Psychomotor Functioning of Children with
Psychiatric Disorders
Claudia Emck1, Ruud Bosscher2 & Theo Doreleijers3
Vrije Universiteit, Amsterdam, The Netherlands
1,2
Faculty of Human Movement Sciences
3
Medical Faculty
Abstract:
Children with psychiatric disorders often show disturbances and peculiarities in
psychomotor functioning. Although studies about specific groups on specific areas of
motor functioning exist, a broader investigation of psychomotor functioning on relevant
aspects for diverse psychiatric disorders is lacking.
This presentation aims to give an overview of knowledge derived from scientific studies
on psychomotor functioning of three subgroups, children with emotional (anxiety,
depression), developmental (autism spectrum) and behavioural (hyperactivity and
conduct) disorders. Psychomotor functioning in children is defined as a compound
developmental area, which contains two main ingredients: movement behaviour and
body image. Concretely, delays in motor development, fine and gross motor functioning
are important domains, as are physical fitness, perceived motor competence, play
behaviour, bodily experience and body image.
Subsequently, preliminary results of our empirical study will be presented. We are
testing a group of psychiatric children with the following battery: the test of gross motor
development (TGMD-II - Ulrich, 2000), a Dutch fitness test (MOPER) (Leyten et al
1982), questionnaires on perceived motor competence and physical appearance
(CBSK M and Ph - Veerman et al 1997; Van Rossum & Vermeer 2000), a Dutch
standardised clinical psychomotor observation (PMDC) (Hammink 2003), a behavioural
inventory (CBCL: parent version and TRF: teachers version) (Achenbach & Rescorla
2001), questionnaires on social behaviour (VISK) (Luteijn et al 2002) and psychiatric
symptoms and syndromes (DISC and Auti-R) (Ferdinant & van der Ende 2002;
Berckelaer-Onnes & Hoekman 1991), in order to describe possible psychomotor
profiles of the specific groups of children. Consequences for psychomotor indication,
therapy, evaluation and research will be discussed.
Introduction
From our point of view, the main task we are facing, in next years, is the development
of a European, or even cross-Atlantic international, framework for psychomotor
therapy. We hope this framework will go beyond national conventions and integrates
specific psychomotor knowledge and practice. We also hope to contribute to ideas
exchange, which will stimulate the effectuation of such framework.
We will briefly discuss the present state of knowledge about psychomotor functioning in
children with psychiatric disorders. The main themes are discussed in light of their
practical relevance for psychomotor therapy. Than we will discuss psychomotor
diagnostics, tests and instruments used in clinical practice and research.
You may wonder why we focus on “psychiatric disorders”. After all, much work of
psychomotor therapists in Europe takes place outside the medical field (e.g.: in
schools). To explain this choice, we have to contradict our earlier proposition about
going beyond national conventions. In fact, in The Netherlands most child practitioners
are working within a psychiatric unit or centre. Therefore, Dutch psychomotor therapists
are trained to use developmental psychopathology and psychiatric classification as a
frame of reference, besides psychomotor theory.
However, there is more. Especially in Anglo-Saxon research literature on child therapy,
DSM-IV fourth edition, (Diagnostic and Statistical Manual of Psychiatric Disorders, APA
1994) is the rule. If we want to join the scientific debate on therapy effects on an
international level, research oriented psychomotor therapists (just like psychiatrists and
psychologists) have to be able to understand and discuss pathology in DSM-IV terms.
From a clinical perspective, it is helpful to describe children who seek help by their
psychiatric complaints. As a therapist, it is relevant to know whether a child has a “full
blown” depression, a posttraumatic stress disorder or mixed features of both anxiety
and mood disorders. Clear language about pathology is necessary to make good
clinical decisions. As a matter of fact, the development of multidisciplinary clinical
guidelines, in USA and The Netherlands, is based on psychiatric diagnostic categories.
Psychomotor therapists participate in tasks forces to develop these national guidelines.
