Original Article

Yonago Acta medica 2016;59:25–35

Realities and Challenges of Support for Children with Special Needs in Nursery
Schools
Kaori Ishiguro*† and Shin-ichi Yoshioka‡*Graduate School of Medical Sciences, Tottori University, Yonago 683-8503, Japan, †Matsue Co-medical College, Matsue 690-0265,
Japan and ‡Department of Nursing Care Environment and Mental Health, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japanⅰ) to raise awareness of such children; ⅱ) to eliminate
regional disparities; ⅲ) to provide professional training
for NSTs specializing in developmental disorders; ⅳ) totrain and re-educate assistant NSTs and ⅴ) to enhance
infant screening.

ABSTRACT
Background

Nursery schools and kindergartens havebeen struggling to cope with increasing numbers of children with special needs. Hence, we conducted a study
on what nursery school teachers (NSTs) will require
regarding learning and societal resources for supporting
such children in the future.
Methods A questionnaire survey was conducted for
2,476 NSTs employed in 154 nursery schools in Shimane
and Kochi Prefectures. The questionnaires were sent by
post to officials at each nursery school. The completed
questionnaires were collected by the school officials andreturned by post. In addition to statistical processing of
the survey results, the content of the free description responses was analyzed using the KJ method.
Results Responses were obtained from 1,509 NSTs
at 118 nursery schools. Of the respondents, 90.7% had
experienced difficulties coping with children with special needs, and 83.9% were in charge of caring for suchchildren. Such children were enrolled in every childcare
facility participating in the survey. The NSTs primarily
needed to learn about specific coping methods, the illness, and skills for supporting parents; concerning thesocietal resources, they needed the addition of assistant
NSTs, the implementation of age-five check-up, and therecruitment of mentors. The free description responses
were categorized into the following five categories: demand for child care administration, cooperation withprofessional staff, support for parents, developmental
health checkups, and on-site needs for nursery childcare.
One of the specific demands was to develop human resources capable of providing parents with appropriate
advice.
Conclusion The results have shown that all NSTs are
required to deal with children with special needs. Futurechallenges for providing support for such children are:

Key words children with special needs, developmental
disorder, nursery school, nursery school teacher

Various neurodevelopmental disorders (NDDs), which
are discussed in the Japanese edition (2014) of “theAmerican Psychiatric Association’s Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition,”1
include intellectual disability, communication disorder,
autism spectrum disorder, attention-deficit/hyperactivity
disorder, specific learning disorder, and motor disorder
including tics. Moreover, the fact that there are caseswith NDD wherein individual children suffer from a
combination of multiple symptoms of the disorders
makes it difficult to diagnose and support such children.
Gillberg2 has coined the term “Early Symptomatic
Syndromes Eliciting Neurodevelopmental Clinical Examination” (ESSENCE) to refer to children whose developments subtly deviate from what may be considered
normal despite having received no clear diagnosis. This
term could describe the ones who could be categorized
into a group of “children with special needs” (ki ni naru
ko, literally “concerned children”) in Japan. It is criticalto provide appropriate support according to the symptoms being presented. In general, in this study, “children
with special needs” refers not only to the children whose
conditions include mildly delayed intellectual or physicaldevelopment and maltreatment but also to the children
who NSTs considered to be “children with special needs
who appear outwardly ordinary” and “children who areleft out of a group of children.” In particular, the NSTs
should be able to perceive that developmental disorder(s)might underlie problem behavior in a child they are
dealing with once they have “noticed” something different about that child at an earlier stage.
In recent years, it has been noted that there are children who require early detection and intervention evenat the nursery school and kindergarten level.3 Shimono

Corresponding author: Shin-ichi Yoshioka, MD, PhD
shiyoshi@med.tottori-u.ac.jp
Received 2015 December 2
Accepted 2015 December 24
Abbreviations: ESSENCE, early symptomatic syndromes eliciting
neurodevelopmental clinical examination; NDD, neurodevelopmental disorder; NST, nursery school teacher; PT, parent training; SST,
social skills training

25

K. Ishiguro and S. Yoshioka

et al.,4 Nakashima et al.,5 and Kurokawa6 have reported
that children with special needs are enrolled in around
70% of nursery schools. Fukuyama et al.7 pointed outthat while 40% of the NSTs were aware of and provided
support to children with special needs, a considerable
number of behaviors and characteristics associated withthe developmental disorders remained.
In this study, in light of the present situation of local support systems, we clarify the societal and learning
resources that NSTs need in the future. While discussing
how administrative bodies and professionals in fields
such as medicine, welfare, psychology, and education
should play their roles and render cooperation support
for those involved, including the parents, we examinedpossible future challenges to enhance support for children and childcare.

Ethical considerations

Regarding ethical considerations, the study was implemented with approval given by the Tottori University
School of Medicine Ethics Committee (dated July 22,
2013, approval number 2240) after obtaining prior approvals from the respective chairs of the Shimane Prefecture Childcare Council and Kochi Prefecture Nursery
School Administrative Council. In addition, the questionnaire was accompanied by an explanation documentthat described the intention, purpose, and ethical considerations of the survey. Participation in the study was voluntary and the choices of the respondents as to whether
to cooperate or not was respected. The questionnaire
responses were anonymous to ensure the privacy of theparticipant.
RESULTS
Responses were obtained from a total of 1,509 NSTs
(collection rate of 60.9%) of 118 nursery schools (collection rate of 76.6%, from 68 schools in Shimane Prefecture and 50 schools in Kochi Prefecture). After excluding incomplete and unclear responses, responses from
1,233 subjects were evaluated for analysis (an effective
response rate of 81.7%). For an analysis of free descriptions about required learning and societal recourses,
responses including some missing data were evaluated.

