Article
Mrs. Monique N. Hammink (M.Sc.)
Preface
In my work as a psychomotor therapist in a clinic for child and adolescent psychiatry care, I was asked to see the children and adolescents and to give my opinion about their problems. This way I could contribute to the overall psychiatric assessment. The problem I was confronted with was that there were no specific psychomotor assessment instruments, nor directives how to do this psychomotor assessment. The only thing I had was my so called 'clinical view'. Often this gave a lot of information, but still it was not very satisfying. When I asked colleagues about it, I learned that in most places it was not very different from my situation. From this 'emptiness' I started my research. I did some literature-research and some field-research in order to give an answer to the question of how important psychomotor assessment within child and adolescent care centres is. Beside that I wanted to give an impression of the state of the art of psychomotor assessment in the Netherlands and I wanted to be able to give a well founded recommendation for systematic psychomotor assessment within these care centres.
The general development of the child and adolescent.
The general development of the child already gives an indication of the importance of movement. During the first years of live, the several parts of development (biological-physical, cognitive and emotional-social) are strongly connected. A motor problem will have influences on the other areas. Because motor skills and movement play such an important role in the early development, they can give an indication about the way the child develops. Depending on its experiences with different stimuli, the behaviour of the child will show more differentiation when it grows older and perception and action will get more integrated. Even though young children do have the capacity to observe the environment, a lot of things have to happen before this observation can be transferred into useful knowledge about the environment and well-aimed action. The efficiency of perception is closely connected with motor development. As soon as the child is able to move itself, it will be able to gather more information about the environment in a more effective way. In this way it can enlarge its implicit knowledge. This knowledge becomes explicit as soon as it leads to new actions when it is combined with observations about the environment. Movement plays, especially during this first years of development, a very important role in handling information from the environment. If the psychomotor development is disturbed, it will have its influences on other aspects of development as well and in this way on the whole child.
Child and adolescent psychiatry.
If the development is not 'normal', the importance of movement is even more evident. Usually, during the first years of life, the development of children and adolescents with psychosocial and psychiatric problems already have been impaired. Since these are the years in which movement plays such an important role, it seems even more essential to include psychomotor therapy in the general treatment program. In order to restore the development, the accent of treatment will be different for each individual child or adolescent. Adolescent psychiatry is more diverse than child psychiatry. Beside child psychiatry disorders, which are chronic or late discovered, there are disturbances that come with the developmental stage and early adult psychiatric disorders. In this presentation treatment will not be further discussed.
What is evident with children and adolescents with psychiatric problems is that it has its impact on the motor development and the way the child or adolescent moves. The motor development can give an indication about the child's experiences with different stimuli. It is possible that a child has been understimulated, but is also possible that there were enough adequate stimuli in the environment, but that the child was unable to profit from it. Children with disturbances in the sensomotor development often show problems in other areas as well and a multi-discipline treatment is necessary.
Systematical assessment.
In order to get a good view at psychiatric disturbances, assessment has to take place in a systematic way. Psychomotor assessment has been incorrectly neglected in this assessment process, in spite of the fact that several psychiatric disturbances are visible early in the development in the motor skills, in the way a child moves and in the relation it has with its body. Because human development starts with movement, this children almost always have a disturbed connection between psychological and physical functioning. Severe child psychiatry disturbances often go together with disturbances in the way the child perceives its body, with problems in control and co-ordination of motor skills and with lack of pleasure in movement.
A systematic psychomotor assessment could contribute to the overall psychiatric assessment and would possibly aid in clarifying indications for psychomotor therapy. In addition it would possibly give an idea of which aspects should play a role in the treatment program.
Psychomotor assessment could be a way to see what went wrong early in the development. At this moment, in child and adolescent care settings, movement is mostly seen as a therapeutic instrument and it is rarely used as a diagnostic instrument in a systematic way. Research of possibilities of movement as an assessment instrument within child and adolescent psychiatry is rare. The question is whether existing psychomotor assessment instruments could be used in these settings and which instruments would be best in that case. Besides motor development, psychomotor assessment could be aimed at what the movement of the child expresses and how the child experiences moving. If there is a problematic development, this will show in the way the child moves. As said before: movement plays a very important role in the development of children and if this development is not 'normal', the importance of movement is even more evident. Because of this it seems to be evident that further research in this area is necessary.
