Journal of the National Institute of Public Health 2013 Vol.62 No.2 p.204−212＜Original＞
Effects of presence in prefectures of short-term therapeutic
institutions for emotionally disturbed children on the types ofchildren that have to be taken care of in self-reliance support
facilities and foster homes
Takako TSUTSUI１），Masaaki OTAGA１，２），Sadanori HIGASHINO３），Alexis COTTENCIN１）
１）National Institute of Public HealthResearch Institute, National Rehabilitation Center for People With Disabilities
３）
School of Management and Information, University of Shizuoka

２）

Abstract
Objective: The purpose of this study was to investigate how the presence in prefectures of institutions
for short-term treatment of children with mild emotional disturbances affects the types of children thathave to be taken care of in self-reliance support facilities and foster homes and the appropriateness of
this care. These short-term therapeutic institutions (referred to here as STTIs) can either admit
children needing treatment for a short period or treat them on an out-patient basis. Besides providing
treatment, such facilities also provide consultation and other forms of assistance.
Method: Data collected in 2009 on children living in all types of children’s institutions (foster homes,
self-reliance support facilities, etc.) were analyzed in terms of the basic attributes of the children, their
psychiatric and psychological characteristics (presence of disorders, psychiatric consultations,maltreatment experiences in their former living environment, and 17 items reflecting their tendency tomanifest emotional and behavioral disorders), and the adequateness of care currently provided(according to staff members working in these institutions). Comparisons were then made between thedata for children living in prefectures with one or more STTIs and the data for children living inprefectures without an STTI.
Results: In prefecture with STTIs, foster homes and self-reliance support facilities have to cover theneeds of a higher number of children. Looking at the characteristics of children placed in foster homes
depending on the existence of STTIs in the prefecture, results show that, in prefecture without an STTI,a higher number of children had emotional and behavioral disorders (8 items out of 17) andpsychosomatic disorders. Children were also more likely to need mental health and psychologicaltreatment. On the other hand, in self-reliance support facilities, 4 items of emotional and behavioral
disorders were more likely to be positive and 5 items less likely. This shows that the characteristics ofchildren placed in foster homes and self-reliance support facility vary depending on whether STTIs exist
in the prefecture.
Conclusion: The results showed significant variations in the characteristics of children placed in selfreliance support facilities and foster homes between children living in a prefecture with at least one
STTI and those living in a prefecture without one. They also showed that STTIs are used to treat
children with emotional and behavioral disorders that self-reliance support facilities and foster homes
are unable to handle. Future research should focus on examining the effectiveness of STTIs.
keywords: short-term therapeutic institution for emotionally disturbed children, children’s institution,
psychiatric and psychological treatment, maltreatment experience, emotional and behavioral disorders(accepted for publication, 13th March 2013)

Corresponding author: Takako Tsutsui
2-3-6, Minami, Wako-shi, Saitama, 351-0197, Japan.
T e l: 048-458-6111
Fax: 048-458-6715
E-mail: tsutsui@niph.go.jp

204

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Effects of presence in prefectures of short-term therapeutic institutions for emotionally disturbed children on the types of children that have to be taken care of in self-reliance support facilities and foster homes

I.

