Psychomotor Limitations of Overweight and Obese Five-Year-Old Children: Influence of Body Mass Indices on Motor, Perceptual, and Social-Emotional Skills

The present research aimed to study the psycho-motor performance of five-year-old children with different body mass indices (BMI). A total of 694 pre-school children in the province of Albacete-Spain participated. Their performance in motor, perceptual, and social-emotional skills was analyzed using a standardized observation sheet (Checklist of Psychomotor Activities—CPA) and then compared according to their BMI using non-parametric statistical methods (Mann-Whitney test). Separate comparisons were made for girls and boys. Results indicated significant differences in performance amongst the groups of girls in all the motor and perceptual activities, and in the social relationships component of the social-emotional factor. These differences seemed to penalize motor activities, perceptual skills, and social relationships in overweight and obese girls compared to normal weight girls. In the case of boys, there were significant differences in laterality and visual-motor coordination (favoring overweight boys). Differences in respiratory control were also found, but in this case, penalizing obese boys compared to normal weight boys. Knowledge of possible psychomotor limitations in obese children could allow psychologists and healthcare professionals to design more focused interventions.


Introduction
Child development is a multidimensional evolutionary process through which human beings acquire increasing autonomy until they reach adulthood. During the first years of life, this development is rapid and very important because it lays the foundation for future learning; it is also closely linked to the quality and quantity of stimuli that children receive during this period. Preschool education plays a crucial role in this development, since it is the first stage of institutionalized learning [1,2]. mental structures as organizational properties of intelligence that are formed during ontogeny by the effect of natural and spontaneous maturation. This paradigm is founded on two basic mechanisms of development: assimilation and accommodation.
Regarding overweight and obesity, they are related to environmental and socio-economic factors, lifestyle preferences and cultural environment [22][23][24]. After comparing the psycho-motor development of 58 children aged 4 to 4.5 years according to nutritional status, Handal et al. [25] emphasized the importance of raising awareness in the educational community of the problems generated by childhood obesity, focusing on reducing sedentary behavior. In this study, the preschoolers with obesity and overweight showed a poorer motor profile compared to their normal weight peers.
Indeed, obesity is an issue that must be taken seriously. Being Overweight in adults has been shown to lead to early-onset health problems [26], decrease quality of life and increase risk of diseases such as type 2 diabetes, certain types of cancer, sleep apnea, depression, and cardiovascular disease [27]. In addition, overweight and obesity can lead to psycho-motor limitations, which result in an increase in social discrimination, low self-esteem, and depression [28]. These emotional maladjustments in youth, during physical activities practice, encourage the group to choose more individualistic and sedentary activities, which reduce opportunities for optimal psychomotor development and the reduction of obesity [28][29][30].
Overweight and obesity also have effects on social-emotional skills. Peralta et al. [31] studied the consequences of obesity on perception of ability and body image in adolescents, finding that obese participants felt less athletic, agile, fast, and fit; overall, they had poorer self-image perception than normal weight participants. In the same way, Utesh et al. [32] have recently found that physical self-concept is a moderate predictive factor of physical activity in a sample of adolescents.
Most of the studies reviewed centered on consequences of being overweight in motor competence, cognition, perception and/or emotional development in adolescents; therefore, the main objective of the present study is to compare the psychomotor development and social-emotional aspects of five-year-old children according to their BMI. This age was chosen because it is a pivotal stage between early childhood education and primary education, when other psychomotor skills are acquired. Furthermore, some studies have reported differences in psychomotor development according to gender [33][34][35]. Preschool girls were found to have more highly developed verbal language and fine motor skills, but there was no consensus regarding gross motor skills. This leads to the second objective of this study, which is to analyze whether there are differences between boys and girls regarding the influence of BMI on gross motor skills, perceptual skills, and social-emotional abilities.
Our starting hypothesis is that overweight and malnourished children (according to their BMI) will perform worse on psychomotor tasks than normal weight children and that these differences will affect girls and boys differently. The results of the present work could allow identification of factors influenced by BMI, enabling the design of both preventive and corrective interventions for use by health professionals to foster the holistic and harmonious development of the child.

