</td><td>5.04</td><td>0.311</td></tr><tr><td>Withdrawn</td><td>4.05</td><td>0.89</td><td>2.03</td><td>1.27</td><td>1.58</td><td>0.23</td><td>0.021*</td></tr><tr><td><strong>Behaviours</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Visual exploration</td><td>88.19</td><td>7.90</td><td>81.16</td><td>15.33</td><td>55.33</td><td>10.30</td><td>0.116</td></tr><tr><td>Postural abilities</td><td>4.60</td><td>1.43</td><td>2.65</td><td>0.53</td><td>1.87</td><td>0.78</td><td>0.329</td></tr><tr><td>Manipulation</td><td>1.08</td><td>0.52</td><td>1.90</td><td>0.79</td><td>2.42</td><td>1.16</td><td>0.382</td></tr><tr><td>Locomotor abilities</td><td>0.82</td><td>0.63</td><td>2.00</td><td>0.93</td><td>11.33</td><td>5.86</td><td>0.015*</td></tr><tr><td>Vocalization</td><td>2.81</td><td>1.06</td><td>15.15</td><td>5.18</td><td>47.62</td><td>15.69</td><td>0.004**</td></tr><tr><td>Smile</td><td>3.55</td><td>1.36</td><td>7.17</td><td>7.03</td><td>8.02</td><td>5.34</td><td>0.344</td></tr><tr><td>Mouth movement</td><td>11.92</td><td>2.66</td><td>5.70</td><td>1.53</td><td>11.08</td><td>2.42</td><td>0.178</td></tr></tbody></table>

Measurement units: Bath time: mean duration (min); Sleep-wake states: mean percentage of time (%); Behaviours: mean frequency (behaviours per hour).

babies, with significantly greater visual exploration in T2 than in T1 (see Table 3). There were no significant effects of age or time on the expression of motor activity (see Tables 2–4). However, we note that the frequency of locomotor abilities was higher in T2 than in T1 for both age groups (see Tables 3 and 4) and that, in oldest babies, the frequency of maintaining/straightening the head and of grasping/manipulation is higher in T2 than in T1 (see Table 4). Finally, the frequency of smiling was significantly greater in Age-2 than in Age-1 (see Table 2) and the frequency of vocalization tended to be greater in T2 than in T1 in both age groups (see Tables 3 and 4).

## The influence of type of placement on the expression of behaviours

Table 5 presents means and *SEs* for each placement type (RC, FF, IMC) and the results of the K-W omnibus tests. Post-hoc comparisons were indicated when K-W signified a significant main effect. We also made the post-hoc comparisons using Bonferroni corrections. Although this more conservative procedure yielded somewhat fewer significant differences, particularly when the comparisons involved FF, our analyses comparing the three types of placement remained substantially similar with or without the corrections. As our research is exploratory, it was decided to report exhaustively all pair-wise comparisons, even when labelled marginal.

Bath time duration was longer in IMC than in RC ($z = -3.10, p < .01$) and in FF ($z = -2.01, p < .05$). The percentage of crying was significantly greater in RC than in IMC ($z = -2.84, p < .01$) and tended to be higher than in FF ($z = -1.61, p < .10$). The percentage of withdrawal is significantly greater in RC than in FF ($z = -2.05, p < .05$) and in IMC ($z = -2.45, p < .05$). The frequency of locomotor abilities was significantly greater in IMC than in RC ($z = -2.69, p < .01$) and tended to be greater than in FF ($z = -1.64, p < .10$). Finally, RC's frequency of vocalization was significantly lower than in IMC ($z = -2.71, p < .01$) and tended to be lower than in FF ($z = -1.69, p < .10$). Moreover, the frequency of vocalization tended to be higher in RC than in FF ($z = -1.83, p < .10$).

## Discussion

### Effects of growth

The time spent in alert wakefulness is very high (>70%), whatever the age group, reflecting bath time's stimulating nature (Karl, 1999). Moreover, we observed a reduction in time spent sleeping

<footnote>*p < .05; **p < .01; ***p < .001.</footnote>
<figure><img src="image_16.png" /></figure>

and an increase in alert wakefulness as infants aged. Infants' disposition to discover and interact with environment (Brazelton & Nugent, 2001) is therefore incremental from birth. However, the relatively important expression of crying demonstrates that bathing can also be a stressful activity. Indeed, the different types of intervention involved in bathing (undressing, soaping, immersing, routine care) can be felt as unpleasant by babies (Karl, 1999). The expression of withdrawal is concomitant with crying and thus seems to be induced by fatigue resulting from protests (Brazelton & Nugent, 2001). However, the decrease in crying over time, among the oldest, indicates that babies are able to adapt quickly to the conditions of the bath episode.