SUBJECTS AND METHODS
Subjects

The study involved 2,476 NSTs employed at a total of
154 randomly selected nursery schools in Shimane Prefecture (n = 79) and Kochi Prefecture (n = 75). The study
was conducted from August 2013 to the end of September 2013.
Methods

A survey was conducted using an anonymous self-administered questionnaire. The questionnaires were sentby post to officials at each nursery school along with
instructions and return envelopes with a request to distribute the questionnaires to NSTs in their schools. The
completed questionnaires were collected by the school
officials and returned by post.

Subject attributes (Table 1)

The majority of the NSTs were in their twenties, andthose with ten to twenties years of the experiences outnumber other years in the years of experience categories.
Two-year colleges accounted for approximately 80%of the institutions where the respondents obtained theiraccreditation. Moreover, 57.2% of the subjects had opportunities to take courses in developmental disorders aspart of their professional education.

Questionnaire contents

The questionnaire was intended to find the attributes of
NST respondents; their ideas about children with special
needs (where to find information, degree of interest,childcare difficulties, workshop participation, the current situation of support systems, required learning andsocietal resources, etc.); and the opinions and requests
they wished to address to government and institutional
officials (free description).

Current situation of the support system (Table 2, 3)

The proportion of NSTs who had experienced difficulties was 90.7%, and 83.9% of them had been in chargeof children with special needs and 48.8% were currently
experiencing difficulties caring for children with special
needs. The proportion of nursery schools employing
NSTs experiencing childcare difficulties was 100%, with
99.2% of all the schools employing teachers with someexperience of being in charge of children with special
needs, and 95.8% of the schools employing teachers currently in charge of such children.
The proportion of the NSTs who had sought advice
about children with special needs in their classes was
79.2%. The first person that these teachers sought advice
from was a colleague (72.4%) had sought advice from a

Questionnaire analysis

For analysis, simple tabulation and cross tabulation wereconducted using SPSS version 19 (IBM, Armonk, NY).
For statistical testing, the chi-squared (χ2) test was usedwith a significance level of 5%. Free descriptions concerning NSTs’ opinions and requests were classified andcategorized using the KJ method for analysis.8
26

Survey on children with special needs

school nurse or physician.
School nurses were present in 63.9% of the nurseryschools, and while 65.9% of the respondents indicatedthat they would consult with their school nurses in theevent they became concerned about a child’s behavior in
the nursery.
Over 60% of the total number of subjects responded
that cooperation with school physicians was easy to obtain. The professional expertise of school physicians was
broken down into pediatrics (61.9%) and internal medicine (39.1%).
As for the frequency with which case study meetings were held in nursery schools regarding children
with special needs, 28.5% of the schools met “regularly,”
47.8% met “when necessary,” and 4.1% met “annually.”
As for the frequency of cooperation with developmental support and counseling centers or related institutions established by prefectures or municipals, 4.2%

cooperated monthly, 23.6% cooperated several times a
year, 48.1% cooperated only when there was a relevantcase.
The proportion of the NSTs who consulted with development counselors was 55.2%, and the occupations of
the circuit development counselors who regularly visitednursery schools were as follows: public health nurses(68.5%), psychotherapists (14.7%), experienced NSTs
(7.3%).
Learning required by NSTs (Fig. 1)

Each of “specific coping methods,” “knowledge of disorders,” “skills of supporting parents,” and “ways of communicating with parents” were required by over 96% of
the respondents.
With regard to how the extent of professional education courses affects a sense of requirement of learning(Table 4), for each of the learning items, the subject

Table 1. Subject Attributes (n = 1,233 )n

Item

Response

Occupation

Nursery school teacher (homeroom)
Nursery school teacher (free)Supervisor
Principal
20–29
30–39
40–49
50–59
60 and above
Less than 5
6 to 1011 to 20
21 and more
Vocational school
Junior college
University
Nursery school teacher test
Yes
No

Age

Years of Experience

Accreditation as nursery school teacher

Opportunity to learn about developmental disorders as a part ofprofessional training

978 (79.3)
89 (7.2)
93 (7.6)
73 (5.9)407 (33.0)
329 (26.7)
238 (19.3)
231 (18.7)
28 (2.3)
280 (22.7)
269 (21.8)
379 (30.8)
305 (24.7)
122 (9.9)966 (78.3)
65 (5.3)
80 (6.5)705 (57.2)
528 (42.8)% in parentheses.

Table 2. Proportion of nursery schools and of nursery school teachers who have felt a sense of difficulty in achild care setting
Item

Response

No. of nurseryschool teachers

No. of nurseryschools

Sense of difficulty in providing child care

Have felt it in the past
Felt it as a homeroom teacher
Feeling it presently

1118 (90.7)1034 (83.9)
602 (48.8)

118 (100)
117 (99.2)
113 (95.8)% in parentheses.

27

K. Ishiguro and S. Yoshioka

group who had taken the relevant professional educational experience had a keener sense of the necessity ofunderstanding the role of interdisciplinary involvement,social skills training (SST), and parent training (PT) (P< 0.01 in each item) as compared with the subject group
without such training. The group with currently experiencing a sense of difficulty felt more strongly that theunderstanding of the role of interdisciplinary involvement (P < 0.01) and the skills of supporting parents (P <0.05) were required learning items.
Societal resources required by NSTs (Fig. 2)

Some of the most required resources were “increasing
the number of assistant NSTs,” “implementation of agefive check-up,” and “recruitment of the mentors.”
With regard to how the extent of professional education courses affect a sense of requirement of the societal
resources (Table 5), the subject group who had taken

Table 3. Support systems for children with developmental special needs (n = 1,233)
Item