Participants
Information was obtained from 694 five-year-old children enrolled in the third year of early childhood education. Data collection was carried out by the teachers of 32 groups in 11 schools in the province of Albacete, Spain, selected at random from a pool of 50 schools (35 public and 15 private) located in Albacete during the year 2016 according to the town hall web page [36]. In order to carry out the collection of information, parental consent was requested and the anonymity of the data was guaranteed. The sample was non-probabilistic, and once the schools were selected, the snowball technique was used to select the participating groups. The sample was composed of 46.7% girls and 53.3% boys. 69% of the students belonged to public schools and 65% of the sample practiced some kind of extracurricular sports activity.
Following the recommendations of the Food and Nutrition Technical Assistance (FANTA III) Project [37] on anthropometric indicators (weight and height) for evaluating overweight and obesity in pediatric contexts, the children were divided into five groups according to their BMI (malnutrition, moderate malnutrition, normal weight, overweight, and obesity).
The procedure to classify the children was as follows: first, the BMI of each child was calculated (BMI = kg/m 2 ). The FANTA III project [37] provides tables on the nutritional status of children from five to 18 years of age based on percentiles obtained in the project. Then, these tables were used to classify the children in terms of nutritional status according to their BMI. Table 1 presents the classification ranges and the number of boys and girls in each group.

Instruments
The evaluation instrument was the Checklist of Psychomotor Activities (CPA) [38], which collects information on three factors of children's psycho-motor development: motor, perceptual and social-emotional. The CPA is composed of 12 variables divided as follows: the physical-motor factor is evaluated by laterality items (LAT-seven tasks), dynamic coordination (DC-six tasks), balance (BAL-five tasks), motor execution (ME-three tasks) and tonic postural control (TPC-three tasks). The perceptual-motor factor measures respiratory control (RC-three tasks), schema and body image (BI-four tasks), motor dissociation (MD-three tasks), visual-motor coordination (VMC-six tasks), and spatial orientation (SO-two actions). Finally, the social-emotional factor was measured by the emotional control items (EC-six tasks) and social relations items (SR-five tasks). Each of the items is made up of the sum of values of the various tasks that compose it. The tasks contained in each of the variables can be found in Table 2.
The CPA was applied in the physical education class (in two classes, concretely: 50 min for the motor tasks and 50 min for the perceptual activities). The teacher and one member of the research team prepared the material previously for the class and then, during the class, each child was observed performing activities. In the case of motor and perceptual activities, the child was asked to carry out each task five times, and the frequency with which they performed each task correctly (1-5) was recorded. The social-emotional items were evaluated by the teacher, who scored the behavior and attitude of each child at the end of the academic term, using a Likert type scale (from 1-5, 5 being the highest score in all cases). The psychometric properties (validity and reliability) of the CPA may be consulted in Romero [38].

Procedure
First, the current study was reviewed and approved by the Research Ethics Committee of the University of Castilla-La Mancha. Second, the observed motor behaviors were recorded by the participating researcher and the classroom teacher. Instructions were given to teachers by a member of the research team 20 min before applying the instrument during recess; following testing, scores were awarded in a consensual manner by both the classroom teacher and the researcher. Teachers and researchers also measured height and weight of each participant. Weight was measured with a scale and height with a meter ruler mounted on the classroom wall for calculating the BMIs. Third, data were preprocessed for the analysis, which involved: (a) assumptions testing (normality), (b) analysis of outliers, and (c) classification of the children according to BMI.

Design and Data Analysis
A quantitative, cross-sectional, non-experimental, descriptive, and explanatory study was carried out [39]. To test the proposed hypothesis, the differences between groups formed according to BMI and gender were analyzed using Kruskal-Wallis nonparametric tests, complemented with Mann-Whitney U tests with Bonferroni corrections as post-hoc measures. We decided to use non-parametric statistics since the previous verification of assumptions using the Kolmogorov-Smirnov test indicated absence of normality for the contrast groups. The statistical package SPSS v.20 (IBM, Armonk, NY, USA) [40] was used to carry out the statistical analysis.