Visual exploration was the most active behaviour observed in this early period and its increase over time among the youngest babies confirms that this ability increases from the first month (Fogel et al., 2006). Concerning motor activities, although no effect of growth was seen, the more important expression of maintaining/straightening the head and of grasping/manipulation over time among the oldest babies highlights the transition that occurs between reflexes and the development of more complex postural and manipulative skills, around the age of two to three months (Lima-Alvarez et al., 2014; Molina & Jouen, 2004). Moreover, the more important expression of locomotor abilities over time, in both age groups, is consistent with the literature (Thelen, 1981) and demonstrates that the bath is conducive to the expression of pedalling movements in particular, contrary to what is generally observed during the feeding context, which is rather characterized by muscular relaxation (Ducreux et Puentes-Neuman, submitted; Paul et al., 1996).

In accordance with the literature (Keller et al., 2008; Kugiumutzakis, 1999; Mendes & Seidl-de-Moura, 2014), we observe an increase in smiles and vocalizations as babies aged, and not in mouth movements. Furthermore, the low expression of the smiles was expected since this behaviour is triggered in the first weeks of life by primary sources of satisfaction (satety, heat) (Emde, 1991), whereas bath time exposes the baby to temperature changes and interventions that can be uncomfortable for him. On the contrary, the high frequency of mouth movements and vocalizations, in a context that does not favour expressions of well-being, and the link established between these two behaviours and locomotor skills suggests that these two behaviours are expressed by the baby to manifest his excitement.

Objective 1 of this study was to describe babies' adaptation to their placement environment by observing their behaviour during bathing routines, and assessing associations among behaviours as well as the effect of growth. Our results suggest that bath time may be a stressful or a stimulating activity which challenges the baby's adaptational capacities. In general, growth effects follow patterns established in the literature, except for visual exploration, which will be detailed in the following section. Finally, an influence of the environment was observed on the expression of babies' behaviours, even those for which the effect of growth was observed as expected.

## Environmental influences

Preliminary analyses show that time allotted to bathing, a variable relative to way placement settings handle everyday routines, may contribute to making this experience stressful. Indeed, in RC, the bath time was the shortest and babies exhibited more crying and withdrawal and less global motricity and vocalizations than babies in other placements. Thus, in RC, the bath period seemed to be mainly a stressful activity. This result may be explained by the number of babies for whom the workers must care at any one time. Sometimes alone to care for seven babies, they do not always have the time to insure the coregulation of the baby's states during the more stressful phases of bathing. These results seem to confirm that the high ratio of children-to-caregivers induces the establishment of rigid routines that precludes acting in a sensitive manner and considering the needs of the child (Bakermans-Kranenburg et al., 2011; Groark & McCall, 2011; Vorria et al., 2003). By contrast, IMC's bath durations were the longest, enabling mothers to meet their child's needs and make bathing a mainly stimulating activity. Indeed, IMC's babies showed less crying and more locomotor abilities and vocalizations than the other babies. Finally, the differences noted between FF's babies
and RC's and IMC's, are not significant but of the order of the trend, placing foster care in an inter-
mediate position.

Otherwise, the very high expression of visual exploration seen in the youngest babies in RC and FF
may explain why, in our data, age did not affect this behaviour, contrary to expectations (Fogel et al.,
2006). Moreover, this suggests that the newborns confronted by the loss of the mother figure
expressed a greater need to explore their new world. This interpretation is consistent with a need
for security experienced at the very earliest age (Bowlby, 1969). Thrust into a completely novel
environment, the baby would seek security through wide-ranging exploration in search of repairs
for his losses. This increased exploration of the environment is manifested only by the younger
babies, indicating that this behavioural adaptation is characteristic of newborns.

The second objective of this study was to explore the impact of placement settings on the behav-
ioural adaptations of newborns. Our results show that placement conditions have an important
influence on the infants' visual exploration abilities. As well, sleep-wake states, locomotor abilities
and facial and vocal expressions are affected by the time and attention afforded to the baby by
the caregiver.

Practical implications

Although the institution recruited for this study has benefited from the improvements suggested by the practice-oriented research of the 50s and 70s (Aubry-Roudinesco & David, 1952; Rapoport & Lévy, 1977), it appeared as the least stimulating of the three placement types. Our results suggested that the main deficiencies result from the lack of sufficient time and sensitive attention given to the babies, which agrees with previous studies (Bakermans-Kranenburg et al., 2011; Groark & McCall, 2011; Vorria et al., 2003). At the structural level, the high children to caregivers ratio seems to induce the establishment of rigid routines aimed at maintaining efficient personnel with little regard for the needs of the child (Bakermans-Kranenburg et al., 2011; Zeanah et al., 2005). In France, the institutional placement for very young infants is carried on while favouring a tie between the child and his biological family. In conferring on the institution a role of evaluating the parents during their visits, this measure is intended to leave some time for the parents to show progress in confronting their problems before administrators decide on a permanent situation for the child. The IMC seeks to achieve the same objective, while supporting the development of the mothers' parenting skills.