Introduction

Since the establishment of measures for assistingorphans after the Second World War, the system of childprotection in Japan as well as society itself has been
through many transformations. The current childprotection system includes six types of children’s
institutions: infant homes (nyûji-in), foster homes (jidôyôgo shisetsu), short-term therapeutic institutions foremotionally disturbed children (jôcho shôgai-ji tanki
chiryô shisetsu) (referred to here as STTIs), maternal andchild living support facilities (boshi seikatsu shien
shisetsu), children self-reliance support facilities (jidôjiritsu shien shisetsu), and homes for self-reliance (jiritsu
shien hômu). As of March, 2012, there were 2,843
children in infant homes (7.0% of all placements inchildren’s institutions), 28,533 in foster homes (70.5%),
1,140 in STTIs (2.8%), 6,250 in maternal and child living
support facilities (15.4%), 1,331 in children self-reliancesupport facilities (3.3%), and 340 in homes for selfreliance (0.08%) [1]. That is, more than 40,000 children
were in children’s institutions, and foster homes (withabout 70% of the placements) represent the core of theJapanese child protection system.
Child protection also includes care provided by foster
care families (sato-oya). In this type of care, theresponsibility for raising the child is transferred to afoster family (selected by the prefecture) and is provided
when the child has no guardians or when theguardianship is considered inappropriate. While 7,669
families are currently registered as potential foster carefamilies, the number legally responsible for raising afoster child is only 4,244, and the total number of foster
children is only 4,930. Foster care in Japan also includes
family homes (famiri hômu) taking care of 686 children [1].
These homes also provide care in a family environment(the house of caregivers) but the main difference with
foster care families is that three caregivers at least areliving in the same home. Besides, a family home can takecare of 5 to 6 children at the same time (against up to 4
children in the case of foster care families). From aninternational point of view, foster care is still notfrequently provided in Japan [2], and the foster caresystem in home care is still underdeveloped, covering
only 10.8% of the 45,367 children in the child protection
system.
The transformations through which the system of childprotection in Japan has been since the Second World War
reflect the evolution of the social structure. For example,
children’s institutions were initially primarily a substitutefor the family, providing care to children without a home(war orphans, etc.) or whose family faced great poverty.
In contrast, most placements nowadays are madebecause the birth parents maltreated or neglected thechild or were unable to provide a proper education to thechild. A similar trend can be seen in Australia, Ireland,Israel, Sweden, England, and the U.S. as a greaternumber of children with behavioral and emotional
disorders due to maltreatment are also being taken careof by the state en these countries [3-7]. The reasons forplacement have thus become more complex, and thesystem must provide care to children who have beenmaltreated or neglected and thus need medical attention
as well as to children who have lost their birth parents.
In Japan, 53.4% of children living in foster homes haveexperienced maltreatment, and 23.4% have some sort ofmental and physical impairment, leading to an increasingneed for specialized care. The average length of stay isalso getting longer (currently 4.6 years), with 10.9% ofchildren staying more than 10 years [1].
Of the children’s institutions mentioned above, thefocus here is on STTIs. The Children Welfare Act, Article
43, Paragraph 5, defines them as facilities admitting
children with mild emotional disturbance for a shortperiod or treating them on an out-patient basis. They also
provide consultation and other assistance to the children
even after being discharged. Psychotherapists and childpsychiatrists at STTIs provide counseling, psychotherapy,
consultation, and assessment of behavioral and emotional
disorders. Compared to that at other care facilities forchildren, the length of stay is relatively short (2.1 years
on average) [1]. Moreover, STTIs provide counseling andguidance on child education to residents of thecommunity. As the length of stay is relatively short,children placed in an STTI usually return to their family
or are placed in a foster homes upon discharge. This
explains why STTIs also provide after care such as day
care services.
A look at the characteristics of children in STTIs showsthat 75% of them have suffered maltreatment, 26% havepervasive development disorder, 12.8% have a light or
medium intellectual deficit, 40% are being treated by achild psychiatrist, and 35% are on medication [8].
In Japan, there is no clear definition of emotional
disturbance for children. However, as suggested by theappellation “short-term therapeutic institutions foremotionally disturbed children,” STTIs were created totake care of children who need psychological carebecause they are suffering from psychological difficulties
and because they are facing various difficulties in their
daily life. Thus, it seems reasonable to consider thatemotionally disturbed children are children who need
psychological care because they are suffering frompsychological difficulties and because they are facing
various difficulties in their daily life. The term“emotionally disturbed” was formerly used to describe a“perturbation of emotion.” However, its use created

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Takako TSUTSUI，Masaaki OATAGA，Sadanori HIGASHINO，Alexis COTTENCIN

