Research ReportLongitudinal Study of Support for children Born after the Disaster :Report on baseline survey results in Miyagi Prefecture
Naru Fukuchi – Director, Doctor 1)
Mikika Abe – Nurse 1)
Chizuru Ainai – Psychiatric Social Worker 1)
Takao Tannno – Psychiatric Social Worker 1)
Reira Onuma – Psychiatric Social Worker 2)
Mebuki Sasaki – Psychiatric Social Worker 2)
Shizuka Oguchi – Psychiatric Social Worker 3)
Shusaku Chiba – Clinical Psychologist 1)
1) Research and Planning Division, Stem Center, MDMHCC
2) Community Support Division, Stem Center, MDMHCC
3) Higashimatsushima City

1. BackgroundIn the emotional development of a child, the environment in which the child grows is important, including
the connection between the mother and child during infancy. Previous research has shown that trauma
suffered during childhood can affect a child’s mental and physical development.1),2) After the 2011 Great
East Japan Earthquake, several studies tracked children who had directly experienced the disaster, andresults similar to those of previous studies were reported 3). On the other hand, as we developed regional
support, we received requests from more than a few children who were born after the disaster and did not
directly experience it. Childcare providers and administrative personnel in the affected areas conveyed theimpression that children born after the disaster are “restless” or “do not fit into group activities,” and we arefinding increasing opportunities to offer consultation to these children. This trend is most noticeable incoastal areas that have taken a long time to recover from earthquake damage. Support for these comments isstill insufficient. There have been no studies involving child development after a large-scale natural disasteror the psychological evaluation of parents, and long-term longitudinal intervention studies on children andtheir families have not been obtained. There is also no clear understanding of what type of support should bedeveloped.
From this background, we identified a need for long-term tracking of children who were born after theearthquake and embarked on this study. The results of this research are a part of the “Longitudinal support
research for children and their families born after the Great East Japan Earthquake,” which is being
conducted in collaboration with Iwate Child Care Center at Iwate Medical University and the Children’s
Mental Health Support Project Promotion Office at Fukushima University. This is a study that has compiled
results only for Miyagi Prefecture. The survey began in October 2015, and the plan is to follow all subjects
until the completion of their compulsory education at the age of 15 (until March 2027). To observe changes
over time, the survey will be conducted for the first three of the twelve years, and every other year thereafter
for the duration of the study.
2. Purpose
This research was conducted for the purpose of assessing the physical and mental health of children bornafter the earthquake in Miyagi Prefecture—where the damage was great—and of providing long-term
support to households in high-risk conditions.
3. Method(1) Target subjects
As of April 2016, we focused our study on households that had given their consent to participate in thisresearch, with the cooperation of preschools in four municipalities in Miyagi Prefecture, children in
their four-year-old classes, and their parents and caregivers. These children were born between April
2011 and March 2012, after the Great East Japan Earthquake. Children who moved from other areas tothe disaster area more than two years after the earthquake and were enrolled in preschools wereexcluded from the study.

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Longitudinal study of support for children born after the disaster(2) Procedures for the investigation
Through the departments in charge of the four municipalities, we explained the project purpose andcooperated with the directors of daycare centers and preschools. In cases where consent was obtained,
survey documents and consent forms were distributed to the families of the appropriate class, andsurvey collaborators were recruited. At the time, we explained that participation in the study wasoptional and that withdrawal of consent was possible at any time.
(3) Duration of study
We conducted a pilot survey of two preschools in February and March 2016 to confirm whether there
were any problems in proceeding with the study. After that, a survey was conducted from July to
September 2016, the recruitment period, and then we proceeded to conduct the study at the schools that
had agreed to participate.
(4)

The questionnaire and interview surveys were conducted with parents and children from whom we
had obtained consent, and a questionnaire survey was conducted with the relevant childcare providers(Table 1). Although various tests were carried out, the results not shown in Table 1 because it is notdirectly related to the survey report. On the day of the survey, parents and children came to thepreschool, and we conducted cognitive development tests for each child, and structured interviews
with their parents. After the survey, all children’s results were reported back to the preschools, andwe provided individual feedback to each household. We conducted individual consultations withfamilies for whom we judged support was needed, connected them to the necessary support agencies,and held case conferences at the preschools.

(5) Ethical considerations
This research was approved by the ethics committee of the Iwate Medical University School of
Medicine and Fukushima University, and care was taken to ensure that the personal information ofparticipants was protected.
This study was approved by the ethics committee of the Iwate Medical University School of
Medicine and Fukushima University, and it was conducted in consideration of the issue of thesufficient protection of personal information.