Indeed, in the IMC, the mothers, under constant supervision by psychoeducators, accorded more
time and active attention to their baby and, as a result, the babies show more optimal development.
Therefore, this modality of placement should be proffered, whenever possible, while reserving tem-
porary placement for specific cases (adoption, physical or psychological danger for the baby).

In our study, the foster care seemed to occupy an intermediate position with regard to its impact
on the babies' development. Past research suggests that previous placements and relational history
may hinder adaptation to the foster family (Oosterman et al., 2007; Taussig, 2002), but the current
sample were either at their first placement or placed from an early age. Thus, this intermediate pos-
ition rather reminds us the difficult role of a foster family, being given the position of temporary guar-
dian (David, 1994; Gillis-Arnold, Crase, Stockdale, & Shelley, 1998). The development of an impersonal
rapport limited mainly to basic needs can be a strategy followed by foster parents to protect them-
selves from making an emotional investment that could be severed at any moment. However, that
attitude hinders the baby's opportunities to develop the array of behavioural and interactive abilities
(De Schipper et al., 2012; Dubois-Comtois et al., 2015; Gabler et al., 2014). To the contrary, the quality
of the fostering relationship ought to be based on empathy and close attention to the baby in order
to understand and respond to the utmost to his needs (David, 1994; Stovall & Dozier, 2000). Our
results highlighted therefore the importance of specific training and support resources for prospec-
tive foster families, with a specific focus on the development of caregiver's sensitivity to the child's
signals (Lamour & Barraco, 1998).
<figure><img src="image_17.png" /></figure>

## Advantages, limitations and perspective

This exploratory study is the first to focus on the adaptive processes of babies assigned for placement during their first months of life. The ethological method used here, by its observational and naturalistic approach, confers ecological validity on the results and fills the gaps in the retrospective or indirect measures often used to describe the behaviour profiles of placed children. Moreover, with its evolutionary perspective the ethological approach allows us to understand the origins of the baby's reactions and to view them in terms of adaptive strategies rather than problem behaviours. This approach is of major importance for clinical research, as it does not stigmatize the individual, but rather highlights the potential actions of his relational environment.

The novelty of this study is also in its detailed examination of three types of placement one of which, the IMC, has never previously been evaluated from a scientific perspective. The observed links between the babies' behaviours and the characteristics of the three placement modalities have permitted us, to a certain degree, to outline the strengths and weakness of the target environments. In addition, a multi-case analysis of intra-placement differences observed among foster families might well reveal the sources of the foster family's intermediate position between the other two placement modalities. Moreover, the small sample did not afford strong external validity and encourages to pursue follow-up studies on this age range with regard to the impact of early experiences on the babies' development.

## Conclusion

This study showed sleep-wake states and behaviours that found variable expression depending on the placement environment and therefore could be considered as markers of the baby's adaptation to his placement milieu in follow-up quantitative studies.

## Acknowledgements

We would like to acknowledge Professors Caroline Desombres and Célénie Brasselet for their careful reading, advice, and time, and Professor John Belmont for his precious help with the translation. Additionally, for their generous support we would like to thank the University of Sherbrooke, (Québec, Canada) and the Institut National Supérieur du Professorat et de l'Éducation (INSPE) Académie de Lille - Haut de France.

## Disclosure statement

No potential conflict of interest was reported by the author(s).

## Funding

This work was supported by International Council for Canadian Studies [grant number 27/01/2009]; Ministère français délégué à la recherche [grant number 2003/2004]; Université de Sherbrooke [grant number 124827].

## Notes on contributors

Edwige Ducreux - Specialized in human ethology, Lecturer at the Institut National Supérieur du Professorat et de l'Éducation (INSPE, Lille), Research Associate at the PSITEC lab (University of Lille) and Associate Professor at the Department of Psychology of the University of Sherbrooke, Edwige Ducreux's research interests focus on the development of the child within his family and his community. Her research on infants placed for maltreatment or adoption has been the subject of training for professionals working in early childhood, in France as in Quebec. Her postdoctoral research, based on the father-child activation relationship, led to the development of an observational evaluation grid to qualify this relationship in vivo during periods of free play. The implementation of this evaluation tool in the services offered by the Youth Program Directorate of the Estrie Health and Social Services Centre helped to offer fathers services adapted to their expectations and specific characteristics. Finally, her current studies focuses on the child's adaptation to school. In teaching as in research, she works on the development of educational or intervention practices, aimed at giving back empowerment to the child and of his relational environment.
*Guadalupe Puentes-Neuman* is a clinical psychologist and an associate professor at the Department of psychology in the Université de Sherbrooke, Longueuil campus. Her clinical and research activities revolve around parent-infant relations and their impact on the child's socioemotional development.

ORCID

Edwige Ducreux http://orcid.org/0000-0003-1788-9064

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