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Part 4: Promoting trouble-free mental development of children and alleviating anxiety about child rearing

1. Recognition of problems

The issue of the mental health of children has been attracting widespread attention in recent years. There is a growing necessity for the health care and medical treatment sector to take necessary action, including preventive measures. It is particularly important to take up the issue of parent-child mental health as a part of the maternal and child healthcare, as it will also lead to the prevention of psychological problems in children during adolescence. Two major problems exist in the mental health aspects of maternal and child health care; 1) the anxieties of parents about child-rearing and the relationship between parental stress and the mental state of the child, and 2) child abuse within the parent-child relationship.

The psychological development of infants is closely related to the mental state of their rearers (usually mothers), and the mental state of mothers is greatly influenced by the attitudes and lifestyles of the fathers. To ensure the healthy psychological development of children in their infancy, it is essential to create a child-rearing environment in which mothers can enjoy raising their child.

Nowadays, many mothers seem to be expressing greater fears about pregnancy, childbirth, the puerperal period, and child rearing compared with those of their seniors. Taking into account the high occurrence rate of maternity blues/postpartum psychosis, this is clearly a problem for mothers. Being less involved, Japanese fathers are not confident about child rearing, and they find it difficult to support their wives.

The following points are raised in regard to the issue of the child rearing anxieties of mothers in Japan, which are perceived as a social issue:

(i) High susceptibility to the social environment

In general, the mental relationship between mother and child is said to be supported by the, formation, development and establishment of the following elements: 1) the mental state of the mother, 2) parents' knowledge of child-rearing methods, 3) child rearing tips handed down by society, seniors and friends, 4) sharing of the burden and joy of child rearing between husband and wife, and 5) a stable living environment. However, the social environment, such as declining birth rate, an increased number of nuclear families, globalization, a working environment which constantly requires long working hours, a social trend that is seemingly supportive of the non-participation of fathers in child-rearing and the decreased ability of the community to support child-rearing, is inhibiting the establishment of healthy mental relationships between parents and children. Unless we take effective measures immediately, we can expect to see an increasing number of mothers who have worries about children who experience a sense of isolation and increase in the incidences and seriousness of psychological problems in children.

(ii) Handing down to the next-generation

It has been noted that parents who grew up without receiving enough affection from adults are prone to face child-rearing problems and to abuse their children. They find it difficult to read the child's mind and desires and do not know how to express their love for their child. In other words, unless we take effective measures immediately, the issue of parent-child relationships will be handed down to the next generation in the 21st century.

(iii) Causal relationship between the magnitude, cause and outcome of the problem

Research on child abuse indicates that all of the following four elements exist in every case of child abuse: 1) parents who were not loved by adults in their own childhood, 2) parents own lives are very stressful due economic anxiety, discord between husband and wife, the burden of child-rearing, etc, 3) parents who are isolated from society and have nobody to support them, and 4) children who do not bond with their parents due to an undesired pregnancy, an inhibition in forming attachment or difficulty in their rearing.

Therefore, effective preventive measures for child abuse will work on parents not to carry any of the four elements. For instance, if a supporter gives advice to a parent who is battering their child, they will no longer be socially isolated, and from that time, the abuse will be alleviated. We should therefore inject every possible social resource to lessen the stress from living, and if the child has any health problems, we should improve the situation without burdening the parents to prevent recurrence. It is said that taking such action for parents immediately following their child's birth can prevent child abuse.

Unfortunately, however, the parties involved in community health care and medical services who are responsible for maternal and child health have not necessarily responded fully to the anxieties of pregnant women and mothers, the mental problems of the child, parent-child problems including child abuse, and support for the basis of living for parents who are in the process of child rearing.

Taking comprehensive initiatives on a national scale for the purpose of eliminating anxiety among mothers concerning pregnancy, childbirth, and child rearing, helping them enjoy child rearing without constraint but with a sense of assurance, letting them love their children, and facilitating the healthy mental development of children can be considered an extremely important measure for maternal and child healthcare for the 21st century.

2. Direction of the initiatives

(1) Child psychology and measures to address anxieties about child-rearing

In order to deal mental problems among parents and children, it is important that the parties concerned, including the parents, first learn about the issue, and then for support to be provided.

Child rearing is an everyday activity, and a trifling matter can become the cause of anxiety over child rearing. The fundamental solution is to solve such trifling anxieties, convince parents of the cause, and help them change their perception of child rearing into something they can enjoy. Take meals, for instance. It has been pointed out that besides the role of offering appropriate nutritional supply, having a meal together can deepen the parent-child ties and contribute to the development of the child's psychological development. Adoption of various ideas is expected to encourage sound development of child mentality. However, as child-rearing methods are diverse, it is difficult to provide uniform support by way of distributing a manual. We must also recognize that when we examine optimal solutions there are limits to our intervention into an individual's economic and cultural environment.

