The COVID-19 pandemic has drawn attention to children’s mental health around the world. In May 2020, the United Nations released a report on children’s mental health in the context of the pandemic. According to the report, restrictions in several countries have been associated with changes in children’s concentration, emotional stability, and nervousness. In Japan, the National Center for Child Health and Development’s “National Online Survey of Children’s Well-being During the COVID-19 Pandemic in Japan (Part 4)” found that, out of all the respondents, 15% of elementary school students (grades 4–6), 24% of junior high school students, and 30% of high school students had symptoms of depression. The findings highlighted the effects of COVID-19 on children’s mental health and reiterated the urgency of the issue. In addition to mental health, the state of child and maternal health care has recently emerged as a major theme in healthcare policy issues. All pregnant and nursing mothers must receive seamless medical care, welfare, and support from pregnancy to child-rearing, and children, from birth to adulthood. 
In order to promote this social momentum and to contribute to the health of children in Japan, we launched the Child Health Project in 2020. The project aims to stimulate discussion in collaboration with domestic and international stakeholders and to make policy proposals based on evidence generated through research. In 2021, we started an initiative on children’s mental health to build on the knowledge gained through HGPI’s Mental Health Project. The initiative, “Building a Mental Health Education Program and Support System that Respects Children’s Rights,” aims to develop and test the effectiveness of a program to help children, mainly elementary and junior high school students, recognize and cope with their own mental health challenges and be able to ask for help when needed. In addition, we will examine concrete measures to prevent mental health problems by taking children’s voices seriously and respecting their right to advocate for themselves.
In this expert meeting, various stakeholders discussed the policy issues surrounding child health and children’s mental health, as well as potential solutions. The discussion focused on mental health issues surrounding children and measures to resolve them, with a particular focus on mental health support and awareness in schools. 

 

・・・

 

Child Health Project:
Building a Mental Health Education Program and Support System that Respects Children’s Rights
The Second Expert Meeting: Identifying Challenges and Developing Solutions
in Schools to Support Children’s Mental Health
Report

 

[Overview]

• Date: Thursday, March 17, 2022; 18:00-20:00 JST
• Location: Zoom Webinar
• Language: Japanese
• Host: Health and Global Policy Institute
• Sponsor: The Nippon Foundation

[Program]

18:00-18:05 Opening Remarks

18:05-18:30 Keynote Speech: Environment Surrounding Children’s Mental Health and Support Systems

• Shinichiro Nagamitsu (Chairman & Professor, Department of Pediatrics, Fukuoka University / President, Japanese Society of Psychosomatic Pediatrics)

18:30-18:45 Report: Mental Health Education for Elementary and Junior High School Students Conducted by HGPI and its Effectiveness

• Eri Yoshimura (Senior Manager, Health and Global Policy Institute)
• Shunsuke Koseki (Associate Professor, College of Arts and Sciences, J.F. Oberlin University)

18:45-19:30 Panel Discussion
Mental Health Issues and Support for Children in Schools: Concrete Steps to Fill the Gap between Policy and the Reality in Schools

Panelists

• Shinichiro Nagamitsu
• Kyoko Tanaka (Head of Department, Center for Patient Liaison and Services, National Center for Child Health and Development)
• Kentaro Kubo (Teacher, Tokyo Gakugei University Setagaya Elementary School)
• Mie Matsuzaki (Senior Specialist for Health Education, Health Education and Shokuiku Division, Elementary and Secondary Education Bureau, Ministry of Education, Culture, Sports, Science and Technology)
• Daiki Sotokawa (Associate Producer, DTx Business Division, Jolly Good)
• Tetsuhiro Ohtani (Professor, Department of Social Sciences, Ritsumeikan University)

Moderator

• Yukiko Kawata (Senior Associate, Health and Global Policy Institute)

19:30-20:00 Q&A Session

20:00 Closing

 

18:00-18:05 Opening Remarks

• Eri Yoshimura (Senior Manager, Health and Global Policy Institute)

Health and Global Policy Institute (HGPI) is a non-profit, independent, private health policy think tank established in 2004. With a mission of “achieving citizen-centered healthcare policy,” HGPI brings together broad stakeholders from industry, Government, academia, and civil society in its capacity as a neutral think tank for repeated discussions to formulate and publicize policy recommendations. HGPI has been included in the Global Go To Think Tank Index Report presented by the University of Pennsylvania for ten years running. We were ranked second in the “Domestic Health Policy Think Tanks” category and third in the “Global Health Policy Think Tanks” category, both of which were the highest positions for think tanks in Asia. HGPI works to address a broad variety of themes, including dementia and women’s health. Today, we would like to focus on mental health and children’s health to deepen the discussions on these topics.

