What is "Rehabilitation"?
"How about taking your child to rehabilitation?"
When parents are concerned about their child's development and consult a public counseling office, medical institution, or a health center conducting infant health examinations, they might be given an answer like that shown above. However, how well do we understand the word "rehabilitation"? What does the word mean?
In this instance, the word "rehabilitation" means "support for the development of children with disabilities or potential disabilities." Suppose you are advised to take your child to rehabilitation. In that case, they mean that you had better send your child to a facility that provides special education and rehabilitation services for children with disabilities. Your child will go to a kindergarten/daycare center every day and attend the facility belonging to the kindergarten/daycare center.
Kindergartens are under the supervision of the Ministry of Education, Culture, Sports, Science and Technology, while daycare centers are under the supervision of the Ministry of Health, Labour and Welfare. This being understood, which government agency supervises rehabilitation facilities?
It is said that the concept of "rehabilitation" was first introduced by Dr. Kenji Takagi, Emeritus Professor of Orthopedics at The University of Tokyo (1888-1963). In 1942, Dr. Takagi established the first rehabilitation facility for physically disabled children in Japan, called Seishi Ryougoen (the Institute for children with mainly physical disabilities; currently the National Rehabilitation Center for Children with Disabilities).
At that time, the word "rehabilitation" was defined as "taking full advantage of modern science and technologies to help children overcome their physical disabilities and learn skills that enable them to live an independent life to the fullest extent possible." In other words, the concept of "rehabilitation" at that time aimed to provide both "medical treatment" and "education" to reduce the incapability of physically disabled children through functional training and help them to achieve independent living.
Later, Dr. Tsurukichi Takamatsu (1930-) at the Kitakyushu Center of Developmental Medicine and Education advocated the importance of child support, which aims to include all children with various types of disabilities into the scope of rehabilitation. As such, the concept of "rehabilitation" has changed with the times. Currently, the word "child development support ("CDS")," which further enhances the framework of rehabilitation, is widely used synonymously with the word "rehabilitation."
What kinds of rehabilitation and CDS services are offered for children with disabilities? There are several types, including CDS services, after-school daycare services, medical treatment-type CDS services, visiting support services at daycare centers, etc. "Attending a rehabilitation facility," as I mentioned above, usually means receiving CDS services and after-school daycare services. The former services are intended for preschool children, and the latter for school children (from elementary to high school).
These rehabilitation facilities and services for children with disabilities are regulated by the Child Welfare Act (Act No. 164 of 1947). The Ministry of Health, Labour and Welfare published the "Guideline for Child Development Support" in accordance with the Child Welfare Act. The guideline states:
"Under the Child Welfare Act revised in 2012, all support facilities previously categorized by each type of disabilities will be centrally managed to provide disabled children with more appropriate support services in their community. After this change, child development support services will be provided mainly for preschool children with disabilities. [...] This Guideline for Child Development Support is established to clearly explain the contents of child development support services as well as the national framework, to ensure the stable quality of these services" (excerpt from Chapter 1 "General Provisions" of the Guideline for Child Development Support).
I'm currently working as a consultant for a child support center established by a government-designated Special City located in the Tokyo metropolitan area. In this city, the number of CDS facilities satisfies the government's requirement. Under the Child Welfare Act the numbers of CDS facilities targeted to enhance the services for children with disabilities are as follows: one CDS center per 100,000 people; one or more CDS offices in each municipal community (or each secondary school zone). As a consultant, I have visited 20 CDS offices/after-school daycare facilities to examine the current situation of CDS services. The following summary is based on the results of my on-site survey.
|Usage frequency||About 60% of the respondents use the CDS services twice a week.|
|Opening hours||Most facilities are open from Monday to Friday; large facilities are open on weekends as well.|
|Form of rehabilitation||CDS centers for preschool children provide both individual rehabilitation and group rehabilitation (each occupying almost fifty percent) for about one hour.|
After-school daycare facilities for school children mainly provide group rehabilitation in the afternoon (between 15:00 and 19:00).
|Staffing||Staffing is specified in the Guideline for Child Development Support as follows:|
"Child development support centers* should have a contract doctor, child development support managers, child-support counselors or caregivers, and functional training staff. In particular, nurses and functional trainers are required for children with severe physical and intellectual disabilities. Meanwhile, child development support offices* should have child development support managers, child-support counselors or caregivers, and functional training staff."