various issues as it was difficult to identify thecharacteristics of children who would fall into thiscategory. Moreover, “disturbed” in Japanese also means
handicapped and was thus considered inappropriate(especially by the families and children themselves) for
describing children with psychological difficulties.
Another problem was the use of “short-term” when the
average length of stay exceeded two years. For thesereasons, the government stated in a notice dated 29
March 2012 that “psychological care facility for children”
could be used instead of “STTI.” This also indicates thatthe government has recently developed an interest in thistype of institution.
Children self-reliance support facilities were formerly
called “juvenile education and protection centers” (kyôgoin) and targeted children who, according to childguidance centers and family courts, “have committed orare at risk of committing offenses.” The appellation waschanged to “children self-reliance support facilities” by arevision of the child welfare law in April 1998. At thesame time, these facilities began to take in “children who
need lifestyle guidance due for example to their family
environment.” As a result, the functionality of thesefacilities was extended to enable the provision of aftercare services, community support services, family
adjustment services, and short stay services. The
decreasing number of placed children in these facilities
may be related to this extended functionality [9]. Despite
their smaller staffs, these facilities started taking care ofdifficult cases, e.g., children needing highly specialized
care, including children with behavioral and emotional
disorders.
The child protection system in Japan has traditionallyfocused on securing placements of children in foster carehomes and has gradually loosened the requirements
placed on each type of facility in terms of the child’s age
and condition despite the inability of some institutions toprovide specialized health care to an increasing numberof children with behavioral and emotional disorders.
Although STTIs and children self-reliance support
facilities were designed especially to provide this type ofcare, it appears that they are still insufficiently developed
and not fully operational.
Data from the National Child Abuse and Neglect Data
System (NCANDS) in the United States [10] suggest that
only children with severe disorders are placed ininstitutions. The data showed that 78.3% of them were
neglected, 17.8% were physically abused, 9.5% were
sexually abused, 7.6% were psychologically abused, 2.4%
were medically neglected, and 9.6% had experienced
another type of maltreatment. These rates are quite
similar to the rates of maltreated children placed in STTIs
in Japan. Obviously, it is not possible to simply compare
these data because of the contextual differences and the206

fundamentally different approach to collecting data (datafrom the United States are based on the number ofmaltreatment reports that were actually certified as
maltreatment cases), but the U.S. data supports theobservation that STTIs in Japan are taking care ofchildren who have experienced serious maltreatment andthus are at high-risk of developing behavioral andemotional disorders.
In November 2000, a national movement in Japan
known as “21st Century Healthy Parents and Children”
recognized the need for facilities, such as STTIs, that cantake care of the increasing number of maltreatedchildren and called for the implementation of at least one
STTI in each prefecture by 2010 [11]. Moreover, the“Vision for Children and Childcare” called for the
implementation of 47 STTIs before 2014 [12]. However,there are still some prefectures in Japan without an
STTI [13].
In our study, we investigated the current childprotection system in Japan, focusing on the role of shortterm therapeutic institutions. The presence of STTIs in
prefectures and their occupancy rates were determinedusing the national database on child protection created in2009. We focused on the effects that the presence andnon-presence of STTIs in a prefecture have onplacements in foster homes and in children self-reliancesupport facilities by comparing the basic attributes andpsychological and psychiatric characteristics of children
placed in these institutions. By determining the effect of
STTIs on other facilities, we can offer insights into the
future direction of the child protection system needed inJapan.

II. Method
1．DataIn 2009, a study of all types of child protection facilities
in Japan collected data on about 36,200 institutionalized
children (complete enumeration). These data werecollected for children living in 441 foster homes(representing 87.7% of all foster homes in 2009) and in 45
support facilities (representing 77.6% of all support
facilities in 2009).
The data included the child’s date of birth, gender, andlength of stay in the facility, the number and types ofplacements the child had had, the difficulties in caring forthe child, the child’s domicile before the placement, thechild’s family, the child’s certified disabilities, the child’s
mental and physical health, the existence or nonexistence of maltreatment experiences, the appropriatenessof the placement (according to staff members working in
the facility), and 17 items assessing the tendency of thechild to manifest behavioral and emotional disorders.
These data were obtained through a questionnaire filled

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Effects of presence in prefectures of short-term therapeutic institutions for emotionally disturbed children on the types of children that have to be taken care of in self-reliance support facilities and foster homes

in by a doctor or facility staff member and through thecollection of assessment grids used in child consultation
centers.
2．Ethical considerations
An explanation of the ethical considerations was sentalong with the questionnaire. It assured the respondentsof confidentiality and explained their right to refuse toparticipate in the study. It stated that, by sending backthe questionnaire, they agreed that the data could be
used for the purpose of this study. The Ethics Committeeof the National Institute of Public Health approved thestudy (approval number NIPH-TRN#08003).
3．Analytical method
Using data from the Ministry of Health, Labour andWelfare [13], we created a variable for the presence or
non-presence of STTIs in prefectures and calculated the
STTI occupancy rate for each prefecture with an STTI.
First, we compared the number of foster homes andsupport facilities, as well as the coverage of each of thesefacilities (in terms of number of children), in prefectureswith STTI and prefectures without STTI. The coverage ofeach facility was calculated using population data
provided by the Ministry of Internal Affairs andCommunications on the number of children under age 20
per municipality [14].
Then, comparisons were made on the basis of whether
a prefecture had an STTI or not in terms of the attributesof children (gender and age) in foster homes and support
facilities, length of stay, certified disability, psychosomatic
disorder, mental health and psychological treatment,
adequateness of care currently provided (according tostaff members), rate of abused children, and 17 items
assessing the tendency to manifest emotional andbehavioral disorders. This tendency was assessed on thebasis of not only the doctor’s diagnosis but also on staff
observations.