18:05-18:30 Keynote Speech: Environment Surrounding Children’s Mental Health and Support Systems

• Shinichiro Nagamitsu (Chairman & Professor, Department of Pediatrics, Fukuoka University / President, Japanese Society of Psychosomatic Pediatrics)

• The paradigm shift in pediatric medicine: Transitioning from medicine that diagnoses the body to medicine that diagnoses the mind
  We are currently experiencing a major paradigm shift in the pediatric healthcare provision system in which we are transitioning from medicine that diagnoses the body to medicine that diagnoses the mind. Advances in the field of medicine have resulted in progress in acute care, relief for and reduction of diseases in the acute phase, the development and dissemination of vaccines, and preventing severe illnesses from becoming chronic or progressing in other forms. Attention is now starting to focus on problems related to behavior and mental health, developmental and learning deviations, the increase in child abuse, awareness toward the difficulty of raising children, chronic illness treatment, and support for health promotion, health activities, and daily routines.
  
  
• The increase in mental health challenges among children due to the COVID-19 pandemic and the need for comprehensive, social support from households, communities, and the Government, as well as in policy
  As you are well aware, the Coronavirus Disease 2019 (COVID-19) pandemic has caused the public to avoid visiting healthcare institutions. There was a particularly sharp decrease in patients at pediatric and otolaryngologic clinics which provide care for acute diseases, and patient numbers have yet to return to their original levels even after Japan lifted its state of emergency.
  
  On the other hand, there are some things that have not changed from before, or have even increased. These are school absenteeism, irritable bowel syndrome (IBS), eating disorders, and allergies among children. It is likely COVID-19 brought out latent psychosocial issues that already existed before the pandemic. In October 2021, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) announced that COVID-19 had resulted historic highs in the number of absentee students as well as suicides among elementary and middle school students.
  
  The increase in psychological problems among children after schools reopened demonstrated just how important being in contact with others in everyday life is for children’s physical and mental development, as well as how much of a burden that contact can be. I think long school closures and changes to familiar routines reset relationships among people, and that many children were overburdened by the great amount of energy needed when schools reopened or these changes reverted. For those children who had been struggling with friendships or encumbered by studies, we can assume that reopening schools after long closures was a heavy burden.
  
  At the same time, there are cases where the opposite is true. Children who felt suffocated at home and who found school to be their sole source of emotional support may have suffered physical and mental problems because of school closures. Mental illnesses are the leading causes of Disability Adjusted Life Years (DALYs), and many of them first appear during adolescence. In the past, as pediatricians, we have treated children when their bodies were ill. In the future, we must treat children using a biosocial model in which we consider behavioral and mental aspects and society’s influence on illnesses.
  
  Children are protected by their guardians and families. Families are protected by communities. And, communities are protected by the Government and by policy. Which social determinants are hindering children’s health? It is important we keep these things in mind when interacting with children.
  
  
• Five percent of middle and high school students have engaged in self-harm, with the top reasons being concerns over plans for the future and grades. Furthermore, cyber bullying was identified as a particularly strong risk factor for suicidal ideation
  Several years ago, we conducted an awareness survey on adolescence among 20,000 middle and high school students. When we asked, “In the past, have you ever thought you wanted to die?” approximately 5% of students in each grade said they had engaged in self-harm in the past, and that 20% to 30% of students said they sometimes or regularly thought about wanting to die. Looking at the sources of concern for students, the most common responses were concerns over future paths in life and grades. “Body image” was in third place, followed by relationships with friends and parents.
  
  Regarding risk factors for suicidal ideation, the 1.8% of children (about 400 respondents) who had reported past experience with cyber bullying expressed very strong feelings toward wanting to die, with an odds ratio of 3.6. They were followed by children who reported problems in their relationships with their parents, with an odds ratio of 2.1. For other sources of concern like grades, future paths in life, and friends, the odds ratios were 1.1.
  
  
• The need for support to address health issues among adolescent children: The effects of adolescent health examinations and app-based interventions
  Looking at average annual per capita health spending by age group, we see that while average spending is ¥201,000 for those ages 0 to 4 and ¥869,000 for those ages 80 to 84, it is only ¥67,000 for adolescents ages 15 to 19. However, people in the latter age group can be affected by important health issues like young pregnancy; tobacco and alcohol use; sexually transmitted diseases; contraception and abortion; smartphone addiction; and bullying. Without sufficient aid, they have no choice but to become adults while shouldering these problems. The Basic Law for Child and Maternal Health and Child Development was enacted in 2018 so I hope to see improvements in the future.
  
  In 2018, we conducted a study on building a next-generation healthcare support system for children using ICT and medical, health, and lifestyle information (titled the FY2018 Japan Agency for Medical Research and Development (AMED) Project for Baby and Infant in Research of healTH and Development to Adolescent and Young adult – BIRTHDAY). Illnesses experienced by adults actually begin during childhood. Mental health issues comprise much of the disease burden during adolescence, and COVID-19 caused child suicides to increase. Therefore, with the goal of improving health promotion for children, we conducted an intervention study using adolescent medical examinations which are not conducted in Japan, and by using a self-monitoring app. We were able to reduce depression and control suicidal ideation among the children.
  
