Critical Review of the Situation of Child and Adolescent Psychiatry in Japan: Proposal of Policy Takahiko Inagaki M.D. Department of Psychiatry, Shiga Prefectural Mental Medical Center Department of Psychiatry, Shiga University of Medical Science 5.26.2016 The 3rd Asian Congress on ADHD at MAX Atria @ Singapore EXPO

Conflicts of Interest I was employed by an endowed chair sponsored by the Government of Shiga Prefecture, Japan Disclosure of research funding: National Mutual Insurance Federation of Agricultural Cooperatives Shionogi & Co., Ltd Otsuka Pharmaceutical Co., Ltd Shiga University of Medical Science The Shiga Medical Science Association for International Cooperation

Japan & Shiga Population: 1.4 million Under 20 years: 0.28 million This area were the most ancient capital of Japan. Shiga Tokyo Kyoto

Something Wrong in Japan The number of junior high school students who withdrew from school was about 100,000 (2.8%). 1) Our government says that 68.4% of the school withdrawals stay out of school for over one year.2) Our government’s definition of school withdrawal excludes those who cannot go to school because of their illness. Therefore, school withdrawal cases never receive mental health services (MHS). Report on School Basic Survey. Ministry of Education, Culture, Sports, Science and Technology, JAPAN. 2017 Report on School Withdrawals. Ministry of Education, Culture, Sports, Science and Technology, JAPAN. 2016

Something Wrong in Japan In Japan, the “school counselor” plays a role in child welfare with regard to connection between schools and MHS. School counselors are deployed in over 75% of all junior high schools. 1) In view of this fact, the rate of school withdrawals who do not receive MHS is extremely high! Perhaps, those in charge of child welfare do not trust MHS? 1) Conference material of Ministry of Education, Culture, Sports, Science and Technology, 2008

Japanese System for Developmental Disorders Act on Support for Persons with Developmental Disabilities This law decrees support with regard to employment and education for persons with developmental disabilities. This law also defines Support Centers for Persons with Developmental Disabilities The law mainly defines the role of welfare. It does not mention the role of medical services in detail. Each region is responsible for specific definitions of medical services.

System for Developmental Disorders in Shiga Prefecture Support Center for Persons with Developmental Disabilities Principals & Family Educational Institutions Mental Health Service (MHS) Governmental Agency Job Assistance Agency

Is the system in Shiga Prefecture Adequate? Have never been referred to MHS: 93％ Who have been referred to MHS before consulting to Welfare: 7％ Percentage of welfare institutions that encourage referrals: 2％ Inagaki. T, Current trial of Child and Adolescent Mental Health in Shiga Prefecture, Japan, Psychiatry, 2016 (Japanese)

Our System for Developmental Disorders is Inadequate Support Center for Persons with Developmental Disabilities Principles & Family Educational Institutions Mental Health Service (MHS) Governmental Agency Job Assistance Agency ×

Failure of Cooperation between Welfare and MHS in Shiga Inagaki. T, Current trial of Child and Adolescent Mental Health in Shiga Prefecture, Japan, Psychiatry, 2016 (Japanese)

Why Does Such a Situation Arise?

Lack of Skilled Services in MHS for Management of Child and Adolescent Mental Health (CAMH) The Japanese education system is responsible for CAMH We have no official license for child and adolescent psychiatrists. We have only private licenses certified by: The Japanese Society for Child and Adolescent Psychiatry (JSCAP) Japanese Society of Pediatric Psychiatry and Neurology (JSPPN) Unfortunately, these certification systems do not reflect the needs of public. We can update our certification only after attending multiple congresses. We have no official license for clinical psychologists. We do not have also private licenses for child and adolescent clinical psychologists.

Problem of Manpower for CAMH The number of doctors certified to manage CAMH is very small. For the 22 million population of children and adolescents in Japan: The number of doctors certified by JSCAP is 274. The number of doctors certified by JSPPN is 293. Because there are doctors who are certified by both societies, the total number of doctors for CAMH is approximately 500. As stated previously, officially, there are no clinical psychologists for MHS in Japan.

Problem of Manpower for CAMH In Japan, we have no system of General Physician. Unless certified by JSCAP or JSPPN, doctors do not receive training to manage CAMH. Many doctors are hesitant to examine CAMH. Except for pediatricians, many doctors are hesitant to examine children and adolescents. Many pediatricians, except for those certified by JSPPN, are hesitant to examine psychiatric issues in children and adolescents. Psychiatrists, except for those certified by JSCAP or JSPPN, are hesitant to examine children and adolescents. In my area, some psychiatrists announce their candidacy of to examine child and adolescent. Because they do not have received training to do so, their action came to the conclusion in loss of the public trust. 私の地域では、何人かの一般精神科医が、「私が児童思春期の患者を診ます」と立候補（宣言でも良いです）した。彼らはそれをするためのトレーニングを受けたわけではなかったので、彼らの活動は市民の信頼を失墜させる結果になった。

Problem with Relaying Information about MHS to the Public In Japan, it is not common for MHS to disclose treatment outcomes to the public and the government. For example, on Google JapanTM, if we search for “school withdrawal” and “treatment outcomes”, we obtain information of only 3 institutes, including ours. Because of this, many Japanese, including teachers and parents of children who withdraw from school, do not believe that MHS can treat school withdrawal cases.

What Should We Do?

To Improve the Quality of Resources for CAMH (Psychiatrist) We can raise the baseline for clinical techniques New semi-official license system for doctors will start in 2017. In 2011, Investigative Commission for Medical Specialist was established in Ministry of Health, Labor and Welfare In 2014, Japanese Medical Specialty Board was established and now they are programming of new training system for every medical field including CAMH. The program includes not only the certification but lifelong education.

To Improve the Manpower for CAMH (Clinical Psychologist) We can improve the manpower of CAMH and raise the baseline for clinical techniques of Clinical Psychologists New official license system for Clinical Psychologist will start in 2017. In 2015, the law for certification of Clinical Psychologist was passed Parliament. The certification system will start in 2017.

Is It Enough?

What Interferes with the Cooperation between Welfare and MHS? Lack of Skill Lack of Manpower Lack of Information MHS Welfare ×

My Proposal We should create a system to declare our treatment results to the public and government. The public are unaware of treatment efficacy. We should provide them with the appropriate information. For technical improvement, the appropriate comparison is necessary between the therapists or the clinics. Inagaki. T, Significance to disclose the outcome to the public: Introduction. Japanese Bulletin of Social Psychiatry. Vol.25(1):33-35, 2016. (Japanese)

How to Improve the Cooperation between Welfare and MHS? Lack of Skill Lack of Manpower Lack of Information MHS Welfare ×

How to Improve the Cooperation between Welfare and MHS? Lack of Skill Lack of Manpower Lack of Information MHS Welfare ×

Summary In Japan, we have a system to support persons with developmental disabilities, including ADHD. However, the system is inadequate because of: Shortage of manpower. Misunderstanding regarding MHS’ role To solve the problem of manpower, new certification systems must be established. I propose to create systems of disclosure of information to the public and government in MHS. To provide appropriate information to the government and public. To provide appropriate comparison to improve our clinical technique.

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