Response

Yes
No
Colleague
Supervisor
Administrator
From whom did you first seek advice about children with special needs?
School nurse(Multiple Responses)
School physician
Parents
Other
Present
Would/do consult
Relationship with school nurse regarding children with special needs
Would not/do not consult
Not present
Very easy to access
Somewhat easy to access
Cooperation with school physician as a system for supporting children withspecial needs
Somewhat difficult to accessDifficult to access
Pediatrics
Internal medicine
Otorhinolaryngology
Medical specialty of school physician
Ophthalmology
Psychosomatic medicine
Other
Regularly
Occasionally as necessary
Frequency of holding case review meetings about children with special needs
About once a year
Not at all
Almost every month
Severaltimes a year
Cooperation with developmental counselling support centers and related
agencies
When there is a relevant case
Not at all
Yes
Involvement of developmental counselorsNo
Public health nurse
Psychotherapist
Speech therapist
Occupation of developmental counselor who regularly visits the nurseryschoolExperienced nursery school teacher
University teaching staff
Other
Experience seeking advice about a child with special needs in class.

% in parentheses.

28n976 (79.2)
257 (20.8)
893 (72.4)
296 (24.0)
240 (19.5)
21 (1.7)
21 (1.7)
6 (0.5)28 (2.3)
788 (63.9)
519 (65.9)
269 (34.1)
445 (36.1)
273 (22.1)
520 (42.2)
261 (21.2)
179 (14.5)
763 (61.9)
482 (39.1)
28 (2.3)
19 (1.5)
16 (1.3)
85 (6.9)351 (28.5)
589 (47.8)
51 (4.1)
242 (19.6)
52 (4.2)
291 (23.6)
593 (48.1)
297 (24.1)
681 (55.2)
552 (44.8)
845 (68.5)
181 (14.7)
106 (8.6)
90 (7.3)
63 (5.1)
252 (20.4)

Survey on children with special needs
Table 4. Learning items and professional training required, relevance to current sense of difficulty
Item

Total

Necessary
Not necessary
NecessarySpecific coping measures
Not necessary
Skills of supporting par- Necessaryents
Not necessary
Ways of communicating Necessary
with parents
Not necessary
Understanding the multi- Necessary
disciplinary roles
Not necessary
Necessary
Knowledge of SST
Not necessary
Necessary
Knowledge of PT
Not necessary
Elementary school support Necessary
systemNot necessary
Necessary
No change necessary
Not necessary
Knowledge of developmental disorders

1212 (99.0)
12 (1.0)1218 (99.5)
6 (0.5)1208 (98.7)
16 (1.3)
1194 (97.5)
31 (2.5)993 (81.1)
231 (18.9)
999 (81.7)
224 (18.3)
1051 (85.9)
172 (14.1)
1153 (94.2)
71 (5.8)
71 (5.8)1154 (94.2)

Professional training
experienceYesNo
696 (99.0)
7 (1.0)700 (99.6)
3 (0.4)693 (98.6)
10 (1.4)
689 (97.9)
15 (2.1)
590 (83.9)
118 (16.1)
594 (84.5)
109 (15.5)625 (88.9)
78 (11.1)
665 (94.6)
38 (5.4)
47 (6.7)657 (93.3)

Currently experiencing aP
sense of difficulty
value*YesNoχ2

516 (99.0)
0.004 0.950
5 (1.0)518 (99.4)
0.136 0.704
3 (0.6)515 (98.8)
0.170 0.680
6 (1.2)505 (96.9)
1.073 0.300
16 (3.1)
403 (77.4)
8.448 0.004
118 (22.6)
405 (77.9)
8.730 0.003
115 (22.1)
426 (81.9)
12.055 0.001
94 (18.1)
488 (93.7)
0.472 0.492
33 (6.3)
24 (4.6)
2.349 0.125
497 (95.4)

594 (99.3)
4 (0.7)594 (99.3)
4 (0.7)595 (99.5)
3 (0.5)585 (97.7)
14 (2.3)505 (84.4)
93 (15.6)
500 (83.8)
97 (16.2)
521 (87.3)
76 (12.7)
568 (95.0)
30 (5.0)34 (5.7)565 (94.3)

618 (98.7)
8 (1.3)624 (99.7)
2 (0.3)613 (97.9)
13 (2.1)
609 (97.3)
17 (2.7)
488 (78.0)
138 (22.0)
499 (79.7)
127 (20.3)
530 (84.7)
96 (15.3)
585 (93.5)
41 (6.5)
37 (5.9)589 (94.1)

Pvalue*

χ2

1.169 0.387
0.765 0.442
5.881 0.021
0.178 0.673
8.421 0.004
3.333 0.068
1.716 0.190
1.315 0.251
0.031 0.861% in parentheses. *χ2 test and Fisher’s exact probability test. PT, parent training; SST, social skills training.

0.5	
  

98.8	
  

Speciﬁc	
  coping	  measures	
  具体的対応策

98.3	
  

1.0	
  

98.0	
  

1.3	
  

96.8	
  

2.5	
  

Knowledge	
  of	
  developmental	  disorders	
  疾患の知識
Skills	  o保護者対応のスキルf	
  suppor8ng	
  parents	
  
Ways	
  of	
  communica8ng	
  with	
  parents	  保護者への伝え方
Elementary	
  school	
  support	  system	
  小学校での支援体制
PT
Knowledge	
  of	
  parent	
  training	  SST
Knowledge	
  of	
  social	
  skills	
  training	
  Understanding	
  mul8disciplinary	
  roles	
  多職種の役割理解

0

5.8	
  

85.2	
  

13.9	
  

81.0	
  

18.2	
  

80.5	
  

18.7	
  
93.6	
  

5.8	
  

現状で十分
No	
  change	
  necessary	
  

93.5	
  

20

40

60

80

100
(%)

Fig. 1. Learning items necessary for nursery school teachers to support children with special needs and their parents. Multiple answers
permitted in the question.