  This initiative, called the “‘Do I Know You?’ Project – Teens’ Health Promotion Through Medical Examinations and a CBT App,” had 217 participants from 38 schools nationwide. In Fukuoka, 160 of the 180 participants who applied through the homepage visited our clinic. After obtaining consent in the presence of their parents or guardians, we conducted a one-hour medical interview and survey in a neighboring room with each of them. The results of that survey were surprising. When asked, “In the past two weeks, have you thought that you wanted to die, or did you think about trying to hurt yourself somehow?” eight of the children said “Over half of the days” or “Almost every day.” Those children were not allowed to participate in the study because of suicidal thoughts and had to undergo medical examinations at a hospital. When I realized a child I had been happily chatting with a few moments ago had been harboring suicidal thoughts, I felt it would be impossible identify such children just by looking at them.
  
  In the intervention study, six of the 217 applicants were excluded due to suicidal ideation. The remaining applicants were assigned to the adolescent medical examination group (n=68), the combined examination and app group (n=70), and the control group (n=71). After starting the intervention, suicidal thoughts were reported by one person at one month, one person at two months, and four people at four months. One of the 138 participants (0.7%) receiving interventions through medical examinations or the app and 5 of the 71 people in the control group (7%), who completed the survey at home, reported experiencing suicidal ideation. This was a ten-fold difference. These results suggest that interventions made through medical examinations and apps may be useful for protecting mental health or controlling suicidal ideation among middle and high school students. The results also showed that the more participants used the self-monitoring app, the fewer depressive symptoms they experienced, demonstrating how self-monitoring can lead to improvements.
  
  
• It is desirable that digital technologies or interventions are utilized for improvement or prevention in children’s mental health care and to promote collaboration among healthcare and education
  Moving forward, I think it would be good to create a next-generation healthcare support system for children that uses machine learning to analyze birth information, health examination information, and other information entered into apps regarding high-risk children in communities to identify children who should receive advance health support and to stratify health. The Global and Innovation Gateway for All (GIGA) School concept means that each student currently has one device[1] . We would like to use those devices to introduce a web-based version of the “Mugimaru” self-monitoring application to connect educational institutions and healthcare institutions.
  
  The healthcare provision system has changed dramatically due to the COVID-19 pandemic. There are growing needs in mental health and health promotion. It is important to promote health for healthy children and adolescents and as a pediatrician, I would like us to continue working to address health issues. In that context, it may also be important to continue utilizing ICT.

[1] An initiative launched in 2019 by MEXT to provide every child and student in Japan with one computer and access to a high-speed network.

18:30-18:45 Report: Mental Health Education for Elementary and Junior High School Students Conducted by HGPI and its Effectiveness

• Eri Yoshimura (Senior Manager, Health and Global Policy Institute)
• Shunsuke Koseki (Associate Professor, College of Arts and Sciences, J.F. Oberlin University)

Background, overview, and results assessment for the project on “Building a Mental Health Education Program and Support System for Children” conducted by HGPI in FY2021

Eri Yoshimura (Senior Manager, Health and Global Policy Institute)

• Early detection and intervention is crucial for mental health issues starting in childhood and opportunities to learn about prevention should be provided
  Mental disorders are one of the five major diseases alongside cancer, stroke, acute myocardial infarction, and diabetes. The underlying causes of many mental disorders including schizophrenia, dementia, depression, developmental disorders, autism spectrum disorder (ASD), and attention-deficit/hyperactivity disorder (ADHD) are considered unknown. Meanwhile, domestic and international surveys and studies have reported that approximately one in four to five people will develop a mental disorder at some point in life, with half of them occurring by age 15. Globally, it is said that one in five children is experiencing problems related to mental health (WHO, 2000), which means early detection and interventions starting in childhood are crucial.
  
  In July 2020, HGPI presented “Mental Health 2020: Proposal for Tomorrow.” As mentioned in one of its recommendations, it will be important to enhance the education and support system for mental health centered around primary and secondary education so mental health issues can be treated over the life course. Because psychiatric and behavioral disorders are the most common issues affecting children from around the age of five, younger age groups require opportunities to acquire mental health literacy through mental health education.
  
  Globally, the COVID-19 pandemic has created harsher circumstances for children’s mental health which is bringing existing issues to the surface. Certain other countries are more advanced in Japan in terms of mental health education for children and adolescents and are expanding programs so they not only cover knowledge but also teach concrete methods of coping or building support systems.
  
  In Japan, the FY2022 high school curriculum guidelines will include mental illnesses in health and physical education classes for the first time in four decades. However, considering the ages at which mental illnesses first manifest, we believe it will be necessary to help children acquire better mental health literacy and learn how to respond to anxiety and stress in school education even earlier, starting in elementary and middle school.
  
  
• A public opinion survey of adults revealed high demand for mental health education in schools, and expectations are high toward the newly-established Children and Families Agency’s role in measures related to mental health
  In a poll of 1,000 adult men and women in the general public conducted by HGPI in FY2021, only 25% of respondents reported that they had learned about mental health in school. Among those who said they had never learned about mental health, over 60% replied that they wish they had.
  
  When asked about issues they would like initiatives from the new Children and Families Agency to focus on after it is established in April 2023, the most popular responses were: bullying countermeasures (48.6%), abuse prevention (34.7%), supporting absentee students and children experiencing social withdrawal (24.9%), and support for mental health (20.8%). Each of these items is related to mental health or is a theme that is related to mental health.
  