III. Results
1．Presence of STTIs in prefectures
As shown in Table 1, STTIs were implemented in 33
different locations (prefecture, city designated bygovernment ordinance or core city) in Japan as of
October 2010. At the scale of prefectures, this means that
only 30 of the 47 prefectures of Japan have implemented
at least one STTI.
Hyogo prefecture had the highest STTI occupancy rate
(97.1%), followed by the city of Hiroshima city with 96.4%,
Wakayama and Shiga prefectures with 93.3%, Osaka citywith 90.7%, and Sendai city, Shizuoka prefecture andTottori prefecture with 90.0%.
The lowest occupancy rates were for Mie prefecture

Table 1 Number and occupancy rate of STTIs in eachprefecture or major city
（2010.10）
Prefecture or
major city

ActualNumber
Occupancy
Capacity number ofof STTIs
rate（B） placements（A）(%)(C/B)（C）

Hyogo
Hiroshima city
Wakayama
Shiga
Osaka city
Sendai city
Shizuoka
TottoriNaganoAichi
Osaka
Yokohama city
Gifu
Nagasaki
Kumamoto
Kagoshima
Iwate
Kyoto
Yamaguchi
Gunma
Hokkaido
KagawaSaitama
Ibaraki
Kochi
Aomori
Nagoya city
Fukuoka
Shimane
Kyoto city
OkayamaTochigi
Mie

1
1
1
1
2
1
1
1
1
2
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

35
28
30
50
75
40
50
30
19
85
154
56
48
40
35
35
50
30
50
38
50
30
50
40
30
30
35
50
20
35
50
35
40

34
27
28
46
68
36
45
27
17
76
136
49
42
35
29
29
40
24
40
30
37
22
36
26
13
12
13
18
7
12
17
7
5

97.1
96.4
93.3
92.0
90.7
90.0
90.0
90.0
89.5
89.4
88.3
87.5
87.5
87.5
82.9
82.9
80.0
80.0
80.0
78.9
74.0
73.3
72.0
65.0
43.3
40.0
37.1
36.0
35.0
34.3
34.0
20.0
12.5

with 12.5%, followed by Tochigi prefecture with 20.0%,
Okayama prefecture with 34.0%, Kyoto city with 34.3%,
Shimane prefecture with 35.0%. There is thus a large gap
in the occupancy rate between prefectures, some with arate greater than 90% and some with a rate below 40%.
2． Presence of STTIs and situation of children in
self-reliance support facilities and foster homes
The differences in the rate of self-reliance support
facilities and foster homes, and in the coverage of each ofthese facilities, depending on the presence or nonpresence of STTIs in the prefecture are summarized inTable 2.
Prefectures with an STTI had a higher proportion of
foster homes (55.8% vs. 44.2%) and a lower proportion of
support facilities (46.5% vs.53.5%).

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Takako TSUTSUI，Masaaki OATAGA，Sadanori HIGASHINO，Alexis COTTENCIN
Table 2 Effect of presence or non-presence of STTIs on establishment of foster homes and support
facilities and on number of placements
STTI present

STTI not present

Total

Foster homes

246(55.8%)

195(44.2%)

441

Support facilities

20(46.5%)23(53.5%)

43

Number of facilities(%)