29

K. Ishiguro and S. Yoshioka
Table 5. Social resources and professional training required, relevance to current sense of difficulty
Item

Response

Presence of special coor- Necessary
dinators in the school
Not necessary
Necessary
Employing school nurses
Not necessary
NecessaryMore assistant nurseryschool teachers on staff
Not necessary
Increasing frequency of Necessary
visits by developmental
Not necessary
counselors
Employing psychothera- Necessarypists
Not necessary
Cooperation with nearby Necessary
nursery schools
Not necessary
Training nursery school Necessaryteachers with special
Not necessary
expertise
Necessary
Recruiting of the mentors
Not necessary
Hosting study sessions for Necessary
parents
Not necessary
Necessary
Health check-up for
5-year-olds
Not necessary
Satisfied with the current Necessary
situation
Not necessary

Total

Professional training
experience
Yes
No

χ2

Currently experiencing aP
sense of difficulty
value*
Yes
No

χ2

P
value*

1003 (82.0)
220 (18.0)
998 (81.7)
224 (18.3)
1099 (89.9)
123 (10.1)

588 (83.9)
113 (16.1)
592 (84.5)
109 (15.5)
627 (89.4)
74 (10.6)415 (79.5)
509 (85.3)
3.888 0.049
107 (20.5)
88 (14.7)
406 (77.9)
490 (82.1)
8.496 0.004
115 (22.1)
107 (17.9)
472 (90.6)
544 (91.1)
0.438 0.508
49 (9.4)
53 (8.9)494 (78.9)
8.341 0.004
132 (21.1)
508 (81.3)
0.130 0.719
117 (18.7)
555 (88.8)
1.819 0.177
70 (11.2)

962 (78.8)

560 (80.0)

402 (77.2)

465 (74.4)

259 (21.2)
496 (40.7)
724 (59.3)
763 (62.5)458 (37.5)

140 (20.0)
292 (41.7)
408 (58.3)
472 (67.4)
228 (32.6)

119 (22.8)
204 (39.2)
0.763 0.382
316 (60.8)
291 (55.9)
17.071<0.001
230 (44.1)

99 (16.6)
256 (43.0)
339 (57.0)
376 (63.1)
220 (36.9)

14.751<0.001
160 (25.6)
240 (38.4)
2.703 0.100
385 (61.6)
387 (61.9)
0.177 0.674
238 (38.1)

1008 (82.5)

592 (84.5)

416 (79.8)

496 (83.1)

512 (81.9)

214 (17.5)
1060 (86.8)
161 (13.2)
982 (80.4)
239 (19.6)
1094 (89.5)
128 (10.5)
78 (6.4)
1144 (93.6)

109 (15.5)
613 (87.6)
87 (12.4)
578 (82.6)
122 (17.4)
636 (90.7)
65 (9.3)
52 (7.4)
649 (92.6)

105 (20.2)
447 (85.8)
74 (14.2)
404 (77.5)
117 (22.5)
458 (87.9)
63 (12.1)
26 (5.0)495 (95.0)

1.442 0.230

4.386 0.036
0.822 0.365
4.797 0.029
2.534 0.111
2.947 0.086

497 (83.4)

101 (16.9)
533 (89.4)
63 (10.6)493 (82.7)
103 (17.3)
542 (90.8)
55 (9.2)
21 (3.5)
576 (96.5)

0.285 0.593
113 (18.1)
527 (84.3)
6.958 0.008
98 (15.7)
489 (78.2)
3.886 0.049
136 (21.8)
552 (88.3)
1.982 0.159
73 (11.7)
57 (9.1)
16.038<0.001
568 (90.9)% in parentheses. *χ2 test.

89.1	
  	
  

10.0	
  	
  

88.7	
  	
  

10.4	
  	
  

86.0	
  	
  

13.1	
  	
  

81.8	
  	
  

17.4	
  	
  

81.3	
  	
  

17.8	
  	
  

80.9	
  	
  

18.2	
  	
  

79.6	
  	
  

19.4	
  	
  

78.0	
  	
  

21.0	
  	
  

More	
  assistant	
  nursery	
  school	
  teachers	
  on	
  staﬀ	
  加配保育士の増員	
Health	  check-­‐up	
  for	
  5-­‐year-­‐olds	  5歳児健診の実施
RecruiEng	
  o助言者の確保	f	
  the	
  mentors	  Training	
  nursery	
  school	
  teachers	  with	
  special	
  experEse	
  専門保育士の人材育成	
調整役の存在	
Presence	
  of	
  special	
  coordinators	
  in	
  the	
  school	
  園内看護師の採用	
Employing	  school	
  nurses	  HosEng	  保護者向け勉強会の開催	
study	
  sessions	
  for	  parents	  Increasing	
  frequency	
  of	
  visits	
  by	
  巡回発達相談の回数増加	
developmental	
  counselors	
  

61.9	
  	
  

近隣保育所との連携	
CooperaEon	
  with	  nearby	
  nursery	  schools	
  

37.1	
  	
  

40.2	
  	
  

心理士採用	
Employing	
  psychologists
	
  

58.7	
  	
  

6.3	
  	
  

現状で満足
SaEsﬁed	
  with	  currently	
  situaEon	
  
0	
  	
  

92.8	
  	
  
20	
  	
  

40	
  	
  

60	
  	
  

80	
  	
  

100	
  	
  
(％)

Fig. 2. Social resources necessary for nursery school teachers to support children with special needs and their parents. Multiple answers
permitted in the question.