  Based on these results, in FY2021, HGPI conducted a project for children’s mental health education to contribute to prevention and advance policy. The four main activities undertaken in that program were: (1) create an educational program on mental health with professionals from multiple disciplines; (2) verify the effectiveness of interventions using that educational program (provided with four one-hour classes that cover: problem solving training, cognitive restructuring, behavioral activation therapy, and social skills training (SST); (3) holding an expert meeting with industry, Government, academia, and civil society on mental health prevention and support systems that children may require (this meeting); and (4) preparing policy recommendations and engaging in advocacy activities.

 

The mental health education needed in real educational settings: Introducing the content of the educational program

Shunsuke Koseki (Associate Professor, College of Arts and Sciences, J.F. Oberlin University)

It has been reported that cognitive behavioral interventions can be effective for addressing students’ psychological issues including irritability, anxiety, and depression. Among those interventions, group cognitive-behavioral approaches including classroom-based approaches have been implemented and have shown results, including:
・ Cognitive restructuring focusing on cognitive assessment (Koseki et al., 2007)
・ Social skills training focused on stressor reduction (Koseki et al., 2009)
・ Problem-solving training focused on coping after stress reactions (Koseki et al., 2014)
・ Behavioral activation therapy focused on the use of coping strategies and their results (Koseki et al., 2016)

Cognitive restructuring aims to help someone learn how to manage stressful situations by knowing there is an element of thinking (cognition) between events (in particular, stress-inducing situations) and emotions (in particular, stress) and by recognizing diversity in cognition (namely, that cognition encompasses various ways of thinking).

Behavioral activation therapy encourages people to realize, “Good things can happen when we take action!” It aims to help people control situations in which they avoid something by not taking action (such as being absent from school).

SST aims to help people understand adaptive behavior and how their actions affect others, and to realize that their actions can change how they are perceived by others.

Problem-solving training aims to help people identify which coping strategies they have for handling stress and to assess those strategies based on (1) how those strategies can benefit them; (2) how those strategies can benefit others; (3) the feasibility of those strategies; and (4) the negative elements of those strategies.

 

Report on the results of the educational interventions for elementary and middle school students

• Eri Yoshimura (Senior Manager, Health and Global Policy Institute)
• Shunsuke Koseki (Associate Professor, College of Arts and Sciences, J.F. Oberlin University)

1. Effectiveness of the classes
Over 90% of students said the classes were effective. Time for each class was limited this time (45 minutes for elementary students and 50 minutes for middle school students), but the fact the classes achieved some results allows us to conclude that their content was appropriate for the students for whom they were designed.

2. Needs for the classes
Although the classes were aimed at students who had been able to continuously attend school as normal, around three out of every four students felt they needed similar classes.
Considering the fact that all students face the risk of experiencing mental distress, or the risks of absenteeism or similar problems if that distress becomes severe, we must establish mechanisms to provide all students with these types of classes on a regular basis with an eye to prevention.

3. Worries and unease students may have
Our results showed that fewer students reported worry or anxiety after the classes compared to before the classes. This may be a sign the students learned to cope with worry or anxiety using the content that was covered by the classes.
It is likely that students can learn methods of solving their problems by having each of them take a close look at what specific troubles they have using worksheets, as we did in this intervention.

4. About getting help when feeling bad
Because many of the students say they still rely on friends and family as sources of support, it is likely that by having students take classes that cover the same content as the classmates with whom they share their daily lives, as we did in this intervention, it will enable them to obtain regular mutual support by sharing coping strategies and solution methods.

18:45-19:30 Panel Discussion
Mental Health Issues and Support for Children in Schools: Concrete Steps to Fill the Gap between Policy and the Reality in Schools

Moderator: Yukiko Kawata (Senior Associate, Health and Global Policy Institute)

Kyoko Tanaka (Head of Department, Center for Patient Liaison and Services, National Center for Child Health and Development)

• The COVID-19 pandemic is having severe effects on children’s minds and bodies
  Many of the children who visit our department for outpatient examinations say, “I can’t trust adults,” or “Nobody listens to me.” When children suppress their feelings and thoughts deep in their minds, down into the realm of the subconscious, their stress begins to show up in physical symptoms. It can manifest in their behavior and can cause them to harm themselves or others.
  
  Just when I felt the number of these children was increasing, other evidence also appeared in the results of the “Corona x Children’s Headquarters” survey, which was established through volunteer efforts by the Center for Patient Liaison and Services at the National Center for Child Health and Development. Those results showed that changes in the environment caused by COVID-19 were causing children’s stress to worsen or become prolonged. In our sixth survey (conducted September 13, 2021 to September 30, 2021), we saw stress reactions in approximately 70% of the children.
  
  There is also data from Japan indicating that the COVID-19 pandemic is causing the number of children with eating disorders to increase. A study conducted overseas reported that symptoms of depression and anxiety in children and adolescents under age 18 have doubled compared to pre-COVID-19 levels (Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID 19: A Meta-analysis: JAMA Pediatr. 2021).
  