Coverage aged under 20 population per facility
Foster homes

61305.7

41899.7

Support facilities

754060.7355236.7

However, looking closely at the coverage (the numberof children in prefectures divided by the number offacilities), it appears that, in prefecture with STTIs, eachfoster home and children self-reliance facility has to cover
the needs of a higher number of children (61305.7 against
41899.7 children per foster home and 754060.7 against
355236.7 children per self-reliance support facility).
3． Presence of STTIs and characteristics ofchildren placed in children self-reliancesupport facilities and foster homes
The basic attributes of children in foster homes andsupport facilities are shown in Table 3 broken down by
the presence and non-presence of STTIs in theprefecture. No significant differences were observed
regarding the gender ratios.
The age and length of stay of children in foster homes
and support facilities were slightly higher for prefectures
without an STTI. According to the medical files and staff
members, a higher number of children are provided withpsychiatric and psychological treatment and a higher
proportion of children are considered to havepsychosomatic disorders in prefectures without an STTI.
Moreover, the number of children who had experienced
physical abuse, neglect, and psychological abuse (otherthan sexual abuse and other specific types of abuse) was
higher in those prefectures. The number of positive items
for assessing the tendency to manifest emotional andbehavioral disorders was also significantly higher, withan average of 9 positive items out of 17, and the numberof children considered by the staff members to bereceiving inadequate treatment was significantly higher
in these prefectures.
Gender differences were not seen for the self-reliancesupport facilities. In prefectures without an STTI,
children self-reliance support facilities had a higher rateof children with physical disorders. Moreover, eventhough the number of children with mental disorders
was lower, psychological therapy was more likely to be
used. This result suggests that, when STTIs does notexist in the prefecture, self-reliance support facilities takecare of children with behavioral and emotional disorders

208

instead of STTIs and that, when STTIs does exist in theprefecture, self-reliance support facilities take care ofchildren with mental disorders that STTIs does notinclude.
The fact that STTIs and support facilities does not takecare of children with the same disorders become evenmore apparent when comparing the behavioral andemotional disorders of children placed in support
facilities depending on whether STTIs exist in theprefecture.
The rate of children in support facilities who had
experienced neglect and other types of maltreatment was
lower in prefectures without an STTI. Four behavioral
and emotional disorders were more common in
prefectures without an STTI: issues with the educator,
substance use, self-injurious behavior, and issues ofgroup adaptation. Six other ones were less common:
eating disorder, sleeping disorders, deficiency to develop
language skills, mental retardation, bullying otherchildren within the institution, and being bullied by otherchildren within the institution.

IV. Discussion
1． Effect of presence of STTI on placement
appropriatenessThat some children are inappropriately placed inchildren’s institutions is commonly known by employeesof these institutions. In Tokyo, which does not have an
STTI, the metropolitan government recognized in 2009that inappropriate care may be provided to some children
placed in children’s institutions due to the lack of an STTI
and thus suggested a “reinforcement of the medical careprovided to abused children.” It was estimated thatapproximately 10% of children placed in foster homes inTokyo should actually be in an STTI [15].
Our research supports this common knowledge andthe statement of the Tokyo Metropolitan Assembly of theJapanese Communist Party. It empirically revealed that,in prefectures without an STTI, children who should bein an STTI due to their condition generally ended up in
foster homes and support facilities. It thus provides clear

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Effects of presence in prefectures of short-term therapeutic institutions for emotionally disturbed children on the types of children that have to be taken care of in self-reliance support facilities and foster homes
Table 3 Characteristics of children placed in foster homes and support facilities according to the presence or non-presence of
STTIs in prefectureevidence that children are more likely to receive
inappropriate care in prefectures without an STTI.
The results are less conclusive for support facilities
and do not suggest that some of the children placed infoster homes should actually be in an STTI. The numberof placements that employees would consider
inappropriate was substantial for foster homes while thenumber was negligible for children self-reliance support
facilities. The recent change in policy extending the roleof children self-reliance support facilities to enable themto take care of increasingly difficult cases can beinterpreted as recognition that foster homes are notappropriate for such cases. However, as discussed later,differences were seen in the behavioral and emotional
disorders of children placed in children self-reliancesupport facilities depending on whether an STTI waspresent or not in the prefecture. This suggests that thesefacilities may have to take in children with differingcharacteristics depending on whether there is an STTI in
the prefecture.
Our research is based on the hypothesis that thepresence of an STTI in the prefecture should affect the