A conceptual framework.
To make a systematic assessment possible, a conceptual framework is needed, which makes it possible to put the many aspects of psychomotor assessment in perspective. This framework could be based on theories about biopsychosocial development and the levels of the International Classification of Impairments, Disabilities and Handicaps (ICIDH-2). Within psychiatric care, usually the DSM-IV and ICD-10 are used. Both are classification systems. Classification is a way to systematically order individuals in groups and is needed for scientific purposes and world-wide registration. Assessment on the other hand tries to give an idea about the individual state of problems. Systematic psychomotor assessment is aimed at this individual state of problems. Classification systems like the DSM-IV and the ICD-10 could be used in the overall assessment, but are not usefull within this research project because a descriptional system is needed. The ICIDH-2 is such a descriptional system. The ICIDH-2 makes it possible to record diagnostic information, to plan and evaluate therapeutic actions and to exchange information with colleagues from different care fields, like rehabilitation and the mentally handicapped care. The ICIDH-2 is not an instrument, but a framework, which can be used for specific goals and needs further development in that case. In order to get a connection with the child- and adolescent psychiatric care field, the biopsychosocial development theories are connected with the ICIDH-2 in this research project. This is needed, because a way of thinking about development and pathology is missing within the ICIDH-2.
The figure shows the conceptual framework. In this figure it is visible that a psychiatric disturbance has its influences on different levels. It has its impact on the structure and function-level, on activity-level and on participation level. This is the case, because a psychiatric disturbance almost always influences different aspects of the development. The structure and function level is placed in the biological centre of development. Problems at the level of activity can evolve as soon as development starts, which is at conception. Problems in participation come with the social development. The arrows between the different levels show the influence the levels have on each other. Beside that, the environment has its impact on the different levels and is influenced by the problems at the different levels as well.
It depends on the setting, the child/adolescent and the time that is available, how extensive a psychomotor assessment can be. To make a short assessment possible, as well as a more extensive assessment, within the psychomotor assessment construct 2 checklists are developed. A central checklist and a supplemental checklist. In field research, this checklists are developed with the help of 13 psychomotor therapists. The checklists contain items of the ICIDH-2 and items of previous field research. This 13 psychomotor therapists could choose for each item to put it in the central checklist, the supplemental checklist or to remove the item from the construct.
The idea is to complete the checklists in a few assessment-sessions. The therapist can choose which movement-arrangements are appropriate for the age and problems of the child or adolescent he or she diagnoses. After both checklists are completed, in a stafmeeting all information from different disciplines can be put together. In this way it can get clear on which level the problems are concentrated. After that, it can be decided that further psychomotor assessment is needed. To make this possible, within this research project, several psychomotor assessment instruments are connected with the items of the checklists.
If psychomotor assessment is taking place as described, all important aspects are being looked at. Besides that, transfer to colleagues is getting easier. An other advantage is that psychomotor therapists can work in a structured manner, but still in their own way as well. Even though they themselves decide how to get the information to complete the checklists, the way of doing assessment is more systematic and better transferable to others. Because of this, implementation of the construct in the daily practice of psychomotor therapists, within child- and adolescent care centres will be easier.
Assessment instruments.
>From literature research of different assessment instruments it can be found that most of the psychomotor assessment-procedures are methodological not well founded. Even though recent assessment instruments are in most cases a lot better than the older instruments, still the choice of instruments is often more decided on practical than on test theoretical criteria like standardisation, reliability and validity. Beside that, most instruments have not been tested on special groups like the child and adolescent psychiatric care population. In addition the norms are often from other countries and can not be used.
The state of the art of psychomotor assessment within child and adolescent psychiatric care in the Netherlands.
In order to investigate how psychomotor assessment is taking place in the Netherlands within the child and adolescent psychiatric care field, a short questionnaire has been send to 118 care centres. From this questionnaires it appears that in 53 settings psychomotor assessment is taking place. These care centres received an extensive questionnaire with 24 questions about psychomotor assessment. A qualitative analysis took place. The goal of these questionnaires was to gather extensive information about the current situation of psychomotor assessment within this care field. Based on these questionnaires 18 psychomotor therapists were selected for interviews. These interviews have been analysed with the computerprogramm 'Kwalitan'.