However, a DSM-IV classification is too narrow for our discipline. We have to combine
psychiatric classification with a more dimensional approach on psychomotor
functioning. Therefore, we need scientific information of psychomotor functioning in
relation to specific disorders and additional data regarding the specific psychomotor
profile of each particular child.
Subgroups
Firstly, we will divide three distinguishable psychiatric subgroups of childeren with
psychiatric disorders.
1. Emotional disorders: these children are characterized by internalisation of their
problems; they are silent, anxious, sad or pondering; they rarely annoy their
teachers because they keep their problems to themselves. In DSM-IV terms, we
speak of depression, social phobia or separation anxiety. Sometimes these
children also suffer from enuresis, eating disorders or somatic complaints.
2. Developmental disorders: these children suffer from mild to severe autism;
many suffer also from mental retardation (about 75%, Lord & Rutter, 1994); but
the main area of deficits concerns communication, social development,
restricted and repetitive behaviours and interests. These are the odd kids in
classroom who do not connect with their peers like others do. The Asperger
subgroup is characterized by good language development and normal (or
above) IQ, but show the same problems in social performance.
3. Behavioural disorders: these children are hyperactive, inattentive, oppositional,
and aggressive or deny social, moral or legal rules - that is, they externalise
their problems, causing others (especially teachers) a lot of trouble. By their
way of behaving they provoke negative responses by others and exclusion of
normal activities. This can lead to secondary problems like a negative selfimage, depression or alcohol and drug abuse.
But what do we know about their psychomotor functioning? How can we discriminate
between them? Do they show typical movement behavior or body image problems?
And, if so, are they specific for the group? Do we find peculiarities in psychomotor
functioning that cross the formal boundaries of psychiatric diagnosis?
Emotional disorders
Anxiety influences psychomotor behaviour in several ways. State anxiety, which is, by
definition, short and foregoing, seems to impair motor performance (Hardy et al, 2001;
Payne et al, 1995; Terelak, 1990; Pokrajc, 1982; Weinberg, 1976; Shepard & Abbey,
1958). And trait anxiety, a part of the character, seems to impair the performance
especially on fine, attentionally demanding motor tasks (Calvo et al, 1988). In other
words, anxious children are likely to perform worse on several motor tasks.
Children with (psychiatric) anxiety disorders show high muscle tone, lack of
performance-motivation and anxiety to fail in motor performance situations (Emck,
1997; Emck & Smit, 2000). Sometimes, these children are also deprived in their
movement activities, which results in lagging behind in motor development. Children
with trauma-related anxiety, as in posttraumatic stress disorders, are clinically
characterized by problematic body experiences (like pain and feelings of discomfort)
and negative body image (Lamers-Winkelman, 1997; Emck, 1997; Emck & Smit,
2000). In a screening profile for sexually abused children, Lamers-Winkelman (1997)
describes amongst other a lack of spontaneous movement in play, a stiff, tense and
wooden movement pattern, fear of body contact and dislike of own body.
To what extend these psychomotor phenomena can be influenced is not sure.
However, psychomotor interventions may improve body image, decrease muscle tone
and stimulate spontaneous play behavior.
In depression, several aspects of motor functioning seem to be impaired. This is
possibly explained by neurological disturbances (e.g., Braun et al, 2000, found that
patients with depression and psychomotor lethargy show left hemisphere lesions).
Nevertheless, most studies on this subject concern adults (and some of them to
adolescents). As there are developmental differences in affective disorders, we must
be cautious to generalize these findings to children. Still, some features are likely to be
shared at all ages.
First, decreased energy and fatigue are common in depressed patients. For instance,
Patton et al (2000) found that depressed adolescents were less energetic than normal
controls. This is, even, more profound in severe episodes, when psychomotor
retardation, and sometimes agitation, is seen. Yet, psychomotor agitation and
retardation in adults are also associated with anxiety (Strain & Klicpera, 1984), which
might also be case in children.
Second, psychomotor retardation in depression is associated with reduced ability to
experience pleasure (Lemke at al, 1999). This also concerns movement and body
experiences normally perceived as nice and enjoyable. This is an important theme in
psychomotor therapy for these patients (Bosscher, 1992).