Analysis of Motor Skills in the Sample of Girls
The results of the Kruskal-Wallis H test for motor skills according to BMI in girls are presented in Table 3. The Table also includes descriptive statistics indicating the lack of normality in the groups, which is why parametric statistics could not be used. * Asterisks indicate significant differences between some groups. LAT = laterality, DC = dynamic coordination, TPC = tonic postural control, ME = motor execution, BAL = balance, SUM = total score on the physical-motor factor, H = Kruskal-Wallis H test. SD = standard deviation, Me = median, G 1 = skewness, and G 2 = kurtosis.
Post-hoc analysis was performed to establish pairwise comparisons (see Mann-Whitney's U in Appendix A). This analysis indicates differences between the group of malnourished girls and the normal-weight, overweight, and obese girls in laterality, with the malnourished girls showing lower scores (see Figure 1). Regarding dynamic coordination, there are significant differences between the groups with normal weight/moderate malnutrition and obese girls. In both cases, the dynamic coordination scores are lower for the obese girls (see Figure 1). In terms of motor execution, there are significant differences between malnourished and normal-weight girls compared to overweight and obese girls. As can be seen in Figure 1, girls with higher BMI obtain worse results in motor execution. With regard to tonic postural control, there are differences between overweight/obese girls and all the other groups. Differences indicate poorer control in overweight and obese girls.
Finally, regarding motor aspects, there are differences in balance between the group of malnourished girls and the remaining groups, with low-weight girls showing better results. * Asterisks indicate significant differences between some groups. LAT = laterality, DC = dynamic coordination, TPC= tonic postural control, ME = motor execution, BAL = balance, SUM = total score on the physical-motor factor, H = Kruskal-Wallis H test. SD = standard deviation, Me = median, G1 = skewness, and G2 = kurtosis.
Post-hoc analysis was performed to establish pairwise comparisons (see Mann-Whitney's U in Appendix A). This analysis indicates differences between the group of malnourished girls and the normal-weight, overweight, and obese girls in laterality, with the malnourished girls showing lower scores (see Figure 1). Regarding dynamic coordination, there are significant differences between the groups with normal weight/moderate malnutrition and obese girls. In both cases, the dynamic coordination scores are lower for the obese girls (see Figure 1). In terms of motor execution, there are significant differences between malnourished and normal-weight girls compared to overweight and obese girls. As can be seen in Figure 1, girls with higher BMI obtain worse results in motor execution. With regard to tonic postural control, there are differences between overweight/obese girls and all the other groups. Differences indicate poorer control in overweight and obese girls.
Finally, regarding motor aspects, there are differences in balance between the group of malnourished girls and the remaining groups, with low-weight girls showing better results.

Analysis of Motor Skills in the Sample of Boys
The results of the Kruskal-Wallis H test for motor skills according to BMI in boys are presented in Table 4. The Table also includes descriptive statistics indicating the lack of normality in the groups; therefore parametric statistics could not be used.

Analysis of Motor Skills in the Sample of Boys
The results of the Kruskal-Wallis H test for motor skills according to BMI in boys are presented in Table 4. The Table also includes descriptive statistics indicating the lack of normality in the groups; therefore parametric statistics could not be used.  * Asterisks indicate significant differences between some groups. LAT = laterality, DC = dynamic coordination, TPC = tonic postural control, ME = motor execution, BAL = balance, SUM = total score on the physical-motor factor, H = Kruskal-Wallis H test. SD = standard deviation, Me = median, G 1 = skewness, and G 2 = kurtosis.
The post-hoc analysis (see Mann-Whitney's U in Appendix A) indicates differences only in laterality (see Figure 2), between overweight/obese boys and the remaining groups. As can be seen in Figure 2, boys with higher BMIs obtain better scores in laterality (a similar result to that of the girls).