Currently, the majority of child-support counselors are nursery staff, followed by those with certain qualifications such as certified social workers, teachers, clinical psychotherapists, occupational therapists, and speech therapists, as well as those who have acquired a bachelor's degree in relevant areas such as psychology, pedagogy, and social welfare studies.
In addition, offices have their own unique staffing policy. For example, some offices have child-support counselors who received training originally created and provided by such offices. Some focus on female child-support counselors.
|Service contents||The city's PR magazine states that "we offer various programs such as craft making, music, outdoor activities, and cooking to enhance children's living/social skills according to the conditions of each child. Each office has its own unique characteristics. Their opening hours, the age-groups of users, the availability/distance of pickup and drop-off services vary."|
The results of my door-to-door survey show that there are offices providing original educational materials for rehabilitation. Most offices implement regular programs and seasonal events for craft making, outdoor activities and cooking. They aim to help children acquire self-reliance, positive motivation, and communication skills through play and other activities.
They also provide various advantages for children and parents, including respite care. For example, children with older ages/developmental ages take care of younger children. In addition, parents can exchange information with each other. Parents can also receive mental support and respite care from the offices.
Challenges for CDS Facilities
Although the environment of CDS facilities is rapidly improving, there are still numerous issues. In addition, there is the issue of quantity.
In the city where I work, the number of CDS centers for preschool children currently meets the target figure specified by the Ministry of Health, Labour and Welfare. There are even some vacancies. In contrast, the number of after-school daycare facilities for school children is far from being adequate. This is because developmental disabilities became widely known to the public. An increasing number of parents obtain information about developmental disabilities through the Internet. More teachers can notice children with developmental disabilities and recommend rehabilitation to their parents. The need for rehabilitation is becoming greater and greater. As a result, afterschool daycare services, which children with disabilities should receive from elementary to high school, are completely unavailable. Some parents told me, "I would be very lucky if I can find a place for my child, wherever it may be."
The issue of quality is also of major concern.
There are various methods to conduct rehabilitation. For individual rehabilitation, internationally well-known and recommended methods include "Applied Behavior Analysis (ABA)" and "Treatment and Education of Autistic and related Communication handicapped Children (TEACCH)" introduced by Dr. Masami Sasaki (source: Mikio Hiraiwa, "Skills that can be acquired at home for children with developmental disabilities necessary to achieve independent living" (2017), PHP Institute.)
Nevertheless, social resources are not sufficient to offer customized programs and training appropriate for each child with developmental disabilities according to their symptoms and difficulties.
There is also the quality issue of training staff. For example, teaching at a special-needs school requires both a regular teacher license and a special-needs teacher license. In contrast, there is no official rehabilitation/CDS training program nor qualification for caregivers and child-support counselors. Each CDS center uses different evaluation tools for the preparation of individual support programs. The necessity of individual support plans is stated in "Article 3 of the Standard Concerning Staff, Equipment and Operation of the Services of Designated Outpatient Support under the Child Welfare Act." However, according to the on-site survey, it is confirmed that some centers conduct rehabilitation activities based on their originally-created programs, or based on the opinions of child-support counselors and the ability of each person. For those facilities providing CDS and rehabilitation services for children with disabilities, the Social Welfare Act requires them to merely "make efforts" to have a third-party assessment. Therefore, only a few facilities arrange a third-party assessment of their services. This situation may lead to lower transparency among rehabilitation facilities.