Belgian colleagues stress a third aspect. They found a relationship between physical
fitness, perceived physical ability and body acceptance in depressed patients. In other
words, depressed patients are likely to be in a bad physical condition, which stimulates
the low physical abilities perception and low body self-esteem (Van der Vliet et al
1999).
This could indicate support for psychomotor therapy because that may have a positive
impact on all these features. We agree with Cloitre et al (1993), who found that
recovery in depression is associated with a shift from impoverished and disjointed
movement to a richer, more coherent non-verbal behavior. Again, this may also apply
to children with depressive disorders, especially when considering that they seem to
show less cognitive features (like guilt) and express themselves more in a non-verbal
way (Harrington, 1994).
Developmental disorders
The second group, children with autism and pervasive development disorders, is
characterized by deficits in communication, social development and restricted
behaviour. Which psychomotor features do they show?
In a beam-walking test, Kokobun et al (1996) found that motor performance is worse in
autistic children than in mental retardation ones. Pry et al (2000) compared those
children (aged 5-7 years) with children with psychomotor developmental problems.
Autistic children showed impairment on postural regulation and balance. Primitive
motor patterns and immature motor organisation are also described within a framework
of disturbances of senso-motor development (Van Loon et al, 1997). Body scheme and
body awareness are both disturbed (a non-integrated body image occurs in these
children). Further, Taylor (1994) points out that autism can be associated with
hyperactive behavior. No specific studies were found on physical fitness, perceived
motor competence, but grounded on profound motor problems we expect these
domains also to be impaired. And although autistic children show psychomotor
impairments, it is still unclear if they are related to autism or associated with cognitive
developmental problems.
As developmental disorders are known to be “life time” conditions, it is hard to tell
whether the associated psychomotor problems can be improved by training or therapy,
or not. Instead of trying to focus the deficits, it seems plausible that helping child to deal
with psychomotor problems is more helpful than trying to solve it. It could also be
helpful to improve perceived competence in order to prevent additional emotional
disorders like depression and anxiety (Lord & Rutter, 1994).
Behavioural Disorders
There are three subgroups in children with behavioural disorders: children with
Attention-deficit / Hyperactivity Disorders (ADHD), Oppositional Defiant Disorders
(ODD) and Conduct disorders. The ADHD group is well known for its striking
movement behavior.
But there is also a silent version: the inattentive subtype. Whereas the hyperactive child
is characterized by disturbing motor behaviour* in the classroom, the inattentive child
will not cause such problems. Problems with attention demanding tasks will influence
schoolwork and social interaction in a less obvious way. We have to keep this in mind
while focus on specific psychomotor behavior.
Barkley (1997) states that 52% of ADHD children have motor problems (35% in the
normal population). Fine motor skills, like writing and shoe lacing, are most problematic
(as well in hyperactive and in inattentive subgroups – Whitmond & Clark, 1996; Piek et
al, 1999). Moreover, many of these children show problems in lateralisation and are
left-handed (Reid et al, 2000).
For ADHD children (7-12 years, n= 19), Harvey & Reid (1997) found that gross motor
skills and fitness condition are below average. And impulsivity, which is seen in most
ADHD children, impairs performance in perceptual-motor tasks and is observable as a
clinical feature in gross motor behaviour (Barret, 1984; Emck, 1997).
Further, ADHD children show difficulties in regulating bodily distance and taking social
perspective in sports and games, which leads to interpersonal conflicts with peers
(Emck, 197; Flavell, 1985). They often show disturbing behaviour, like verbal and
physical aggression, which is followed by social exclusion. Because they like to interact
with their peers, rejection will have a negative impact on their self-image (Verhulst,
1997). From this perspective, it is not surprising that co-morbid depression occurs in a
quarter of these children.
For the psychomotor therapist, the question rises on which aspects to focus. Should we
try to improve motor skills, boost fitness, increase control over impulsivity or stimulate
adequate play behaviour and self-image? And what are the chances of a successful
intervention?