30

Survey on children with special needs

the relevant professional educational experience hada keener desire for cooperation with nearby nurseryschools (P < 0.001) as compared with the subject group
without such training. They also felt a greater necessityof the employment of school nurses (P < 0.01). Furthermore, the group with relevant professional educational
experience was also somewhat more affirmative withhaving special support coordinator personnel in nurseryschools, training of a professional NST specializing indevelopmental disorders, and convening the study session for the parents (P < 0.05).
As shown in Table 5, the group with currently experiencing a sense of difficulty felt the strongest desire toincrease the number of visits by the itinerant counselors(P < 0.001) as well as a stronger desire for the presenceof coordinating personnel and the recruitment of thementors (P < 0.01), with many also indicating the desire
to host parent-oriented study sessions (P < 0.05). While
over 80% of both groups favored the training of professional NSTs specializing in the developmental disorders.
Opinions and requests to administrative bodies
and institutions (Table 6)

The collected free description responses using the KJ
method into 26 subcategories, were then grouped into
the following five categories: i) requests for the childcare

Table 6. Classification of nursery school teachers’ opinions and requests to administrative and institutional
officials
Requests for childcare administrative bodies (n = 90)
Response
Desire to increase the total capacity of nursery school teaching staff and implement a smaller homeroom system
29 (32.2)
Augmenting staff in specialized departments and improving classroom environments to facilitate cooperation
21 (23.3)
Increasing operating funds and insufficient subsidies (not enough for paying assistant nursery school teachers)
16 (17.9)
Childcare system that can easily provide assistant nursery school teachers (institutionalized by the national govern12 (13.3)ment) and new childcare systems
Expansion of Rehabilitation Centers (Counseling sites are too far, which causes delayed response)
5 (5.6)
Concerns about the acceptance of children with disabilities under a new system that would involve "certification of
4 (4.4)childcare needs"
Desire to be led to appropriate treatment agencies by administrative guidance
2 (2.2)
Maintaining the current system to provide assistant nursery school teachers
1 (1.1)
Cooperation with professional staff (n = 77)
Increasing the number of psychotherapists and counselors who can provide accurate, personalized advice
24 (31.2)
Implementing systematic skill training
19 (24.7)
Desire to increase the number of visits by developmental counselors to ensure their grasp of the on-site situation
11 (14.3)
Desire for opportunities to learn (e.g., through case studies) together with specialized staff such as developmental
11 (14.3)
counselors and public health nurses
Desire for close cooperation with rehabilitation centers and specific opinions by attending physicians
5 (6.5)Training nursery school teachers with medical expertise
4 (5.2)
Regular visits to nursery schools by childcare instructors
3 (3.8)Desired changes for developmental health check-up (n = 34)
Desire to conduct health check-up for 5-year olds (few opportunities for children to see specialists until they reach13 (38.2)
school-age)
Desire to perform a close examination to detect disabilities at the health check-up for 3-year-olds (overlooked in many
9 (26.5)
cases)
Need to review how the health check-up for 5-year-olds should be (improve the quality of the staff, etc.)
4 (11.8)
Requests to physicians: improve the institutions (e.g., assistant teacher staff) based on their diagnosis
4 (11.8)
Clarify the real situation of the follow-up after the health check-up for 5-year-olds; Passing on the information to those
3 (8.8)involved after school enrolment
Desire to mitigate parents’ distress caused by knowing the result of 1.5 year health check-up
1 (2.9)Desired changes for supporting parents (n = 16)
Providing opportunities to interact with parents to maintain positive relationships with them
14 (87.5)
Improving the role of nursery school teachers to support the independence of children requiring rehabilitation
2 (12.5)
On-site childcare needs (n = 8)
Appreciating the importance of working as a team among nursery school teachers
5 (62.5)
Expanding freedom for principal’s assistants
2 (25.0)
Needing a full-time assistant nursery school teacher to do a job using the physicians’ diagnosis (to secure safety)
1 (12.5)% in parentheses.

31

K. Ishiguro and S. Yoshioka

al.10 also indicated the necessity of having dedicatedphysicians able to offer counsel to each nursery school
regarding developmental issues. If school physiciansview themselves as members of the nursery school staff
and observe children on a continuous basis throughregular school visits, then they would notice any abnormalities and share their observation with parents andother NSTs. This we believe will help build a systemthat better facilitates consultations regarding subsequent
approaches.
Among the choices of learning required by NSTs,
the following items were seen to be needed from theperspective of NSTs (Fig. 1).
As a quality of the experts from whom NSTs would
like to seek advice regarding children with special
needs, “offering suggestions about specific methods” was desired, as was noted by Hidaka et al.11 andKuboyama et al.12 In addition, to understand specificcoping methods, it is important to gain accurate andbasic knowledge about the disorders that a child might
have. If NSTs are able to grasp the mechanisms thatgive rise to behaviors that should not be considered as
those of spoiled or selfish children but as symptomaticof an underlying disorder, then a better understandingof children with special needs will be obtained. For thisreason, holding workshops with physicians and othermedical and psychological professionals will be important.
NSTs also felt that supporting parents was as important as dealing with children with special needs.
As reported by Inoue et al.,13 it was found that many
NSTs sensed the importance of ways of listening to andspeaking with parents, and desired to learn them. It is
important for NSTs to not only inform the current stateof the children with special needs to their parents who
are not mentally prepared for that fact but also display
an attitude and demeanor that is sympathetic toward theparents who may be shocked and bewildered with suchinformation.
It became evident that the foremost social resource
demanded by NSTs was increasing the number of assistant NSTs (Fig. 2). It is necessary to have assistant
NSTs to alleviate the physical and psychological burden
on teachers. This suggestion seems to be backed by reports that state the staffing shortages might be related tothe increase in the number of children with tendencies
toward developmental disorders and the prevalence of
burnout among NSTs.14
The second highest score of responses was to callfor the implementation of age-five check-up. The agefive check-up is an optimal time to ensure the observations made by NSTs and to promote awareness among