Analysis of Perceptual Skills in the Sample of Girls
The results of the Kruskal-Wallis H test for perceptual skills according to BMI in girls are presented in Table 5. The Table also includes descriptive statistics indicating the lack of normality in the groups; therefore, parametric statistics could not be used.

Kruskal-Wallis Test Classification
Descriptive Statistics

Analysis of Perceptual Skills in the Sample of Girls
The results of the Kruskal-Wallis H test for perceptual skills according to BMI in girls are presented in Table 5. The Table also includes descriptive statistics indicating the lack of normality in the groups; therefore, parametric statistics could not be used. Post-hoc analysis (see Mann-Whitney's U in Appendix A) indicates significant differences between groups of girls in all the variables that compose the perceptual factor, as explained below. In respiratory control, there are significant differences between overweight/obese girls and the remaining groups (see Figure 3); analysis of average ranges shows that in all cases, girls with higher BMI have lower respiratory control scores. Regarding body image, there are differences between malnourished and obese/overweight girls and also between girls with normal weight compared to obese/overweight girls (Figure 3). In all cases, mean ranges indicate lower scores in overweight and obese girls. The same occurs with the motor dissociation variable. With regard to visual-motor coordination, there are significant differences between normal-weight girls and obese/overweight girls, with normal weight girls presenting higher scores (see Figure 3). Finally, in terms of spatial orientation, girls with normal weight have higher scores than overweight girls (Figure 3).

Analysis of Perceptual Skills in the Sample of Boys
The results of the Kruskal-Wallis H test for perceptual skills according to BMI in boys are presented in Table 6. The Table also includes descriptive statistics indicating the lack of normality in the groups; therefore, parametric statistics could not be used. malnourished and obese/overweight girls and also between girls with normal weight compared to obese/overweight girls (Figure 3). In all cases, mean ranges indicate lower scores in overweight and obese girls. The same occurs with the motor dissociation variable. With regard to visual-motor coordination, there are significant differences between normal-weight girls and obese/overweight girls, with normal weight girls presenting higher scores (see Figure 3). Finally, in terms of spatial orientation, girls with normal weight have higher scores than overweight girls (Figure 3).

Analysis of Perceptual Skills in the Sample of Boys
The results of the Kruskal-Wallis H test for perceptual skills according to BMI in boys are presented in Table 6. The Table also includes descriptive statistics indicating the lack of normality in the groups; therefore, parametric statistics could not be used.  Post-hoc analysis (see Mann-Whitney's U in Appendix A) indicates significant differences in respiratory control and visual-motor coordination (see Figure 4) between malnourished and overweight/obese boys. Mean ranges indicate that boys with obesity and overweight have lower RC scores, but higher VC scores.  Tables 7 and 8 show the results for the social-emotional factor in girls and boys, respectively. There are significant differences between the groups of girls in terms of social relationships, namely between girls of normal weight and the malnutrition group (U = 1629; Z = −2.316; p = 0.021; r = 0.155) and between girls of normal weight and overweight (U = 3482; Z = −2.395; p = 0.017; r = 0.153). In the group of boys there are no significant differences (see Table 8).   Tables 7 and 8 show the results for the social-emotional factor in girls and boys, respectively. There are significant differences between the groups of girls in terms of social relationships, namely between girls of normal weight and the malnutrition group (U = 1629; Z = −2.316; p = 0.021; r = 0.155) and between girls of normal weight and overweight (U = 3482; Z = −2.395; p = 0.017; r = 0.153). In the group of boys there are no significant differences (see Table 8).  * Asterisks indicate significant differences between some groups. RC = respiratory control, BI = body image, MD = motor dissociation, visual-motor coordination (VC), SO = spatial orientation, SUM = total score on the physical-motor factor, H = Kruskal-Wallis H test. SD = standard deviation, Me = median, G 1 = skewness, and G 2 = kurtosis. * Asterisks indicate significant differences between some groups. EC = emotional control, SR = social relationships, SUM = total score on the physical-motor factor, H = Kruskal-Wallis H test. SD = standard deviation, Me = median, G 1 = skewness, and G 2 = kurtosis.