Another issue that has been indicated is the emergence of parents who do not know much about children. Here, we need to offer opportunities for such parents to acquire knowledge of child-rearing methods and experience. It is particularly important that parents are mentally well prepared to bring up their child. Therefore, it is necessary for schools to provide appropriate support at the earliest possible time. Another important approach would be to deepen understanding of contacts between parents and infants, which would foster parental feelings.

Anxieties over child rearing are diverse: general anxiety about child-rearing; anxiety about being compared with others; anxiety about being told something by a third person; anxiety about not being able to control one's child without having the requisite knowledge; and anxiety over the handicap of the child. Fundamental support would be to deal appropriately with such diverse anxieties and help parents enjoy child rearing with confidence.

It is also necessary to improve the child-rearing ability of fathers, families, and communities, and to improve the ability of the systems to support child rearing, in order to prevent mothers from struggling alone. Other measures to be taken would include enhancing the social environment to make child-rearing easier, and the development of corporate climates in which not only mothers but also fathers can take child care leave without hesitation.

As discussed above, it is necessary to construct a care system from the standpoint of mental problems targeted at child rearing throughout pregnancy, childbirth, puerperal, and child rearing, and to watch over the growth of one human being in an optimal environment. To do this, the flow of maternal and child healthcare services in the community which starts by issuing a maternal child health handbook and the flow of the community medical services which start from medical check ups on pregnant women must be integrated, and a consistency in providing care before and after childbirth must be assured. In particular, in order to respond to the psychological problems of parents and children, healthcare and medical institutions in the community must change their routine work centered around the detection of disease and screening into one in which they are always conscious of psychological issues. In promoting such system, studies on granting subsidies for facility costs, personnel costs, operation costs, etc. as well as measures for medical treatment fees will also be necessary.

Human warmth of doctors, midwives, community health nurses, and nursing professionals who often have direct contact with parent-children is important. It is pointed out that a piece of advice from one of these specialists can encourage parents and make child-rearing an easier task. We should be reminded of the fact that the very source of support for child rearing is such personal contact.

(2) Measures against child abuse

The types of child abuse vary depending on the age of the child. Abuse of infants up to three years old is mostly by physically abuse or neglect and a number of deaths are recorded. Many infants aged between 3 and school age are physically abused/neglected, or psychologically abused. Grade school children are abused in a similar way to pre-school children, but cases of psychological abuse become more marked. Although fewer cases of physical abuse are reported on junior high school or high school children, more cases of psychological abuse and sexual abuse are reported. As the data shows, we need to ascertain the type of abuse by age, and take appropriate measures. It is particularly important to recognize that activities in community health care and medical services can play an extremely important role in preventing child abuse, by detecting such conduct at an early stage and preventing its recurrence, and that continued observation and intervention is possible.

3. Specific initiatives

(1) Child mentality and measures for anxiety over child rearing

A. Community health care

As has been pointed out, community health care has tended to provide standardized health care guidance such as early detection of diseases/disorders and medical treatment and education at an early stage. We need to take another look at existing systems from the standpoint of providing support for child rearing.

Another indication is that conventional medical check ups of infants have not contributed to the development of child-rearing ability of mothers or improvement in their lifestyles. Therefore, we should study an ideal medical check up system that can function as a learning opportunity for mothers to develop their child-rearing abilities, recognize the development stages of their children and conceive their own child rearing methods.

With regard to group medical check ups for infants, we should study an ideal system that will not be used to only detect diseases/disorders, but also to ascertain the psychology of the parent-child relationship, which can also be used as an occasion for exchanging information about child-rearing and having one's story heard. We should also improve the system so that medical check ups can be taken on holidays to increase the participation of double-income parents and fathers.

As an accessible place for consultations on child rearing anxiety and child mentality problems, individual consultations by pediatricians and psychologists, as well as support for parents and parent-child voluntary group activities should be given at public health centers and municipalities.

Public health centers should also play a leading role in cooperating with medical institutions in the secondary medical care area, and build a healthcare system for high-risk groups from the perinatal period through the time after discharge from the hospital.

In providing various kinds of child-rearing support, the parties involved in community health care should cooperate with the welfare sector, including nursery schools, infant homes, child guidance centers, and community centers for children, and help develop voluntary private child-rearing groups. In particular, they should strive to actively foster child-rearing groups that are faced with issues such as polyembryony, extremely low birth weight infants, children suffering from chronic diseases and autistic children.

The parties involved in the community health care should also make efforts to realize cooperation and coordination between these institutions and in systematizing the activities. At the same time, they should strive to gain related techniques.