  
• Teachers are also experiencing significant stress due to the COVID-19 pandemic, and we should not only rely on educational institutions to respond to children’s mental health needs
  From January 2021 to the end of February 2021, we surveyed educational institutions and human rights organizations in Setagaya City on items like stress among teachers. The results revealed that a large proportion of school teachers were experiencing high levels of stress due to the COVID-19 pandemic, with many expressing decreased motivation toward work. I believe this finding shows it is undesirable that we rely only on educational institutions to meet the mental health needs of children.
  
  When we asked teachers which health conditions they felt had grown more common among children compared to before the COVID-19 pandemic, a high proportion of respondents selected “Problems at home such as abuse” and “Depression, anxiety, and other mental illnesses” (n=106; multiple responses allowed). In our clinic, we have also received the impression that family problems which existed before the COVID-19 pandemic grew even worse, and that in many cases, people are not being connected to good support even when interventions are provided.
  
  
• Some are voicing expectations for improvements to measures and policies for children’s mental health and human rights
  We are currently conducting a survey called, “Let’s Think About Children’s Rights! Survey on the Opinions and Wishes of Children.” It will continue until March 31, 2022 and targets children from grade one of elementary school to grade three of high school (ages 6-18). As an interim report, I would like to introduce some of the responses we have received.
  ・ I want children’s opinions to be heard more.
  ・ I want to feel it is okay to be cared for, and to have my honest, real self be accepted.
  ・ I want human rights education that contains prejudices to be stopped.
  ・ I want people to take children more seriously when they ask for help.
  ・ I think you should always ask if what you are trying to accomplish is truly for the sake of children, and if you fully understand children’s positions when you act.
  ・ A Minister or other high-ranking official should spend a week or so living in the home of a troubled child and directly face the problems children face.
  ・ Adults should learn about children’s rights. Mental health is the most difficult thing to consult people about.
  
  
• Measures for supporting children’s mental health currently required in the U.S. can serve as a reference for Japan, and “Supporting effective, school-based models of providing mental health care” and “Accelerating the integration of mental health care in primary care (pediatric medicine)” are particularly important
  The American Academy of Child and Adolescent Psychiatry (AACAP) has identified the following measures as necessary right now:
  ・ Increase federal funding to ensure all families can access mental health services
  ・ Improve access to telemedicine
  ・ Support effective school-based models of providing mental health care
  ・ Accelerate the integration of mental health care in primary care (pediatric medicine)
  ・ Strengthen initiatives for reducing suicide risk among children and adolescents
  ・ Solve workforce issues and shortages so children can access mental health services wherever they live
  
  I think “Support effective school-based models of providing mental health care” and “Accelerate the integration of mental health care in primary care (pediatric medicine)” are especially important. In Japan, to prepare for the development of psychoeducation tools and their launch in schools in 2022, we created a leaflet (in the FY2020 Health and Labour Science Research Grant for Improving Resilience and Other Forms of Physical and Mental Health among School Children and Adolescents). Starting next fiscal year, we plan to have psychiatrists and pediatricians conduct outreach to schools and provide psychoeducation together with teachers using that leaflet.
  
  Support for stress and coping begins with adults acquiring the skills needed to talk to children with kindness. It is important to provide thorough human rights education starting from elementary school using tools that facilitate interaction with children, like our leaflet. After listening to children’s voices to learn what forms of support they need or do not think they need, we must make sure their voices are fully reflected in the system.
  
  At the same time, cooperation with medical services will be necessary to address psychosomatic disorders, school absenteeism, and stress-related illnesses. Considering factors from stress-related illnesses such as psychosomatic disorders and school absenteeism in terms of the biosocial model, we see that cooperation between education and healthcare is all the more necessary right now.
  
  To improve resilience among children in the wake of the COVID-19 pandemic, it will be crucial for us to work on both the environment in which children grow up in as well as the issues facing children themselves. Providing psychoeducation by holding conversations at schools is particularly important for children’s mental health.

Kentaro Kubo (Teacher, Tokyo Gakugei University Setagaya Elementary School)

• Sources of stress children face in real-world educational settings today include peer pressure, comparison, hierarchy, and division within their groups. These can be viewed as challenges rooted in Japan’s outdated school system established after the Industrial Revolution
  As they progress through the grades, children in Japan today face increasing challenges including struggles with exams, adjusting to peer pressure, and hierarchy, division, and labeling in their peer groups. Circumstances are particularly severe for children living in urban areas. Furthermore, the COVID-19 pandemic is forcing children into situations in which they lack connections and the presence of others, play has disappeared, the demands of daily life continue nonstop without release, and opportunities to have fresh encounters with the moment that make one forget oneself have vanished.
  
  Observing children in schools, we see that even if they have something like an iPad as a form of escape, they encounter vast amounts of information which forces them to examine themselves even more closely and, in the end, there is no escape. Then, they have to once again take up their roles in their peer groups where comparisons, hierarchies, and labeling are rampant.
  
  In the first place, the school education system itself is something that forces children who are fundamentally different from each other to conform to a “standard model” established after the Industrial Revolution. That system naturally results in comparisons, hierarchies, and divisions among children belonging to the same age groups, so there are many problems with the school system itself.
  