administration; ii) cooperation with the professional
staff; iii) check-up for developmental health; iv) waysof supporting parents and v) on-site childcare needs.
Requests for the childcare administration was expressedby most respondents, with many expressing requests
related to staffing, such as increasing the total capacityof the NSTs and reducing the number of children perhomeroom, and other requests such as improving theclassroom environment and augmenting staff in the specialized departments. The next most popular request wascooperation with professional staff, with many expressing expertise-related requests, such as increasing thenumber of psychotherapists and counselors and implementing a systematic skills training. In the third place,with regard to check-up for developmental health, theimplementation of age-five check-up was most desired.
As for ways of supporting parents, there was a request
for opportunities to interact with parents to maintain apositive relationship with them. As for the on-site childcare needs, there was a desire for fostering positive relationships with the fellow teachers as a team.
DISCUSSION
Since it was found that children with special needs,
whom the teachers felt difficult to cope with, were enrolled in all the target schools, it became evident that all
NSTs were required to cope with children with special
needs (Table 2).
The number of NSTs who consulted with their colleagues was 72.4% (Table 3). In addition, from their inschool discussions and case review meetings, it was inferred that they would implement a policy to cooperatewith specialized agencies. These results were thought tosuggest that approximately 80% of the respondents desired to attempt solutions through such regular cooperation. The proportion of respondents who consulted withschool nurses was 65.9%. In nursery school with nurses
on staff, Tsuda et al.9 reported that approximately 50%of the staff consulted with their nurses. While it is desirable that nurses be assigned as nursery school staff
members, it is required that they be more involved inconsultation as a part of child care support, along withhealth and safety management of children with special
needs.
For NSTs, school physicians are the most accessible
medical professionals. The proportion of subjects who
responded that they found it relatively easy to liaise withschool physicians on a daily basis was 64.3%. While theprincipal task of school physicians is normally to visit
schools on several occasions throughout the year, it isdesirable that physicians be actively involved in providing support for children with special needs. Takada et32

Survey on children with special needs

parents. It has been reported that a majority of NSTs
lack professional expertise regarding developmental andbehavioral disorders,15 suggesting the possibility that therecognition could be delayed. However, there are also
reports stating that, while cognitive delays in children
with developmental disorders begin to be discernible ataround the age of two years old, with careful observation, most cases can be diagnosed by the age of five.16
Gillberg2 reports that even when major symptomsof ESSENCE begin to appear, there are many cases
where diagnoses are not sufficiently certain before theage of five, and that the drafting of intervention plans
and follow-up diagnoses are important. In addition, it isalso reported that since factors such as an environment
and parents’ level of education influence social attitudes
and hyperactivity of the children, it is important to havemedical check-ups between the ages of five and six.17
The conventional way of examination overlooked
half of the cases of mild developmental disorders. By
conducting check-ups at the ages of three and five andcombining these with detailed observation records, individual interviews, and questionnaire surveys performed
by NSTs, the ratio of overlooking high-functioning
pervasive developmental disorders can be broadly reduced. Furthermore, the age-five check-up can serve asa screening for developmental disorders to be found, andthe period around age five is known as the preparatory
period for school enrollment, and thus, it is positioned
at an ideal time, neither too early nor too late, to detecta type of the disorder.18 In addition, by knowing the results of the age-five check-up, understanding what is going on with a child will be easier if problems arise after
enrollment in a school, suggesting that it would be easierto provide them with support from the teachers.19
Even when NSTs become concerned about behavioral or emotional aspects of children’s development, they
did not feel the desire to convey such concerns directly
to the parents and often experienced difficulties when
dealing with them. Partnering with experts would allow
for not only the strengthening of the relationship between NSTs and parents but also making the children’s
lives better. In anticipation of what would await for time
to come, it is important to perform health check-ups at
the proper time and to continue supporting children withspecial needs and their parents.
The desire for the recruitment of mentors was third.
Specifically, NSTs sought experts to advise them onmatters including disorder-related knowledge, and skillsof supporting and communicating to parents, and they
desired to be able to obtain multi-disciplinary advice ina timely and regular manner.
However, as reported by Miyake,20 there are very

few mentors with specialized knowledge of developmental disorders of young children, and it is challenging
to secure and train mentors who can play an active partin the field.
We investigated whether there was any association between either experience taking a professional
educational course on developmental disorders or ongoing feelings of difficulty in dealing with children withspecial needs and learning items and societal resources
required by NSTs.
The result showed that both those who had undergone the professional education and those experiencing
ongoing feelings of difficulty significantly felt the needfor understanding the multi-disciplinary approach. In
terms of cooperation, some desire to know what types ofoccupations exist and the specific duties of those likely
to be involved, such as public health nurses, psychotherapists, and speech therapists. The investigation also
found that those who had pursued professional education strongly felt the importance of PT and SST and felt
more strongly about the necessity of knowledge of thedisorders. Those experiencing the ongoing difficulties
strongly felt the need for skills of responding parents.
With regard to the relevance of the required societal
resources, those who had pursued professional education felt strongly about cooperating with nearby nurseryschools and employing school nurses, and many of themfelt the need to hold study sessions for parents, to train
NSTs with relevant expertise, and to ensure the presenceof the special support coordinator. And, those experiencing ongoing difficulties had a strong feeling about thenecessity of personnel able to provide advice when difficulties arose, thus expecting to increase the number ofvisits by development counselors, recruiting mentors, or
ensuring the presence of a special support coordinator innursery schools.
Asked to provide their frank opinion on the childcare administrative bodies and institutions, the respondents provided responses that were divided into fivecategories, as shown in Table 6. Regarding cooperation
with professional staff, the proportion of responses “toincrease the number of psychologists and counselors
capable of offering accurate and individualized advice”
was 31.2%. These respondents expressed their desire toenlist cooperation and participation from professionals.
The term “cooperation” in providing support here
is defined as: i) mutual sharing of information amongexperts; ii) evaluation and analysis from a multidisciplinary perspective; iii) determination of a direction of
the support and iv) leveraging of societal resources toprovide the support, of which it is significant that ii) andiii) are firmly conducted by professionals.
33