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placement of children in other facilities such as foster
homes and children self-reliance support facilities.
It is important to note that placements in an STTI
represent only 3% of all placements in children’s
institutions and that, even if the goal of implementing 47
STTI by 2016 is reached, the number of children being
treated in an STTI in each prefecture would not exceed afew dozen. Thus, considering that more than half of thechildren in foster homes and two-thirds of the children inchildren self-reliance support facilities have experienced
maltreatment, the role that STTIs may be able to play inthe future seems limited.
Nevertheless, even though the average length of stayin an STTI keeps increasing, STTIs were initially created
to provide short-term care and thus allow temporarytransfer from foster homes. STTIs may be better suited
as a back-up for psychiatric and psychological treatment
through short stays and temporary placements than for
multi-years treatment of maltreated children who havebeen admitted. Considering that some STTIs have been
implemented in hospitals and are focusing on this type ofcare, it may be worthwhile to encourage this back-up
function of STTIs.
2． Effect of presence of STTI on situation in
foster homes and children self-reliance support
facilities
When comparing the situation in foster homes andchildren self-reliance support facilities, it appears that,even though no significant differences were seen in the
disability certifications, children placed in foster homes
in a prefecture without an STTI are more likely to havephysical and psychiatric disorders. In the case of children
placed in children self-reliance support facilities, thesame tendency was seen for physical disorders while
psychiatric disorders were more likely to be seen inchildren self-reliance support facilities when there was an
STTI in the prefecture. Considering that children inchildren self-reliance support facilities are placed there
because they would be difficult to take care of in otherfacilities, this trend suggests that STTIs do not have thecapacity to take care of all the children with psychiatricdisorders and thus have to rely on placements in children
self-reliance support facilities.
Higher rates of children provided with psychiatric andpsychological treatment in foster homes were seen when
there was no STTI in the prefecture while higher rates
were seen only for psychological therapy in children selfreliance support facilities. This is understandable giventhat children self-reliance support facilities are a closed
environment, so visits to external medical facilities arenaturally uncommon. Moreover, considering that STTIs
were created to provide this type of psychologicaltherapy, it is not surprising that the number of children in

210

need of psychological care is higher in children selfreliance support facilities when there is no STTI in theprefecture.
The rate of children with a maltreatment experience ishigher for children placed in foster homes but lower forchildren placed in children self-reliance support facilities
when there is no STTI in the prefecture. This may berelated to our finding that, in prefectures without an
STTI, an increased number of children were placed not
due to maltreatment but to misbehavior.
Eight behavioral and emotional disorders were more
frequent in children placed in foster homes when there
was no STTI in the prefecture: autistic tendency,
tendency toward attention deficit or hyperactivity,
tendency toward antisocial behavior, tendency toward
depression, self-injurious behavior, issues of group
adaptation, eating disorders, and sleeping disorders. In
prefectures with STTIs, only mental retardation was
more common. This means that, when there is no STTIin the prefecture, children who should be in disabledchildren facilities due to their severe behavioral andemotional disorders end up in foster homes and thatmany children with mental retardation are placed infoster homes.
The types of emotional behavioral disorders inchildren living in self-reliance support facilities thatvaried depending on the presence of an STTI in theprefecture differed from those in children living in foster
homes. When there was an STTI in the prefecture six
disorders were less frequent in children living in children
self-reliance support facilities: eating disorders, sleeping
disorders, language skills development deficiency, mental
retardation, bullying, and being bullied. On the other
hand, four disorders were more frequent: issues with theeducator, substance use, self-injurious behavior, andproblems with group adaptation. This suggests that thetypes of emotional and behavioral disorder that STTIs
and children self-reliance support facilities can deal withare different.
These results suggest that the presence of an STTI in
the prefecture affects the placement of children in foster
homes and children self-reliance support facilities. In
Japan, child guidance centers screen children needing
help and determine the best placement option. In
prefectures with an STTI, these centers have anotherplacement option. Moreover, since STTIs are targeted ata specific population of children, there are clear
standards on which to base the decision. In prefectures
without an STTI, the standards for determining thebest placement are rather vague, leading to an increase ininappropriate placements. This means that the screening
function of child guidance centers is hindered by the lackof STTIs in the prefectures.
To cover the needs of maltreated children and to be