*
fidgets with hands, leaves seat, runs / climbs, playing problems, talking, impulsive answering, not waiting
turns, interrupting...
The other behavioural disorders*, oppositional defiant (ODD) and conduct disorders
(CD) often lead to antisocial behaviour in adulthood. These children are at risk to
develop personality disorders and substance abuse (Earls, 1994).
Some developmental psychologists suggest that children with these disorders do not
show remarkable psychomotor behaviour (Netelenbos, 1998). But Aendekerk (1997), a
Dutch psychomotor therapist, takes another view. She describes the movement pattern
as characterised by rash, impulsive and unconscious action, motor restlessness,
violence, agitation and hyper alertness.
Also, bodily tension and a disturbed development of body awareness occur.
Furthermore, these children overestimate their motor abilities (Aendekerk, 1997).
Unfortunately, there is a lack of sound studies on this subject.
An overview
So far, we can identify some main problems in psychomotor behavior in each group:

In emotional disorders, anxiety is associated with problems in perceived motor
competence, a negative body image and a lack of spontaneous movement play
(sometimes together with a fear of body contact). In depression, the same items are
problematic. Although not much is known about play behavior, we expect that this
will be negatively influenced by decreased energy and reduced ability to experience
pleasure.

In pervasive developmental disorders the immature motor organisation has its
impact on gross motor functioning, body scheme and body image. By definition,
play behavior with peers will also be disturbed.

In behavioural disorders, ADHD children are below average in gross motor skills
and physical fitness. Play behavior is characterized by impulsivity and interpersonal
regulation problems. The risk of developing a negative self-image may have an
impact on perceived competence as well on body image. In the ODD, play
behaviour will be problematic because of the awareness and unrealistic positive
perceived motor competence.
*
Behaviour disorders and mood disorders are often intertwined. According to Baker (1998), these so
called mixed disorders are typically characterized by irritability, uncooperativeness and psychomotor
agitation. However, Kashani et al (1983) did not find differences in psychomotor agitation between
depressive and non-depressive delinquent boys. In short, it remains unclear if we can characterize these
children by their psychomotor behaviour. But if in future we can, psychomotor therapy may also contribute
through community based models of intervention with sports and games. However, the presence of nondeviant peers in the group is an essential component for a good outcome (Feldman et al, 1983).
Here, two questions rise. First, how this global characterization applies to individual
psychomotor performance? For instance, do all children of a sub-group show the same
features? How is the variation between subgroups? And what impact has a certain
psychomotor feature on the overall functioning of a particular child? Second, do we
have good instruments to measure the relevant items of an individual level?
An explorative field study
In our study, we focus on psychomotor functioning of children with psychiatric disorders
(N=90). We are investigating which psychomotor profiles occur in the three groups
earlier mentioned. Our test battery covers two areas of functioning:
1. Psychiatric
diagnosis,
complaints
and
behaviour
problems.
Those instruments include systematic interviews and questionnaires for parents
and teachers.
2. Psychomotor functioning, including motor development, fitness, perceived
competence,
psychomotor
diagnoses
and
therapy
indication.
We are especially keen on broad-spectrum psychomotor diagnosis, including
several domains besides basic gross motor functioning, like perceived
competence, body awareness and play behaviour.
For this second domain we use amongst other the Psychomotor Diagnostic Construct
(PMDC – Hammink, 2003). This construct includes a procedure to choose
psychomotor activities, a checklist with instructions for observation and interview and a
list of instruments for progressive diagnostics. After implementation, therapists and
psychiatrists were enthusiastic about the systematically derived psychomotor
diagnosis. For our present study we are developing a new scoring system, which will
give us the opportunity to investigate reliability and validity, and at the same time allows
us to look for scores of individual children.
The PMDC is based on the ICIDH-model and contains several dimensions and
domains. The first dimension - structure and function, refers to anatomical,
physiological and psychological qualities. Second dimension concern activities that the
child is able to perform in an ideal situation. In participation, the third dimension, we
see whether the child is actually involved and participating according to his or her age.