4. Results(1) Basic attributes of target households
We requested cooperation from 28 preschools in four cities and towns and were able to obtain consent
from 18 locations. We asked the families of 353 students enrolled in these preschools for their135

Research Reportcooperation with the survey and were able to obtain consent for 74 children (39 boys, 35 girls, consent
rate 20.9%). Four of them who had some missing data were excluded, and 70 subjects were analyzed.
No data concerning parents was lost, and 73 subjects were analyzed (one family had twins). The
average age in months of the children at the time of the interview survey was 59.1 months (6.4 SD),and the average age of parents was 36.2 years (5.1 SD). Additionally, 25 of the parents (33.8%) werewomen who were pregnant with a child at the time of the disaster.
The family casualty situation was 70% for families who suffered slight to serious harm because of
the earthquake/tsunami (Table 2); 29% for those who lost family members or relatives; and 4% for
those who had family members they lived with die or be listed as missing.

(2) Concerning children① Results of questionnaire survey (Figure 1)
a. CBCL/TRF
Child Behavior Checklist (CBCL) 4 is a widely used evaluation scale for measuring problem
behavior in children. Parents fill out the evaluation, which consists of 100 questions. The childchecklist (Teacher’s Report Form, hereafter referred to as TRF) is an evaluation scale that theteacher (preschool teacher) fills out using the same criteria as CBCL. These two evaluations are
combined and then classified into “normal range,” “borderline range,” and “clinical range” intotal scores and subscales. In this survey, 10 (14.3%) total CBCL scores by parents were“borderline,” and 9 (12.9%) were “clinical.” On the other hand, 17 (24.3%) of the TRF total
scores submitted by preschool teachers were “borderline,” while 24 (34.3%) were “clinical.”b. SDQThe child’s Strengths and Difficulties Questionnaire (hereafter SDQ) 5) is an evaluation scale forscreening children’s behavioral problems such as the CBCL. Scores for the 25-item
questionnaire, which is answered by parents and caregivers, are categorized as “low need,”“some need,” or “high need” for combined total scores and subscales. In this study, the total
score based on parents’ responses was 2 children with “some need” (2.9%) and 1 with “highneed” (1.4%). According to evaluations completed b childcare providers, there were 2 children
with “some need” (2.9%) and 6 with “high need” (8.6%).

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Longitudinal study of support for children born after the disasterc. M-CHAT
Infant Autism Checklist (Modified Checklist for Autism in Toddlers; hereafter M-CHAT) 6) is anevaluation tool developed for the purpose of screening autism spectrum disorders. A parent isasked to fill out a 23-item questionnaire. Total scores are classified as “healthy range” and“clinical range.” In this study, nine (14.3%) M-CHAT surveys completed by parents resulted in
an identification of “clinical range.”② Results of cognitive developmental tests (Fig. 3)
The Wechsler Preschool and Primary Infant Intelligence Test (WPPSI) is a 10-item intelligence test
for infants that can evaluate their language and motor abilities. The Kaufman Assessment Batteryfor Children (K-ABC) is a 14-item intelligence test for infants that evaluates their intellectualactivity and is characterized also by its usefulness in teaching.
The Picture Vocabulary Test-Revised (PVT-R) measures the child’s verbal development by
having the child select the most appropriate of four pictures. For this survey, the “picturecompletion” and “blocks” segments from the WPPSI and the “number recitation,” “word sequence,”
and “hand movement” segments of the K-ABC II were extracted; the PVT-R was conducted asusual.
All test results were converted from approximate points to evaluation points, calculating theaggregate with average 10 and standard deviation ± 3. Each evaluation point was assessed asfollows: painting completion 8.70 (3.13 SD), blocks 8.94 (3.40 SD), number recitation 9.06
(3.31 SD), word sequence 8.27 (2.70 SD), hand movements 8.19 (3.18 SD), and painting and verbal
examination 9.20 (3.40 SD). The evaluation point average for each test was within the range ofaverage to below-average. Differences among test items were not observed.

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Research Report(3) Concerning parents
In principle, the answers to questions and the interview survey for parents were intended for mothers,
but in four families, the father was the person who cooperated with this study.
① Results of questionnaire survey (Fig. 4)
The Kessler Psychological Distress Scale (K6) 7) was developed as a tool for screening overallmental health, a simple scale consisting of six items, with the cutoff point for the total score being
13 points; scores are classified as belonging to the “healthy group” or the “clinical group.” The
Beck Depression Inventory-Second Edition (BDI-II) 8) is a measure developed to screen for andevaluate the extent of depression; it consists of 21 questions, and total scores are classified as “verymild,” “mild,” “moderate,” or “severe.”
The Impact of Event Scale-Revised (IES-R) 9) is a measure for evaluating the symptoms
associated with PTSD screening and trauma; the cutoff point for the total score is 23 points, andscores are classified into a “healthy group” and “clinical group.” In this survey, parents were asked
to fill out their respective evaluation scales. The K6 “clinical group” had 22 people (30%); the BDIII “moderate” group had 5 people (7%), and the “severe” group had 3 people (3%); and the IES-R“clinical group” had 9 people (12%).

