Child Abuse is re-discovered. Outright acts of child abuse by modern-day standards have existed from times of old, often considered permissible against the social and cultural backdrop of the age. In recent times, intervention for child abuse coming to the notice of private individuals or nongovernmental welfare organizations has opened the way to the guard and protection of such traumatized children with the backing of public institutions and the judicial system. The“Battered Child Syndrome”reported by Kemp et al. led to transition in the framework for capturing child abuse from welfare to that of medical evaluation and treatment. Since then, specific behaviors of abused children have come to be regarded as symptoms of psychological trauma, and not only the psychopathology of parents or caregivers but conditions such as socioeconomic status have become incorporated as factors giving rise to child abuse. Medical and psychological research for the evaluation and treatment of traumatized children have accumulated, upon which effective methods of intervention and treatment have been proposed and employed. Furthermore, understanding of human attachment has deepened, and reconstruction and correction of the relationship between the caregiver and child has become one of the major concerns in treatment. While medical care has played a large part in therapeutic intervention, the mutually augmentative roles of welfare institutions, health authorities, educational institutions, and the judicial system are indispensable, and collaboration between these facilities is essential for the effective support, rearing and care of child victims of abuse.
Recent research is clarifying how childhood maltreatment, which markedly increases the risk for psychopathology, is associated with structural and functional differences in the brain. For example, childhood exposure to parental verbal abuse (PVA) can cause increase in gray matter volume in the auditory cortex, witnessing of interparental violence to decrease in gray matter volume within the visual cortex, in addition to association with negative outcomes such as depression, PTSD, and reduced cognitive abilities. Association between other forms of childhood abuse and brain structure and/or developmental alteration is also becoming clear. Brain regions that process and convey adverse sensory input from maltreatment appear subject to modification from such experiences, particularly upon exposure to a single type of maltreatment, while exposure to multiple types of maltreatment is more commonly associated with morphological alterations in the corticolimbic regions. Furthermore, studies on maltreated children and adolescents with reactive attachment disorder (RAD) have revealed marked reduction in striatal neural reward activity, suggesting the dopaminergic dysfunction occurring in the striatum of such subjects may be further indication of the close neurobiological association between childhood maltreatment and future risk of problems such as substance abuse.
This paper aims to review: the definition of sexual abuse in children, multi-disciplinary team (MDT) networks responding to cases of child sexual abuse, minimum knowledge required of the professionals working with child sexual abuse, and the Child Advocacy Center (CAC) model recognized as the global standard of MDT response to child sexual abuse in the developed nations. The CAC model constructed by the National Children's Alliance featuring both intervention and treatment functions lists 10 criteria for accreditation as CACs: 1) MDTs bridging professionals in medical care, welfare, and law enforcement, 2) Cultural diversity and problem-solving competency, 3) Forensic interview, 4) Victim support and advocacy, 5) Comprehensive medical evaluation, 6) Mental health support, 7) Case review by the MDT, 8) Case tracking, 9) Organizational capabilities (including training), and 10) Child-focused orientation. The development of such networks in Japan must start with the establishment of a framework to facilitate and promote the construction of MDTs to integrate the professionals responding to child sexual abuse within the various medical, welfare, and judicial agencies.
The importance of evaluating and treating children who have been subject to abuse and neglect from the standpoint of trauma is being underscored by growing international recognition and emphasis. Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based, first line treatment program for abused children, for which feasibility studies on implementation have also been conducted in Japan. This paper introduces the theory and structure of TF-CBT, presents a case treated by TF-CBT in Japan, alongside discussion of the importance of PTSD assessment and trauma treatment in caring for victims of child abuse.
The majority of children living in child care homes today have experienced abuse, for which they exhibit various symptoms of trauma beyond the understanding of most care workers as well as the children themselves, leaving them with a sense of deepening powerlessness and isolation. The Osaka Prefecture Child Family Center has started incorporating trauma-informed care into the child welfare system. This paper reports on results from a survey on the efficacy of continual training for clinical psychologists, which showed meaningful change in both their consciousness and clinical competence. The results indicated the importance of continual multi-stage training to empower clinical psychologists in providing trauma-informed care to the victims of child abuse aiming for the construction of a sustainable system of support capable of providing children with safety and protection.
There are several fundamental elements required for the recovery of a child entering care from an abusive environment. These include an environment where the child is safe and feels safe from violence, and a home wherein the child's ongoing attachment with the caregiver is guaranteed over time. However, at present, the Japanese alternative care system is centered around large scale institutional care, which house the large majority of such children placed under care. In large scale institutions, violence between children is a common occurrence, as are difficulties regarding attachment formation with the caregivers. The foster care system is still in the process of developing, and adoption is as yet not fully functional due to legal constraints.