The fourth and last dimension – context, refers to external factors influencing the other
three. These dimensions are divided in domains, wich refer to the developmental
areas: physical, emotional, cognitive and social development.
An example: the case of JJ
JJ is a boy of eleven years old. His new schoolteacher suspects him of ADHD. His
mother, recently divorced, is not convinced by this. Nevertheless, she is willing do
participate in our research project in order to ground or reject possible psychiatric
diagnosis and determine if some form of treatment for JJ is advisable.
Table 1. PMDC scores of JJ
Dimension
Str/F
Act
Part
Context
Total
Bodily
0.02
0.01
0.06
0.020
Cognitive
0.05
0.03
0.00
0.040
Emotional
0.00
0.00
0.000
0.19
0.160
Domain
Social
002
0.05
0.04
0.00
0.005
Let’s have a look at the example of JJ’s scores on the PMDC. The domains are easily
understood. They refer to the child’s bodily, cognitive, emotional and social functioning
within the context of psychomotor activities. In this case, it’s possible to observe that all
scores are near zero on a scale of 0-2; 0 means no abnormalities, 1 means slightly
abnormal and 2 is clearly abnormal. If a child has a score of 2 there may be an
indication for psychomotor therapy, which was not the case for JJ.
Lets
have
a
look
at
the
other
scores.
Are
they
in
the
same
line?
Table 2. JJ’s overall results
Intrument
Outcome
DISC
No DSM-IV classification
AutR/Visk
No autism or PDD
CBCL
Internalisation (at home)
TRF
Internalisation (at school)
CBSK-m
Perceived motor competence above average
CBSK
School.76; social .88; sport .80; physical appearance.40
behavioural attitude.78; global self worth .57
TGMD
Good motor development
MOPER
Fitness below average (inadequate norms?)
PMDC
No indication PMT
On the psychiatric instruments, JJ does not meet the criteria for any classification.
However, there are symptoms of separation anxiety (fearful thoughts and dreams) and
restlessness, together with a state of some emotional distress, and in school JJ has
trouble to stay focussed.
Looking at functioning at home, we see internalisation scores (anxiety/depression) just
in the clinical range. In school functioning, the scores on externalisation were in the
clinical range. Apparently, JJ’s behaviour at school differs from home.
JJ shows average results in perceived competence at all domains (clinical range >. 85
and <. 15). His motor development is very good, according to TGMD, but surprisingly,
the MOPER fitness score is below average. Based on data we collected so far, we
think this may be due to inadequate norms for the present population. Finally, very low
scores on the PMDC give no indication for psychomotor therapy.
JJ’s psychomotor test results (his psychomotor profile) were very useful in this
diagnostic process. The conclusion was that, although JJ has some emotional and
school problems, psychiatric treatment is not indicated. We advised his mother to
arrange some support for JJ to make a successful transition to high school. A school
counsellor would be sufficient. Mother, JJ and the school counsellor were all satisfied
with this recommendation.
Some remarks for the future
To become a discipline no longer divided by national conventions, we must look for a
common research framework. In this, several elements are important, specially the use
of sound instruments, which has to be a major priority. From this point of view, we will
end with a few statements:
1. International psychomotor research must be based on the use of similar
instruments. Otherwise, we can never compare our interventions on an international
level.
2. Many instruments are of unknown validity: we do not know exactly what they
measure. This is difficult, because our outcome measures are broader than motor
performance. That’s why we need instruments covering whole psychomotor domain.
3. Instruments must be, also, reliable. When observational procedures are completely
idiosyncratic and stem from the experience of a single therapist, they are not yet
suitable for research.
4. Instruments should be, also, informative for clinical practice. When a therapist is
trained in the use of instruments, they have to experience that valuable information
about the case is provided. Only in this way, this experience is successful.
5. And last but nor least, instruments must be manageable for practitioners. We don’t
want an unwieldy battery of tests and procedures that burden our therapist.
A second priority is establishing a research-oriented journal, which is also of clinician’s
interest. We need to exchange ideas on a more frequent level. We would like to invite
the scientific committee to brood on the possibilities of giving birth to such a journal.
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