  
• It is important for children to have both self-affirmation and self-efficacy. Practical mental health education based on cognitive-behavioral therapy with continuous follow-up in educational settings is necessary
  At the discretion of head teachers for each grade, topics similar to mental health education can be covered in elementary schools, but some schools face circumstances where this cannot be done. Although mental health is covered during fifth grade health classes, I think we must follow-up on children’s mental health when interacting with them on an everyday basis. We must build a system in which everyone acquires cognitive-behavioral therapy-based methods for doing things like interacting with children, giving them perspectives on the future, and solving problems, like in Professor Koseki’s report.
  
  In recent years, we hear about the importance of having a sense of self-affirmation. However, the reality children live in is not one in which they are told, “You’re fine just the way you are,” and then are able to live true to those words. Instead, they must suffer through various hardships. They are being placed in a contradictory, double-bind situation.
  
  Therefore, the question is what measures should be taken to help children have perspectives on the future when some problem occurs, while staying true to themselves. It is important for them to gain experience with methods of solving problems and heighten their sense of self-efficacy (recognizing if one has or does not have the capacity to select and perform the appropriate actions to get results in certain circumstances). I feel that both a sense of self-affirmation and self-efficacy are necessary.
  
  
• As a method of addressing the mental health issues of children and teachers, we should consider how to best create schools that are open to society
  Taking a look at issues surrounding school education and children’s mental health education, first, teachers do not possess sufficient understanding toward the importance of children’s mental health education, and think it is something children naturally acquire by themselves, either over time or by making realizations after mistakes. In addition, mental health education is only treated as part of managing each grade, and it is difficult to say the content of that education has been identified, in a scientific, empirical manner, as content that should be taught.
  
  As a result, homeroom teachers are the ones who must shoulder the burden. I think it would be better if the roles of each staff member within schools and their horizontal connections were made more transparent, and for there to be bridges that seamlessly link to outside the school. Right now, children and teachers might both be exhausted due to the double bind caused by society’s desire to socialize children and the demands being placed on schools.

Tetsuhiro Ohtani (Professor, Department of Social Sciences, Ritsumeikan University)

• Speaking through experiences with the Great East Japan Earthquake: Teachers should face mental health issues regardless of the degree of damage from the disaster each child has experienced and provide health education from positions that are close to children
  When the Great East Japan Earthquake occurred, I was serving as a training supervisor (as a clinical psychologist) responsible for providing educational consultation (namely, support and training). After the earthquake, I was active on Iwate Prefecture’s Children’s Mental Health Support Team and its Mental and Physical Health Observation and Analysis Team (a position I currently maintain), as well as a school counselor at a high school affected by the disaster. Based on these experiences, I would like to introduce some topics regarding support that was provided in schools immediately after the disaster.
  
  After the sudden occurrence of the earthquake, there was confusion regarding who needed support first and who should provide that support. Our school board considered principles of systematic and continuous support and built a support system based on those principles.
  
  Our first principle of psychological support was to establish a shared understanding that the entire prefecture had been affected by the disaster. Even outside of the severely-affected coastal regions, seismic intensity in certain inland regions was low 6. There were cases where family members could not come pick their children up. Because recognition can depend on how children and students perceive events (through past or cumulative experiences that shaped their perception) or their cognitive processing, rather than thinking that the degree of damage equals the degree of their fear, we viewed the entire prefecture as having been afflicted.
  
  Our second principle of psychological support was to recognize that because the supporters are teachers, they are providing mental health education, not care. It is natural for stress reactions to occur during the acute phase of physical symptoms and other sources of stress. After deciding we should support the children’s own initiatives to use each resource including school life to recover, we concluded that we would respect each child’s capacity to recover.
  
  Our third principle of psychological support was the recognition that the parties responsible for providing direct support are teachers. Educational activities undertaken by teachers can be considered a form of stress management itself (because those activities are likely to include the basic elements). Therefore, we established the principle that teachers should be considered the parties responsible for providing direct support instead of school counselors or other outside specialists.
  
  Our fourth principle of psychological support was the idea that no assessments should take place without support. An assessment only reminds the child of their trauma. This was a point of criticism after the Great Hanshin-Awaji Earthquake. Therefore, we created a teaching aid called “Observing Mental and Physical Health” and used it to provide a three item set that included (1) classes on psychological support (psychoeducation and relaxation); (2) observing mental and physical health; and (3) individual interviews conducted by homeroom teachers, who observed progression. If a child exhibits discomfort toward a stimulus, assessment and support should be provided in a set until the child can benefit. In other words, we established a principle of not conducting any assessments without support.
  
  
• As time goes by, the effects of the earthquake are starting to settle and children with mental health issues for reasons other than the earthquake are being supported, but adults must face children’s mental health with sincerity in addition to teaching coping methods
  An analysis using published data on the rates at which children are deemed to require support through observations of their mental and physical health showed the effects of the earthquake settle or are likely to settle after five years for elementary school students, eleven years for middle school students, and thirteen years for high school students. In Iwate Prefecture, our understanding is that it is a stress reaction in daily life after the effects settle.
  