B. School health care

Having limited experience in coming into contact with children due to the declining birth rate, children in grade schools, junior high schools, and high schools are prone to have anxiety about child-rearing when they themselves become parents. Therefore, we should encourage opportunities for students to have contact with infants, by taking advantage of the maternal and pediatric health activities and child nursing activities of the municipalities. We should also provide opportunities for children to have contact with each other, with nature and with animals.

C. Medical institutions

(a) Perinatal medical services

In addition to providing information on safety and comfort in childbirth, maternity departments should check the awareness and anxiety of parturient mothers and refer them to community health care institutions and pediatric departments as necessary based on the results. In addition, as a supportive measure to promote the formation of affection between mother and child from pregnancy or immediately after childbirth, prenatal visits, rooming-in, sharing of the room by mother and child, and breast-feeding should be encouraged and promoted.

We also need to promote the initiatives for the prevention, early detection and treatment of mental disorders such as maternity blues/postpartum psychosis, which may frequently develop after childbirth.

Since the high-risk parturient mothers and low birth weight (under 1500g) infants who are the recipients of high-level perinatal medical service tends to have protracted problems in terms of pediatric health and development in addition to the mother's concerns over the health of the child, attachment forming, and child-rearing, a follow-up system should be established under the cooperation of the medical institutions on the secondary medical care area level and the community health care centered around public health centers.

As a measure for the treatment of infertility, we should provide various kinds of information, and try to step up our measures to address anxiety during the treatment period, acceptance of pregnancy, and anxiety over child rearing after childbirth. In particular, as women undergoing fertility treatment are often of higher age with risks of multiple pregnancy and delivery of premature babies with fertility treatment, they are more prone to anxiety when compared with pregnant women who are not undergoing such treatment. Therefore, a system that can fully respond to such anxiety should be established.

(b) Pediatric medical treatment

In addition to the diagnosis and treatment of diseases, pediatric departments should strive to provide care and give counseling, by observing the parent-child relationship, the psychology of mothers, the cooperative relationship between husband and wife, and the effects of these elements on the psychology and development of their child. They should strengthen ties with maternity departments through prenatal visits, and maintain close ties with child psychiatrists and health care and welfare organizations in the event of the discovery of a case requiring support from such institutions.

When we consider the situation in which a great number of children visit outpatient departments for the child, it is hard to believe that specialists (child psychiatrists, psychologists, etc.) alone can provide sufficient services. Therefore, the parties involved in pediatric health care should set up a system that can cope with problems related to child psychology.

In particular, doctors, community health nurses, midwives, nurses and child-rearing supporters should be trained, secured, and given lectures as the parties responsible for early detection of mental problems, regular consultations and diagnosis.

Among other issues, in order to deal clinically with the psychological problems of children, a seminar system concerning the issue of child psychology should be established not only for pediatricians but also for doctors and nurses outside the pediatric department, physical therapists, and linguistic therapists who are involved with pediatric medical treatment.

(2) Measures for child abuse

As infant abuse often leads to death, the establishment of a system where infant abuse can be detected at an early stage at community health care and medical treatment institutions as well as at nursery schools, is urgently required. Public health centers and municipal health centers should clearly position child abuse measures as part of their major maternal and pediatric healthcare services and carry out activities accordingly.

As a primary preventive measure, support for child rearing through home visits by public health nurses and midwives to high-risk mothers and children from their perinatal period are important. In community health care, we should promote the following three initiatives: 1) offering knowledge on child development, 2) creating a child-rearing support network, and 3) providing a link with public services.

We should strive to grasp the child-rearing anxieties of mothers and parent-child relationships by using the opportunity of infant health check ups, and step up measures such as guidance during visits by public health nurses for families with infants who have yet to receive infant medical check-ups.

Medical institutions and the community health care sector should cooperate in locating and identifying battered children, protecting them after rescue, preventing recurrence, giving psychological and physical treatment to the children, restoring the parent-child relationship, and following up on the problem.

With regard to the protection of battered children after discovering and rescuing them, measures in cooperation with the child welfare sector are important. Medical institutions and the community healthcare sector should cooperate in taking measures to prevent the recurrence, mental and physical treatment of children, restoration of the parent-child relationship, and long-term follow-up activities.

In carrying out the above-mentioned activities, the parties concerned should actively establish stronger ties with welfare-related organizations including child guidance centers and residential treatment centers for emotionally disturbed children, as well as with medical institutions, police department, and private organizations.

As counseling in this field is particularly important, a system will need to be established so that toll-free telephone counseling by specialists regarding anxiety about child-rearing and prevention of abuse can be offered twenty-four hours a day, seven days a week. In establishing such a system, we expect private organizations to play a leading role.

With regard to domestic violence against women, which can have a major impact on the mental and physical condition of the mothers, community measures will need to be further developed while taking into consideration their relevance to community measures against alcohol that have already been implemented.

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