② Results of interview survey (Table 3)
The Multi-International Neuropsychiatric Interview (M.I.N.I.) 10) is a simple structured interview
method developed to diagnose mental illness; it is meant to be administered without any changes at
all in advance to question items or their order. This tool can evaluate the risk of mental illness andsuicide without being affected by the bias of the interviewer. In this study, M.I.N.I. wasadministered to parents, and some mental illness was detected in 20 people (27%). The breakdownof the diagnoses is shown in the table below.

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Longitudinal study of support for children born after the disaster(4) Selection and follow-up for families that need support
Based on a comprehensive assessment of the survey, including the questionnaire survey results and theresults of the interview survey, criteria were set for families that required support. The following four
items were presented, and it was determined that a family required support when two or morecorresponded to a family’s situation.
① Three or more of the six evaluation points in the cognitive development test for children are present.
② In the TRF and CBCL administered to parents, more than one clinical area is identified.
③ A categorization of the child being in the “clinical” range according to the M.I.N.I. administered toparents.
④ A categorization of “high need” according to the SDQ administered to the child care provider; theM-CHAT administered to parents has the result of “clinical range”; the K6 or IES-R administeredto parents has the result of “clinical range”; and the BDI-II administered to parents has a result of“medium” or “severe.”
According to these criteria, 15 families were assessed as requiring support, and personalconsultations with a child psychiatrist and case meetings in preschools were convened. We also
provided support to parents in families that had been assessed as needing support and encouraged themto connect with an institution that could provide the appropriate consultation.
5. Discussion
This report is the result of analyzing only Miyagi Prefecture among the three prefectures participating in theJoint Health Survey. In the first year of the overall 12-year plan, after obtaining the agreement andregistration of 74 families residing in four cities in Miyagi Prefecture, we were able to form the basis for along-term longitudinal investigation. We set the required support criteria based on a comprehensive
evaluation by means of questionnaire and interview surveys of children and parents, and we sought toprovide immediate assistance when it was needed. In the evaluation of children, behavioral aspects wereassessed by means of a questionnaire, and cognitive development was assessed based on psychological tests.
In the behavioral evaluation, children who were judged to need some kind of support constituted 14.3% in
the CBCL based on parental evaluation, and 24.3% in the TRF based on evaluation by childcare providers.
When a similar questionnaire was administered to the general population, the proportion of support
required for children in this study was high because it constituted about 10% of the required support. On theother hand, children who were judged to require some kind of support according to the SDQ constituted139Research Report
4.3% based on parental evaluations and 11.5% based on evaluations by preschools, and neither was a highratio compared with the general population.
In the evaluation of cognitive development of children, the results were less than one standard deviationfrom the average value in all test items. Although it is difficult to verify whether there was a statisticallysignificant difference in this research report, given that the number of subjects was only 74, the results
suggest that it is necessary to carefully observe the progress of children’s cognitive development. Parental
evaluations were assessed through questionnaires, and psychiatric diagnosis was performed throughstructured interviews. Parents with a moderate or higher depressive state according to the BDI-II constituted10%; parents with some trauma-related symptoms according to the IES-R constituted 12%; and parents withmoderate or greater psychiatric symptoms according to the K6 were 30%.
All these are high percentages when compared with those of the same questionnaire administered to thegeneral population. Additionally, parents who meet the criteria for clinical diagnosis on the M.I.N.I. reached27%. As a result of these outcomes, it is clear that the mental health of parents living in disaster areas has
been challenged even six years after the disaster, and the need for comprehensive support, not only forchildren but also for parents, has been reconfirmed. There are, however, some limits to this study.
First, it is difficult for the subjects of this research to serve as a group representing the region because theconsent rate of families whose cooperation was requested was 20%. Because of the uneasiness that persistsin these children and families, there was little possibility of their agreeing to the study and requestingsupport. Next, because the study is based on a one-time questionnaire and a single interview, it is notpossible to confirm the status of children and parents only by using the information obtained. Finally,
because this study did not establish a control group of children in a nonaffected area with which to compare
this group, we could not conduct research on whether the subjects of this study are in a difficult situationcompared to those in nonaffected areas.
In this study, we suggest that living in stressful circumstances for a prolonged period after an earthquake
may be influencing the development of children born after the earthquake. Periodic longitudinal surveys
have been conducted since the year after the disaster, and we plan to continue to work toward understanding
and changing the circumstances of children and guardians in the wake of the Great East Japan Earthquake,and to continue to carry out interventions for families participating in the study.

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