Because it is impossible to give all the results of this field research within this presentation, a selection will be presented:
* There are many different educated psychomotor therapists in the Netherlands. There is also a great difference in the way they are educated in doing assessments. Every psychomotor therapist seems to have its own way of working. Knowledge and way of working often stay implicit and are not made explicit in the daily practice of the therapists.
* The reason why psychomotor therapists are doing assessments, is mostly because the care centres ask them to. Most therapists feel a need to do assessments as well.
* With psychomotor assessments, psychomotor therapists try to contribute to the overall psychiatric assessment, to clarify indications for psychomotor therapy and to get an idea of the aspects that should be involved in the treatment programs.
* Most of the psychomotor assessments take place during the first weeks of treatment. Assessment later on during the treatment program or follow-up assessments at the end of the treatment program are seldom taking place.
* There is a great variety in how often a child or adolescent is seen for psychomotor assessments en how long assessment sessions will last. This varies from 1 to 5 times, during 30 to 75 minutes.
* Slightly more than half of the respondents are using existing assessment instruments, when at the same time all of the respondents are using their 'own' assessment instruments. If existing instruments are being used, they are often being transformed, depending on the situation. Reliability and validity do not seem to be important in choosing instruments.
* The person of the psychomotor therapist, who tells the team about the results, seems to be more important than the instruments that are being used in the assessments.
* The surplus value of psychomotor assessment is found, according to the respondents, in the information from movement behaviour and bodily experiences. Beside that, the playful character and the direct joining with the world of the child or adolescent during the sessions seems to be important. In addition sexuality is an item that is rarely assessed at other disciplines. An other aspect is that during staff meetings concrete examples can be given of where things go wrong.
* There is a need for more clarity in psychomotor assessment strategies, in order to make transference between colleagues more easy and to make it unnecessary for each therapist to find his own way of doing assessments. There should be some directives or guidelines.
* Most psychomotor therapist do not experience any problems in combining the roles of therapist and diagnost. They experience it as an advantage, because of the fact that during the assessments the first contact is made and that they get an idea of the problems and of ways to handle them.
* A new assessment construct should reply to several demands, according to the respondents:
* It should be valid, reliable and standardised
* It should be practical and not too extensive
* It should give information about different aspects of the development
* It should give information about the overall psychiatric problems
* It should differentiate between several disturbances.
* The way of doing assessment is nowadays dependent on the person of the psychomotor therapist, the situation of the moment and the choices of the care centres.
Randpanel.
In order to verify the results of the literature and field research, a panel of experts was formed. In this panel, different disciplines were represented: 2 experts from the field of child and adolescent psychiatry (a psychiatrist and a manager), 2 experts from the ICIDH-2 collaborating centre, 2 movement scientists and 3 psychomotor therapists who had experience in working with children or adolescents with psychiatric problems. They had to judge several decisions and reasonings from the researcher in a questionnaire. After analysis of these questionnaires, a live discussion meeting was set up. Only points of discensus were discussed. Based on the results of this meeting, there were some adjustments made on the psychomotor assessment construct. These adjustments were judged by the experts again.
The panel of experts was set up like a Randpanel-method, which is a derivation from the Delfimethods. The Randpanel-method can be used if scientific literature is not sufficient to verify conclusions. In that case, the clinical experience of experts can be used.
In this presentation, it is not possible to discuss the results of the expert meeting. The discussion was mainly based on the question:' Which items should always be a part of psychomotor assessment and which instruments are relevant and usable?'
The interaction between the experts gave a lot of extra information, that was very useful. Because of this interaction this information had a surplus value. In questionnaires it would be impossible to gather this kind of information.
Continuation.
Based on all results from the research so far, the psychomotor assessment construct will be further adjusted. In the second half of this year, an implementation will take place in several child and adolescent psychiatric care centres. After that, evaluation of the construct will be possible. The goal is to be able to give a well founded recommendation for systematic psychomotor assessment within the field of child and adolescent psychiatry.