The May 2016 revision of the Child Welfare Act specifies that family-based care be given precedence over other forms of alternative care. Therefore, we can expect increase in the number of children allocated to foster care, adoption, and small community-based residential care homes. To this end, there is a need to expand community-based specialist support from child psychiatrists, clinical psychologists, and other professionals. Support from these specialists should not be limited to the victims of abuse alone, but should also be extended to the providers of foster care, adoptive parents, and staff in the small community-based residential care homes, with hope that the support and advice will empower and restore self-confidence to the providers of care whatever the environment.
As only 7% of abuse cases handled by the Child Guidance Centers in Japan result in removal of the children from their homes, the majority of maltreated children continue life within the community with their original families. Although community support is available for parents and children of mild to moderate abuse cases, lack of human resources and effective programs for their support and treatment remain the challenge.
The aim of support in abuse cases is to help children recover from the negative impacts of abuse, allowing for healthy development through nurture of self-esteem. Family support is provided to achieve that goal by changing abusive parenting behavior, and shifting the home into an environment conducive to the child's emotional and physical development. This process often requires support not only for the parents, but multidimensional approaches including care for the child, the parent-child relationship, and help in bridging the parents with support from relatives, acquaintances, and the community. Abusive behaviors can at times be lessened by helping to relieve parents from isolation, reducing stress in their everyday life, and promoting the family's strengths and independence. However, some parents, particularly those with histories of being abused, require treatment and education to acquire appropriate parenting skills, and to reconstruct the parent-child relationship.
This article reviews the compound factors giving rise to child abuse, classification of abuse by the mechanism fostering abuse helpful in determining the types of required support, supportive networks encompassing welfare, education, medical care and justice. Treatment and educational modalities are overviewed, including the Alternatives for Families: A Cognitive Behavior Therapy (AF-CBT) —an evidence-based treatment program developed in the US targeting both parents and children—comprised of core elements with proven efficacy in supporting families with abuse issues (safety planning, psychoeducation, emotion regulation, restructuring thoughts, parent training, and clarification of responsibility for abusive behavior and apology).
It is far beyond the imagination of most parents to have a child with a terminal illness. In such situations, there is little medical staff can do to lighten the parents' pain. Even so, is there anything that can be done when faced with the parents of terminally ill children. This report describes our involvement with one mother in such a situation.
Son B of mother A was diagnosed with gastroschisis in the prenatal period. The bowel, which had escaped from the abdominal wall, necrotized at birth, and the baby also suffered from various symptoms attributed to very low birth weight. Treatment was initiated, but his condition steadily deteriorated. Mother A sought out psychiatric support when B was seven months old.
Mother A was a nurse. She was courageous and committed to caring for her son, but when we met, her words were filled withdistress. Continuing to listen as she expressed her emotions left me overwhelmed and at a loss for words. While wishing to lighten her anguish, A related that talking helped her to feel calm. From this I perceived her need to talk, after which I continued listening to her story and sharing in her silence. This became the experience of sharing in her pain as if it were my own, and coming to accept the pain and distress for what it was.
A and her husband decided to take B back home one month later, and parents and relatives were present for his final moments. A's agony and sadness was strong and deep. I continued to meet with her.
The factors of significance in the approach to A appeared to be responding flexibly within a consistent framework, psychiatric assessment, creation of a stable environment for A by listening both passively and actively, remaining silent, and maintenance of unwavering, undivided attention and interest in the subject throughout.
Children with learning disorders (LD) experience low self-esteem and loss of self-confidence at school and in everyday situations, in addition to difficulties with learning, which potentially lead to school refusal and/ or social maladaptation. We present a case of a child diagnosed with attention deficit/ hyperactivity disorder (ADHD) and suspected LD at initial examination during his first year of elementary school. Subsequently, the child experienced school maladaptation during early adolescence following a traffic accident resulting in interruption of therapy. Maternal anxiety contributing to detrimental mother-child attachment factored in persistence of the child's school refusal to nearly three years. Such circumstances led up to the child's inpatient treatment at Asunaro Hospital.
While the suspected diagnosis of LD was confirmed during the hospital treatment, training, and schooling over a period of 18-months, he underwent gradual improvement in social skills accompanied by elevation of self-esteem. Improvement of his long-term school refusal allowed the child to advance on to high school, where he is now leading a smooth life. Constructing a solid relationship with him and his parents, understanding their anxieties and emotional conflicts, was of great importance in determining valid treatment policy.
While outpatient treatment is limited to hospital assistance and day care, enrollment in the comprehensive inpatient treatment program enabled provision of more effective treatment tailored to the needs of the child, through a combination of family support and therapy, education, social skills training, grounded upon a relationship of mutual trust, supported by close cooperation among the various specialists involved.