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able to treat emotional and behavioral disorders byproviding specialized care, it is crucial to promote andsupport the screening function of child guidance. The
results of this study help clarify the characteristics ofchildren in the child protection system and thus support
a more effective screening process.
3．Future challenges in promoting STTIs
The child protection system has focused on taking careof children with various problems. However, mostchildren’s institutions are not currently equipped toprovide the specialized care needed to deal with therecent increase in the number of children with emotionaland behavioral disorders. Children’s institutions were
initially more a place for children to live than atherapeutic facility, so providing medical services for thechildren in an everyday setting may have been
considered inappropriate.
As of October 2010, STTIs were implemented in only
33 prefectures and government ordinance cities, which isless than half of all prefectures and government
ordinance cities (47.8%). According to the Ministry of
Health, Labour and Welfare, only five local authorities are
currently implementing or planning on implementing an
STTI [13], and there is no indication that this number will
increase in the near future. However, implementing
more STTIs is obviously necessary considering the
rapid increase in the number of maltreated children.
The main reasons given for this shortfall in thenumber of STTIs implemented are “Difficulty in finding
managing agents,” “Difficulty in finding psychotherapists
and doctors,” and “Lack of children to place in such an
institution.” It appears that the recognition of theimportance of STTIs varies greatly among municipalities[13], showing not only a lack of comprehension by somemunicipalities about the actual situation but also the
problem of funding the construction of STTIs. Thus, thelack of STTIs is not only the responsibility ofmunicipalities but also of the national government, which
has failed to make a strong case for the construction of
STTIs and does not provide strong enough incentives fortheir construction.
In the U.S., where the child protection system iscentered on placements in foster families, supporting
data has been collected [6]. One study has revealed, forexample, that 60% of children placed in foster family
return to their former home in less than six months [16].
Other studies have shown that 70 to 80% of the children
receiving out-of-home care had experienced maltreatmentin their previous home and that, overall, the foster caresystem is effective in preventing abuse [17-20]. Other
studies revealed that the incidence of neglect or physicalmaltreatment by the birth parents decreased after thechild returned home [21-23].

However, empirical studies on the outcomes of thechild protection system in Japan are still remarkably
lacking [24]. Moreover, since the Japanese system isbased on residential placement rather than on foster
family placement, there is a strong need to conduct
research specific to the situation in Japan to clarify how
this child protection system affects the emotional andbehavioral disorders of children. Moreover, Japan should
also conduct research on the care provided by STTIs andthe outcome of this care, as STTIs are actually able toprovide the care needed to treat emotional andbehavioral disorders.
There have been few studies that focused on how thepresence of an STTI in the prefecture affects otherchildren’s institutions. Future research should focus on
examining the effectiveness of STTIs and how better
cooperation between STTIs, foster homes, and children
self-reliance support facilities could improve the careprovided to children. At the same time, clinical studies
are needed to reveal how the care provided in foster
homes and children self-reliance support facilities differs
depending on the presence of an STTI in the prefecture.

V.

Conclusion

By comparing the characteristics of children in foster
homes and children self-reliance support facilities
depending on the presence or non-presence of an STTI in
the prefecture, we found that some children who should
be in an STTI due to their maltreatment experience
and/or their emotional and behavioral disorders actuallyended up in a foster home. We also found that, whenthose placements are made, they are consideredinappropriate by the staff members of foster homes.
When there is an STTI in the prefecture, children selfreliance support facilities tend to have a higher rate ofchildren with psychiatric disorders and who are more
likely to have issues with the educator and problems withgroup adaptation and to exhibit self-injurious behavior
and use substances, which suggests that these children
should not be placed in an STTI but in a self-reliancesupport facility.
Our results show that the presence of an STTI in theprefecture affects the placement of children in foster
homes and children self-reliance support facilities. They
also suggest that STTIs are used as a last resort forchildren with maltreatment experience and/or behavioral
and emotional disorders.
Thus, future research should focus on clearly defining
the purpose of each type of child care institution so thatappropriate care can be provided and on collecting data
regarding the care provided in each type of institution,
the possible cooperation between institutions, and theoutcome of care.

J. Natl. Inst. Public Health, 62（2）: 2013211

Takako TSUTSUI，Masaaki OATAGA，Sadanori HIGASHINO，Alexis COTTENCIN

Acknowledgments
This research is part of the “Research on therelationship between the condition of abused children or
children with disorders and the level of care needs”
funded by the Japanese Ministry of Health, Labour andWelfare.