Discussion
The main objective of this study was to analyze the psychomotor performance of physical-motor, perceptual-motor and social-emotional skills in five-year-old girls and boys with different BMIs (malnutrition, moderate malnutrition, normal weight, overweight, and obesity).
Firstly, observing the results obtained according to gender, it can be concluded that there are significant differences between the BMI groups in all the physical-motor and perceptual skills in the case of girls, whereas amongst the groups of boys, differences were found in only some isolated aspects (laterality, respiratory control, and visual-motor coordination). Therefore, it can be affirmed that BMI has a stronger influence on the performance of physical-motor and perceptual-motor skills amongst girls. Specifically, girls with normal weight show better results compared to overweight and obese girls.
A priori, these results are in contrast to those obtained by Peyre et al., Flatters et al., and Toivainen et al. [32][33][34], who found no differences in gross motor ability between girls and boys. Meanwhile, other authors who analyzed motor differences between boys and girls in different educational stages and in some studies according to BMI, did find that boys displayed better motor performance [41,42]; they thought this may be due to higher levels of motor involvement compared to girls. It is possible that, in the case of girls, differences in BMI have a greater impact on psycho-motor ability because they practice less physical activity and have fewer motor experiences than boys [43,44].
If we examine physical and motor skills in detail, we can see that obese girls exhibit lower scores than their normal weight peers in more than half the tests, namely in dynamic coordination, motor performance and balance. At the same time, in tonic postural control, they obtain the second worst score, very close to the worst score (obtained by the girls with overweight). In all of the motor factor tests, the girls with normal weight and malnutrition obtained the best results. Along these lines, Bucco-Dos Santos et al. [43] found that performance of normal-weight girls was significantly better than their counterparts with obesity in variables such as gross motor skills and balance. Likewise, Laguna et al. [45] found that children between the ages of 6 and 12 with obesity presented worse results in balance and dynamic coordination. They argue that balance problems in overweight children result in poorer dynamic coordination due to lower awareness of weight distribution and center of gravity.
The results also show that girls with malnutrition perform better in some aspects, such as motor skills, tonic postural control, and balance. It is possible that these results are owing to the fact that to accomplish tasks, a lower body mass is easier to manage; therefore they are better at motor execution and controlling tone and balance. As Aleixo et al. [46] stated, obesity and excess body mass cause postural changes, reduce stability, and require an increase in biomechanical adaptations. In relation to these results, Nascimento et al. [47] also found, when comparing the chronological age and the motor-coordination age in boys and girls from nine to 11 years, that the participants with low weight (malnutrition state) presented a higher motor-coordination age compared to chronological age.
On the other hand, it is noteworthy that, in the laterality tests, the obese and overweight participants obtained the best results, above all the other groups. One possible explanation for this may lie in the lower motor skills of the groups with the highest BMI [48], requiring better lateralization in order to adapt to situational characteristics when interacting with the environment. However, this superiority of obese and overweight participants in laterality occurs in both girls and boys, which seems to indicate that there are no differences in laterality according to gender, a feature highlighted in other studies [49,50].
To conclude with the motor factor, girls with normal weight appear to be the most stable group, as stated by Bucco-Dos Santos et al. [43] and Méndez et al. [25]; they obtain the best scores in tests of dynamic coordination and in the sum of all variables. In addition, they are (1) significantly better than overweight and obese girls in motor performance, tonic-postural control and balance, (2) better than girls with obesity in dynamic coordination, and (3) better than girls with malnutrition in laterality. It is important to emphasize that possible motor deficiencies in obese children should be treated with caution and may be due to the influence of education and motor stimulation.
Secondly, with regard to perceptual aspects, it should be noted that overweight and obese boys have poorer respiratory control than their counterparts with lower BMI, but are better in visual-motor coordination. Regarding the other perceptual-motor aspects, no significant differences were obtained between the groups of boys.