  During the in-person consultation process, some of the students who showed high reactions have complained of maladjustment to their classes or bullying. There have also been cases in which they talked about discord or violence among their parents in everyday life or revealed they were exposed to mental abuse. Because there are people like these who need support for reasons unrelated to the earthquake, Iwate Prefecture has expanded the scope of support to include responding to bullying and suicide prevention to meet the mental health needs of children.
  
  I think the type of support children need right now is to be taught methods for coping with mental health issues so they can work toward solutions. However, the question remains if the idea of teaching and resolving issues is sufficient on its own. It is also important to consider the attitudes the adults responding to those children have when they listen to the children’s stories.

Daiki Sotokawa (Associate Producer, DTx Business Division, Jolly Good Inc.)

• Collaboration among services like after-school day care and schools has made it possible to more effectively match the goals and content of support to children’s needs and has also improved parents’ and guardians’ attitudes toward child care
  An issue facing many services like after-school day care services is that there are differences in perspectives among school guidance policies and after-school day care service support policies in terms of how they view children. This raises hurdles for keeping content consistent when providing education or support.
  
  A facility I once belonged to provided education and support programs (mostly SST) for children with disabilities with a heightened focus on adapting to daily life at school or in the home rather than adapting to the facility. This meant it was necessary for us to know how life was for the children at school and the degree to which they were adapting. How firmly did the skills take root at school? Aiming to share information, our collaboration with schools began by us making small talk when picking the children up from or dropping them off at their school. As our intent to get involved became clear, our interactions with the teachers became more concrete. Parents’ and guardians’ opinions can be heavily influenced by what they feel are problems, so the perspectives of third parties become more important.
  
  At the special-needs class that served as our point of contact when we began our collaboration, we have implemented SST using virtual reality (VR) within classes on a trial basis. Because behavioral data for each student participating in the class had already been collected, collaboration was very easy. Utilizing VR tools means we are able to generate records automatically. Line-of-sight data is particularly useful because we can focus on “Looking at the other person’s face,” a behavior that tends to be vague in conventional SST.
  
  Then, by utilizing similar tools as in the special-needs class, we were able to collaborate with a stronger sense of having a shared purpose. Furthermore, we observed behavioral changes in which the children’s responses changed according to where the SST was provided, even using the same tools, which allowed us to provide more detailed feedback to parents and guardians . Feeling there were connections between teachers and supporters led to peace of mind for many of the parents and guardians who had wanted consistent support between the special-needs classes and the after-school day care services, which improved attitudes toward child care among those households.
  
  
• SST using VR makes it possible to respond to children’s issues on an individual basis and is highly effective
  It was very difficult to share scenes in conventional SST because the scenes on which training is based are mainly described using picture cards and words. JOLLYGOOD+ makes it possible to provide SST in a manner that is easy for children to understand by allowing them to experience those situations directly.
  
  It provides many different scenes for users to experience which are designed according to themes one often encounters at school or in the workplace. By experiencing those situations, users can learn social skills that have been defined independently by Jolly Good Inc. All VR lessons are arranged by target social skill and include greetings, listening to others carefully, skillfully turning people down, treasuring oneself, controlling one’s emotions, acting while understanding one’s feelings, becoming friends, and thinking of ways to solve problems. The theme of the SST can be selected according to the challenges the user is facing.
  
  
• Mental health support can be made more optimal if multi-disciplinary professionals collaborate with the shared goal of promoting child development, then conduct evidence-based interventions and verify those interventions continuously
  Special-needs classes and after-school day care services share the goal of promoting child development. If every professional involved shares the same goal, there is no reason they cannot cooperate. I think it will be important for them to have relationships in which multi-disciplinary professionals can consult with each other when reaching plateaus.
  
  When providing special needs education and support for children with disabilities in the future, it will be necessary for interventions to be based on data or evidence that is visible rather than interventions based on the experiences and feelings of teachers and supporters. I believe that by verifying which results were obtained through those efforts, it will become possible for us to find the best methods of supporting each child.

Mie Matsuzaki (Senior Specialist for Health Education, Health Education and Shokuiku Division, Elementary and Secondary Education Bureau, Ministry of Education, Culture, Sports, Science and Technology)

• School nurses serve as coordinators in joint efforts to promote children’s mental and physical health with related parties inside and outside of schools, and the number of cases in which they provide continuous support, such as through health consultations, increases with school grade
  The main duties of school nurses include providing first aid, managing health through medical examinations and disease control and prevention, providing health education, engaging in health organization activities, and providing health guidance and counseling. It is important for related parties such as faculty members, parents and guardians, school organizations, school physicians, school pharmacists, and local healthcare institutions to collaborate in all of these activities, and school nurses also serve as coordinators during such collaboration.
  
  According to the results of the Japan Society of Social Health’s FY2016 survey on the use of school infirmaries, the most common issues related to mental health observed by school nurses in the previous year at elementary schools were “Problems related to developmental disabilities (or suspected cases),” “Relationship problems with friends,” and “Problems related to bullying,” respectively. At middle and high schools, the most common issues were, in order of frequency, “Relationship problems with friends,” “Problems related to developmental disabilities (or suspected cases),” and “Relationship problems with family.”
  