To be qualified for support services, it is necessary to submit an application form to the municipal government in accordance with the provisions of the Child Welfare Act concerning outpatient support for children with disabilities. Depending on the qualification process of each municipality, this application is usually permitted without showing a rehabilitation/disability certificate or a doctor's certificate. The government will issue a recipient certificate for a child needing rehabilitation if a doctor/clinical psychotherapist's statement is provided. Therefore, neither a doctor's diagnosis nor a rehabilitation/disability certificate is a prerequisite to receiving support services.
As a matter of fact, there are children who are often referred to as being "gray zone." These children may be slow in developing their cognitive and speech skills due to the factors of growing environment, rather than their individual factors, and are not officially diagnosed with developmental disabilities. In addition, there are parents who willingly send their child to CDS facilities because they don't want to leave the child home alone (in the case of nuclear households), or they are too busy to take the child out for various enrichment activities or look after their child's homework, and gratefully take advantage of the center.
Everyone has their own strengths and weaknesses, which differentiates them from others. Nevertheless, after the term "developmental disability" became common, more and more parents started to check the symptoms on the Internet and worry if their child is in this category. I often see parents seeking any cure to make their child "normal." The number of such parents will continue to increase and the shortage of support facilities will never diminish unless we stop categorizing children into two types: "healthy children" and "children with disabilities." Instead of labeling a child, who is different from others, as "strange" to exclude them, we should accept the child's characteristics even if the child has difficulties in certain aspects, and provide a supportive environment suitable to the child. If such a concept of inclusion becomes more common in the education system and more teachers and parents uphold inclusive practices, children with disabilities can freely develop their skills. In this way, we can ultimately create a comfortable society for all those who feel different or have difficulties in living their lives, regardless of whether they have a disability or not.
* The term "child development support" has two types of facilities: (1) a child development support center defined as the category of child development welfare facilities, and (2) child development support offices.
- Naoko Ichikawa & Hitomi Okamoto, "Introduction to Rehabilitation and Child Development Support: Aiming to become a professional for children with developmental disabilities" (2018), Kanekoshobo
- Meiming Zhao, "Influence of the Law for the Welfare of Physically Disabled Persons on the formation of Kenji Takagi's rehabilitation theory in the pre-war era" (2008), Japanese Journal of Social Welfare, Vol.49, No.2, Japanese Society for the Study of Social Welfare
- Tsurukichi Takamatsu, "What is rehabilitation? Remedies for disabilities and issues of community affairs divisions" (1990), Budousha
- Naoko Kondo, "What is rehabilitation? Delivering smiles to parents and children" (2018), National Developmental Support Outpatient Business Liaison Council, Creates-Kamogawa
- Mikio Hiraiwa, "Skills that can be acquired at home for children with developmental disabilities necessary to achieve independent living" (2017), PHP Institute, Inc.
- Ministry of Health, Labour and Welfare, "Guideline for Child Development Support"
https://www.mhlw.go.jp/file/06-Seisakujouhou-12200000-Shakaiengokyokushougaihokenfukushibu/0000171670.pdf (in Japanese)
- CDS Japan, "CDS Guidelines" (revised in 2016)
http://www.cdsjapan.jp/wp/wp-content/themes/cds/download/guideline_2016.pdf (in Japanese)
- Akio Nakai, "Rethinking of rehabilitation: the body creates the brain, and physical movements create the mind in an environment" (2011), Nou To Hattatsu, Vol.43, No.6, The Japanese Society of Child Neurology
https://www.jstage.jst.go.jp/article/ojjscn/43/6/43_432/_pdf (in Japanese)
- Akihito Ihara, "The right of children with disabilities to extended care and education in the Convention on the Rights of the Child" (2009), Journal of Bukkyo University Graduate School, Faculty of Social Welfare Studies, No.37
http://archives.bukkyo-u.ac.jp/rp-contents/DF/0037/DF00370L001.pdf (in Japanese)