K. Ishiguro and S. Yoshioka

In our survey, 68.5% of visiting developmental
counselors was public health nurses; this is the highest
ratio, followed by psychotherapists (14.7%). The survey
revealed that psychotherapists capable of providing advice on regular and timely basis are required more thanpsychotherapists working in nursery schools full-time.
Similarly, Hidaka et al.11 reported that clinical psychotherapists are the experts from whom advice was mosteagerly sought, presumably because there was likely aneed for a counseling form of support that could recognize NSTs’ sense of difficulty. The presence of psychotherapists in a support role for children with special
needs and their parents is expected to be effective inmaking social adaptation possible, assisting them withforming a sense of attachment.
The kind of support for children with special needs,
which NSTs can provide by making the most use of theirexpertise, is to quickly identify children who experience difficulties in kindergarten because of their uniquecharacteristics in a group living and to make carefulobservations for compiling the childcare record so thatthey can enlist proper assistance and cooperation fromprofessionals.
Many expressed their desire to “augment staff in
specialized departments” and “improve an environmentthat would facilitate regular cooperation.” With thispoint, it is expected that seeking advice and planningcooperation from a multidisciplinary standpoint (involving, e.g., physicians, public health nurses, psychologists,
speech therapists, occupational therapists, elementary
school teachers, and administrative staff) would give a
direction for both short- and long-term support and leadto the effective utilization of social resources.
Mori et al.21 reported that kindergartens and nurseryschools do not fully understand the role of professionals
who conduct periodic counseling visits. Furuichi22 has
examined how to work together with visiting counselors
and has indicated the need for improving mutual communication and understanding. In addition, Sano et al.23
suggested that there are regional differences to cooperation and that there is an urgent need to expand institutions in keeping with local childcare needs.
With regard to “a systematic skill training,” Haraguchi et al.,24 consistent with the results of our own
study, pointed out that while NSTs do not lack desire forfurther training, implementation of the training in mostnursery schools is actually inadequate and consideration
should be given to training methods with a high degreeof effectiveness and efficiency.
More than half of the free descriptions showed adesire to increase the number of assistant NSTs and suggested that more inclusive childcare can be realized if

the NST shortage could be resolved.
The Comprehensive Support system for Children
and Childcare was launched in April, 2015. Accordingly, it would be desirable in the future to construct a
more comprehensive system of childcare for children
with special needs.
Concerning challenges related to childcare forchildren with special needs and measures for handlingthese, the results of this study suggest the following. i)
Improving awareness of children with special developmental needs: most, if not all, of the nursery schools
enroll children with special needs, and if NSTs are currently coping with the difficulty, they should first gain afirm understanding of normal development and acquire
knowledge about developmental disorders. We recommend that they should spend ample time for handson childcare training in training courses for NSTs. In
addition, we would also wish that parents have morelearning opportunities to gain knowledge about developmental disorders. ii) Eliminating regional differences:
there should be no shortage of societal resources, suchas inadequate personnel, who should cooperate among
themselves, caused by local circumstances. Continuous
cooperation is also necessary, and to achieve it, humanresources should be developed and cooperation systems,
including administrative bodies, should be constructed.
It is also important to gain an accurate and timely understanding of local childcare needs. iii) Training of
NSTs specializing in developmental disorders: training
professional NSTs by, for example, cooperating with
developmental support centers in order for them to playa central role is necessary. For instance, this role would
be a position similar to specialist nurses at visiting nurse
stations. Such staff would play a leadership role in, forexample, case review meetings held in nursery schools.
iv) Training and reeducating assistant NSTs: in thecontext of a nationwide shortage of NSTs, it will be important to offer rewards to accredited NSTs and employ
them after arranging for their re-training as well as toguarantee their employment on a multi-year basis rather
than a single-year basis if possible. v) Enhancing infant
health check-up: since it is possible that children withspecial needs or with clear physical or cognitive developmental disorders included among those who have yet
to undergo health check-ups, it is important that followup and dialogue with those involved, including parents,
should be performed. In parenting counseling sessions
conducted at the same time for five-year-olds, an effort
should be made to deepen parents’ understanding andcope with their anxieties about childcare.
In conclusion, despite increasing social concerns
about children with special developmental needs, it was34

Survey on children with special needs

found that coping difficulties remained in childcare
settings. However, early detection and early response
can alleviate difficulties in childcare to some degree.
To understand such children, it is important to improve
the quality of NSTs, build their empirical knowledge
base, and cooperate with professionals across various
occupations. Furthermore, it is desired that NSTs, psychologists, and other experts be involved in providing
parental support from an early stage.