References[1] Ministry of health, Labour and Welfare, Equal
Employment, Children and Family Bureau.
Shakaitekiyogo no genjô ni tsuite 2012.11 (inJapanese). 2012.
http://www.mhlw.go.jp/bunya/kodomo/syakaiteki_yougo/dl/yougo_genjou_01.pdf (accessed 2012/12/1)[2] Thoburn J. International Perspectives on Fostercare. How Does Foster Work? International
Evidence on Outcomes. London: Jessica Kingsley
Publishers; 2010. p.29-44.
[3] Ainsworth F. A research agenda for group care.
Child and youth care Forum. 2005;24:215-30.
[4] Barth RP. Residential care: From here to eternity.
International Journal of Social welfare. 2005; 14:15862.
[5] Bates BC, English DL, Koudou-Gilies S. Residential
treatment and its alternatives: A review of literature.
Child and youth care Forum. 1997;26:7-51.
[6] Curry JF. The current status of research inresidential treatment. Residential treatment forchildren Youth. 1995;12(3):1-17.
[7] Whittaker JK. The future of residential group care.
Child Welfare. 2000;79:59-74.
[8] Ministry of health, Labour and Welfare, Equal
Employment, Children and Family Bureau.
Shakaitekiyogo no kadai to shouraizo no torikumi
jokyo (in Japanese). Nov 2012.
http://www.mhlw.go.jp/bunya/kodomo/syakaiteki_yougo/dl/yougo_genjou_02.pdf (accessed 2012-12-1)[9] Fujiwara M. Jidojiritsushienshisetsu: Sono rekishi
kara kangaeru (in Japanese). Jidojiritsushienshisetsu
no kanosei kyogoin kara no baton tacchi. Mineruva
Shobo; 2004. p.14-75.
[10] Children’s Bureau, U.S. Department of Health andHuman Services. Child Maltreatment 2009. 2010.
http://www.acf.hhs.gov/programs/cb/pubs/cm09/cm09.pdf (accessed 2012-1-2)[11] Healthy parents and children 21. National plan forthe health of mothers and children until 2010. 2000.
http://www1.mhlw.go.jp/topics/sukoyaka/tp1117-1_
b_18.html#betu (accessed 2012-1-2)[12] Cabinet Office. Kodomo kosodate bijon ni tsuite,
kodomo no egao ga afureru shakai no tame ni (in212Japanese). 2010.
http://www8.cao.go.jp/shoushi/vision/pdf/b2.pdf(accecced 2012-12-1)[13] Committee of specialist on child protection of theSocial Security Council. Shakaitekiyogo no minaoshi
ni kansuru toumen no kadai ni tsuite (in Japanese).
Dai jukkai shiryo 1. 2010.
http://www.mhlw.go.jp/stf/shingi/2r9852000000ybr9-att/2r9852000000ybxd.pdf (accecced 2012-12-1)[14] Ministry of Internal Affairs and communications.
Jumin kihon daicho ni motozuku jinko, jinko dotai
oyobi setaisu (Annex 5, shichoson no nenreikaikyubetsu
jinko)(in Japanese). 2009.
http://www.soumu.go.jp/main_content/000033895.xls[15] Tokyo Metropolitan Assembly of the JapaneseCommunist Party. No more abused children inTokyo: Recommendation from the JapaneseCommunist Party, 2010.
[16] Tsutsui T. Actual state of maltreated children placedin children’s institutions in Japan. Journal of healthand welfare statistics. 2011;58(15):26-33.
[17] Arad BD. Prenatal features and quality of life in thedecision to remove children at risk from home. Child
Abuse and Neglect. 2001;25:47-64.
[18] Curtis PA, Dale G, Kendall JC, Rockefeller JD. The
foster care crisis: Translating research into policy
and practice. Lincoln, NE: University of Nebraska
Press; 1999.
[19] Jones MD. A second chance for families: Five years
later follow-up of a program to prevent foster care.
New York: Child Welfare League of America; 1985.
[20] United States General Accounting Office. Child
welfare: Complex needs strain to capacity.
GAO0HEHS-95-208. Washington, DC: Government
Printing Office; 1995.
[21] Landsverk J, Davis I, Ganger W, Newton R, et al.
Impact of children psychosocial functioning on
reunification from out-of-home placement. Children
and Youth Services Review. 1996; 18(4/5): 447-62.
[22] Landsverk J, Garland AF. Foster care and pathways
to mental health services. In: Curtis PA, Dale Jr G,
Kendall JC, editors. The foster care crisis:
Translating research into policy and practice.
Lincoln, NE : The University of Nebraska Press, inassociation with the Child Welfare League ofAmerica; 1999. p.193-210.
[23] Zuravin SJ, DePanfilis D. Factors affecting foster
care placement of children receiving protective
services. Social Work Research. 1997;21:34-42.
[24] Tsutsui T, Otaga M. The system of child protectionin Japan: Shift in residential placements for children
and the necessary conditions to restructure the careprovision system. Journal of the National Institute of
Public Health. 2011;60(5):401-10.

J. Natl. Inst. Public Health, 62（2）: 2013