In the case of girls, significant differences between groups are again found in all perceptual aspects. Overweight and obese girls score worse than girls with lower BMI in respiratory control, body image and motor dissociation. Moreover, overweight girls also present the worst scores in visual coordination and spatial orientation, contrasting with normal weight girls who achieve the best scores in both aspects. These results are in accordance once more with those obtained by Bucco-Dos Santos et al. [29]; their normal weight participants had better body schema, spatial organization and temporal organization than their counterparts with overweight or obesity. The results also coincide with those of Brum et al. [51], who affirmed that children with obesity had greater problems with body schema and temporal organization. As in the motor factor, normal weight girls are the most stable and superior group since they obtain the highest scores in some aspects (visual coordination, spatial orientation) and the second highest scores in the remaining perceptual-motor skills.
Thirdly, there are significant differences in social-emotional aspects only in the case of girls. Specifically, girls with normal weight have better social relationships than those with malnutrition or obesity. These differences may be related to factors such as low self-esteem amongst extremely thin or obese girls; this result is supported by the research of Molina et al. [43], who found that obese children scored lower on dimensions of self-esteem and quality of life related to health. The fact that, in our study, girls with obesity obtain poorer results in social relationships may encourage them to engage in individual activities, including sedentary activities, which reduces opportunities for optimal psycho-motor development and obesity reduction [28,30].
Despite the interesting results discussed above, the present study has some limitations. First, since the sample was not probabilistic, the results are not generalizable to the wider population. Additionally, the children were classified based on BMI as a single indicator; in order to achieve a richer and more accurate classification, other anthropometric, biochemical, clinical (e.g., nutritional requirements), and dietary intake measures would need to be considered. Future research in this field can be directed along these lines.
Finally, despite the large sample size, it was necessary to use non-parametric statistics due to non-compliance with the assumptions; parametric Analysis of variance could not be used to test interactions between BMI and gender. Despite this limitation, the present research has several practical implications for teachers, healthcare practitioners, and children. The results may be used to develop or re-establish children's capacities, focusing on their potential and the different aptitudes we found to be influenced by gender and BMI profiles. Psychomotor interventions to improve the different skills contemplated here (motor, social-emotional, perceptual) must respond to schemes based on the analysis of children's characteristics and knowledge of how overweight and obesity affect children's psychomotor functioning. Taking these specificities into account will permit the design of both preventive and corrective interventions based on contents and methods adapted to the different groups of children. The results of the present study may be used in both educational and clinical settings (reeducation or psychomotor therapy) to foster the holistic and harmonious development of the child.

Conclusions
The main finding of this study is that, in the case of girls, there were significant differences in task performance according to BMI across all the psychomotor variables analyzed. These differences indicate poorer performance of obese and overweight girls in motor activities, perceptual skills, and social relationships compared to normal weight girls. On the other hand, in boys, differences between groups were found in only some isolated aspects, such as laterality, respiratory control, and visual-coordination. Contrary to what was expected, differences in laterality skills favored the group of overweight boys; however, overweight and obese boys presented poorer performance in respiratory control and visual-coordination tasks. These results have important practical implications, as interventions to improve physical-motor and perceptual skills can be focused on overweight and obese girls. Additionally, it is important to generate programs that facilitate social relationships in this group of girls. In the case of boys, it is important to focus on laterality training in children with low weight and on the improvement of perceptual abilities, such as respiratory control and visual coordination, in overweight boys.
Secondly, children with normal weight showed a more stable and superior motor performance, although they were surpassed by the low weight group in two variables: tonic postural control and balance. Again, this result indicates that it is essential to design health prevention programs that promote adequate weight control, seeking a balance that allows children to develop motor competence.
Finally, obese and overweight children (boys and girls) obtained higher scores in laterality; this result suggests that educational programs be designed to help overweight children use this trait to their advantage.