11 Hidaka K, Hashimoto S, Akiyama C. Development and application of “ Checklist of children special needs education” innursery daycare and kindergarten. Bulletin of Tokyo Gakugei
University. Section1, Science of Education. 2008;59:503-12.
Japanese.
12 Kuboyama S, Saito Y, Nishimaki K, Toushima S, Fujii S,
Takigawa K. Survey on awareness of and response to “childrenof concern” and “parents of concern” by preschool teachers and child-care providers: Considerations in providingorganizational support to preschools and child-care centers.
Bulletin of the National Institute of Special Needs Education.
2009;36:55-75. Japanese with English abstract.
13 Inoue K, Ishikawa H, Aizawa N. Problems and Counselingneeds Nursery Teachers Have. Journal of Human Life Science. 2007;29:61-9. Japanese.
14 Kiso Y. The Relationship between the Number of Children
with Suspected Developmental Disorders and Burnout in
Nursery School Teachers: A Cross-Sectional Postal Survey.
Research on Early Childhood Care and Education in Japan.
2013;51:199-210. Japanese with English abstract.
15 Lian WB,Ying SH, Tean SC, Lin DC, Lian YC, Yun HL. Preschool teachers’ knowledge, attitudes and practices on childhood developmental and behavioural disorders in Singapore. J
Paediatr Child Health. 2008;44:187-94. PMID: 17927728.
16 Cheng ER, Palta M, Kotelchuck M, Poehlmann J, Witt WP.
Cognitive delay and behavior problems prior to school age.
Pediatrics. 2014;134:e749-e57. PMID: 25113290.
17 Perren S, Stadelmann S, von Wyl A, von Klitzing K. Pathways of behavioural and emotional symptoms in kindergarten
children: What is the role of pro-social behaviour? Eur Child
Adolesc Psychiatry. 2007;16:209-14. PMID: 17149542.
18 Koeda T. [The Significance of Medical Check-Ups for 5-yearolds. What We Already Know about Children’s Developmentfrom Pediatric Clinical Pyxis]. Igarashi T, editor. Nakayama
Shoten; 2010. p. 94-97. Japanese.
19 Shimoizumi H. [Cooperation and Awareness of Developmental Disorders in Medical Check-Ups for 5-year-olds]. Current
Information of Maternal & Child Health. 2011;63:38-44. Japanese.
20 Miyake M. Needs of support for nursing preschooler who
need special consideration. Journal of the Faculty of Human
Cultures and Science of Fukuyama University. 2010;10:131-38.
Japanese with English abstract.
21 Mori M, Hayashi E. Present Conditions and Problems in
Itinerant Consultation Services for Kindergarten Teachersand Nursery School Teachers Taking Care of Handicapped
Children: Focusing on Professionals’ Support Practice at
Kindergartens and Nursery Schools. The Bulletin of Saitama
Prefectural University. 2012;14:27-34. Japanese.
22 Furuichi M. [Child Care Consultation Requirements for Children in Need of Special Assistance]. Aichi University of Education Kindergarten. 2005;34:55-64. Japanese.
23 Sano Y, Kawaike T, Kawana H, Amemiya Y, Yoneyama
M, Asahi Y. Basic Study of a Regional Model for a Support
Network for Infants with Disabilities and their Parents (I).
Bulletin of Faculty of Human and Social Services, Yamanashi
Prefectural University. 2011;6: 33-45. Japanese with English
abstract.
24 Haraguchi H, Noro F, Kamiyama T. Current Issues of Special for Young Children with Special Educational Needs inNursery School: Comparison of the Support by the Existenceof Diagnosis of Disabilities. J J Disa Sci. 2013;37:103-14. Japanese with English abstract.

Acknowledgments: We benefitted greatly from the cooperationof the chairman of the Shimane Prefectural Childcare Council
and the Kochi Prefectural Nursery School Council Chairman,
for which we would like to acknowledge our grateful thanks. Additionally, we would like to express our thanks for the responses
provided by the principals and NSTs in the two prefectures.
The authors declare no conflict of interest.

REFERENCES
1 Desk Reference to the Diagnostic Criteria from DSM-5®
American Psychiatric Association , Tokyo: Igaku Shoin; 2014.
p. 17-41. Japanese.
2 Gillberg C. The ESSENCE in child psychiatry: Early Symptomatic Syndromes Eliciting Neurodevelopmental ClinicalExaminations. Res Dev Disabil. 2010;31:1543-51. PMID:
20634041.
3 Sasamori H, Gokami T, Kuboyama S, Kobayashi M, Hirose
Y, Sawada M, et al. Current situation and problems for early
detection and early support for children with developmental
disability. Bulletin of the National Institute of Special Needs
Education. 2010;37:3-15. Japanese with English abstract.
4 Shimono M, Inatomi M. The “disturbed” Child in a Nursery:
Characteristic Actions, Accordance with Child Caretaker,
Child-parent Relationship. Bulletin of the Faculty of Education, Kochi University. 2007;67:11-20. Japanese with English
abstract.
5 Nakashima M, Takeo A, Yano A. The Situation of Children
with Developmental Disorders and Children of Concern on
Attend Nursery School. Journal of the School of Education,
Sugiyama Jogakuen University. 2012;5:69-80. Japanese.
6 Kurokawa K. The Problem on the Support for Infants with
Special Needs in Day Nursery. Journal of The Development
Research, Minamikyushu University. 2012;2:57-68. Japanese.
7 Fukuyama K, Miyagi M, Uehara M, Maeda K, Sakugawa H,
Sunagawa K, et al. The early detection and early support ofthe developmental disease in childcare workers. The Okinawa
Journal of Child Health. 2012;39:49-52. Japanese.
8 Kawakita J. [The KJ method: Teasing Narrative from Chaos].
12th ed. Tokyo: Chu-kou-shinsyo; 2004. Japanese.
9 Tsuda A, Kimura R. Factors disturbing the early detection
and intervention of developmental disorders in nursery school
children –Awareness and support of childcare givers on children with special care needs–. Journal of the Tsuruma Health
Science Society, Kanazawa University. 2014;38:25-33. Japanese with English abstract.
10 Takada S, Ishioka Y. [Medical treatment for children with developmental disorders and cooperation with nursery schools,
kindergartens, and schools]. Japanese Journal of PediatricMedicine.2010;42-3:491-5. Japanese.

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