  The main topics of discussion during health consultations were “Physical symptoms,” “Relationships with friends,” and “Vague unease,” but also included “Concerns about studying,” “Developmental disorders (including suspected cases),” “Sleep,” “Relationships with family,” “Physical growth and development,” “Relationships with faculty members,” “Problems related to sex,” “Bullying,” and “Child abuse.” Looking at these subjects, we can see that school nurses handle a broad range of mental and physical health problems.
  
  
• MEXT has developed and is disseminating guidelines on handling children’s health issues with school nurses as the main target audience
  MEXT created a reference document titled, “The Role of School Nurses in Supporting Children with Modern Health Challenges” (presented in March 2017). It illustrates the roles expected of school nurses in addressing various health challenges children face today and describes collaborative efforts for school nurses and all faculty members including administrators and the heads of each grade to engage in with specialists like school physicians, school counselors, and school social workers.
  
  In those guidelines, “Chapter 2 – The Basic Procedure for Solving Problems for Students in Schools” provides four steps for responding to students with various health problems.
  
  In Step 1, “Identifying Who Requires Support,” it is important for schools to establish systems for cooperation inside schools and with related institutions in the community in advance. Early detection and response help prevent problems from growing severe and facilitate solutions. Faculty members should carefully observe each student’s school life and try to notice changes in their physical and mental health or signs from students as early as possible. When detecting a change or a sign, they are to quickly share that information with related parties and report to school administrators.
  
  In Step 2, “Grasping the Problem Background,” head teachers for grades, school nurses, administrators, and specialist staff members use various methods to gather information and analyze it from their own perspectives. Committees are convened to assess health issues and include administrators, head teachers, school nurses, and other related staff members. Under the leadership of principals, these committees work to obtain an accurate grasp of the backgrounds to students’ health issues. There are times the backgrounds to students’ challenges are complicated by multiple factors (such as their family’s economic situation, family problems, friendships, and characteristics of the community). Faculty members must always remain aware of the fact that necessary support or support methods may differ according to the reasons for and backgrounds to the problems, even when students exhibit similar behaviors.
  
  During Step 3, “Examining and Implementing Approaches to and Methods of Support,” short- and long-term goals are set and a shared understanding is formed among all faculty members while making specific decisions on which methods will be employed, who will provide support, and when and how support will be provided. Rather than head teachers for each grade and other teachers attempting to handle everything on their own, they should cooperate with other staff members like leading faculty members, head teachers, and school nurses to provide support. While remaining aware of the need to provide support as an organization, each individual’s role is clarified. Without persistently attempting to solve problems with internal efforts alone, top priority is given to solving students’ issues through cooperation with related institutions. When faculty members are at a loss on a decision, they must seek advice from other staff members like school physicians, school counselors, and school social workers.
  
  During Step 4, “Confirm the Student’s Situation and Reexamine and Implement Support Approaches, Methods, etc.,” changes in the student’s situation are accurately grasped by each faculty member from each of their respective positions. If they determine that the situation has not changed or has worsened since introducing support, the causes are analyzed, then support is revised and implemented. Even when the situations have improved, faculty members must not only look at the situation at that time; they must confirm the child’s circumstances continuously, such as by making sure to confirm their progress.
  
  This pamphlet is being distributed to all schools nationwide and efforts are currently being made to disseminate its content through all training programs.

19:30-20:00 Q&A Session

Q. I think cooperation between healthcare and education is crucial for children’s mental health, but in practice, it is limited to case-by-case cooperation. Due to insufficient human resources and time, it is often difficult to cooperate in a manner that results in comprehensive community support. I would like to hear some innovative examples at the national or regional level.

A.

• • All teachers must have a good understanding of the importance of children’s mental health. They must avoid thinking, “It will be faster for me to take care of this on my own,” and instead must collaborate with those in other professions and deepen mutual understanding with each other in real-world educational settings.
  • A system for collaborating with family doctors and mental health specialists must also be created. If we first held case conferences stationed with key persons who could coordinate multiple organizations and professions, it would lead to continuous and vigorous collaboration promotion.
  • MEXT has recently revised its “Teachers’ Guide for Children’s Health Consultations and Health Guidance,” which teaches fundamental methods of providing support and engaging in collaboration using examples for various issues. It should be used as a reference.

 

Q. When introducing mental health education to schools like in the survey and research project conducted by HGPI, who will be introducing it and in what format? Can it be conducted remotely in multiple schools or classes by psychologists?

A.

Although the program can be conducted remotely, it is important for actual interventions to be introduced in daily life. When doing so, it is likely to be effective if school teachers and school counselors who observe the daily lives of students work with students so those interventions can be put into practice effectively. At the same time, results can be enhanced by using apps and other tools to confirm the degree to which students are using what they learned in their daily lives. Clear distinctions must be made among the things homeroom teachers can teach, what school counselors and mental health specialists can do, and what schools and healthcare should collaborate on. While advancing, it is important to conduct appropriate assessments.

 

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[Event Report] Child Health Project Expert Meeting: Building a Mental Health Education Program and Support System that Respects Children’s Rights The First Expert Meeting: A Life Course Approach to Children’s Mental Health (December 16, 2021) >