Challenges and Recommendations for Responding to Child Abuse Revealed Through Reviews of Child Fatality Cases

The number of child abuse cases handled by child guidance centers has continued to rise steadily. Reviews of fatal cases reveal the challenges that child guidance centers must overcome—including the accumulation of professional expertise—in order to eliminate child abuse deaths.

• The Ongoing Tragedy of Child Abuse Deaths
• Main Issues and Challenges Commonly Seen in Responses to Fatal Cases of Child Abuse
• Toward Zero Deaths in Reported Child Abuse Cases

The Ongoing Tragedy of Child Abuse Deaths

Cases of child deaths due to abuse show no sign of abating. According to the government’s review report*¹, the number of children who died as a result of abuse over the 20 years from 2003 (Heisei 15) to 2022 (Reiwa 4), when the national survey began, reached 1,680 (1,045 from abuse other than murder-suicide, and 635 from abuse in murder-suicide cases).

Although mandatory reporting of suspected abuse has been codified in law, the same report indicates that in individual fatal cases, reports were filed in only about 22% of abuse cases other than murder-suicide and about 13% of murder-suicide cases. To reduce deaths from abuse, thorough enforcement of mandatory reporting is indispensable. At the same time, in fatal cases, child guidance centers and municipalities were involved in about 22% of non-murder-suicide cases and about 12% of murder-suicide cases. Why were these institutions—which should serve as the “last line of defense” for children suffering abuse—unable to save them?

I myself have been engaged in reviewing fatal cases for the national government as well as for many municipalities. From these experiences, I have come to feel that there are common problems and issues in the responses that lead to abuse-related deaths. In this article, I will present these issues and discuss measures to prevent such deaths.

Main Issues and Challenges Commonly Seen in Responses to Fatal Cases of Child Abuse

(1) Insufficient Assessment Capacity and Lack of a Sense of Urgency

A striking problem in fatal cases is the lack of a sense of urgency and inadequate assessment capacity. In child abuse response, risk assessment is one of the most critical tasks. For example, although risk assessment sheets designed to aid in risk judgments have been provided by the national government and municipalities, there are not a few cases where they were not used. As a result, situations arose where a complacent judgment such as “it is probably fine” was made, or where authorities took an optimistic view simply because parents began to consult about their worries, thereby overlooking cases where serious abuse was actually occurring. There are also many cases in which, despite the increased frequency of injuries following the appearance of a parent’s new partner, the severity of the abuse was not re-evaluated and responses remained limited to each individual report or piece of information, without a comprehensive or chronological perspective. Furthermore, beyond risk assessment itself, perspectives such as understanding the parents’ developmental history and feelings, or assessing the family as a whole, were lacking. As a result, parents sometimes grew distrustful of aid workers and refused them access to their children, leading to the worst possible outcomes. Building organizational systems and improving staff competencies to strengthen assessment capacity are therefore among the highest priorities.

(2) Prioritizing Relationships with Parents

There are also prominent cases in which prioritizing relationships with parents over protecting children’s rights led to neglect in verifying and ensuring children’s safety, ultimately resulting in fatalities. While it is understandable to value relationships with parents in light of family reintegration after protective measures, if this compromises the child’s life or well-being, it is a complete reversal of priorities. The proper approach is to place the welfare of the child first, and only afterward to work toward restoring trust with the parents.

(3) Insufficient Information Sharing and Coordination among Related Agencies

Child abuse involves many complex, intertwined factors. Therefore, it is difficult for a single agency to handle cases alone, making it essential to share information and perspectives among agencies, and to provide assistance through division of roles. The Regional Council of Countermeasures for Children Requiring Protection (Yōtaikyō), which forms the foundation for interagency collaboration, manages the progress of all registered cases. However, because of the need to process a vast number of cases in a limited time, it has been unable to conduct in-depth reviews. One of Yōtaikyō’s functions is to convene individual case review meetings in which all parties involved in a specific case gather to discuss responses. Yet according to the government report, among 52 children who died from abuse other than murder-suicide in FY2022, only 10 cases (19.2%) were examined in such individual case review meetings. Active utilization of Yōtaikyō and measures to prevent the hollowing out of its meetings are pressing challenges.

(4) Lack of Organizational Response

In fatal abuse cases, it is notable that caseworkers often carried the burden of cases alone. Within organizations, it is indispensable to maintain systems that constantly support caseworkers and to ensure organizational responses. The organizational framework must be reconsidered to prevent caseworker isolation.

Toward Zero Deaths in Reported Child Abuse Cases

The issues and challenges described above have been repeatedly pointed out in many past review reports. In other words, the findings of these reviews have not been reflected in practice, and the same “mistakes” continue to be repeated. Behind this lies structural problems such as the fragility of staffing systems in child guidance centers and municipalities, and the lack of professional expertise among their personnel. Unless these problems are directly addressed, the number of fatal abuse cases will not decrease.

As reports of child abuse surge, staffing has not kept pace, leaving personnel exhausted and causing the problem of burnout to grow ever more serious. For child welfare officers at child guidance centers, staff allocation standards have been codified in law, and the national government has been striving to increase personnel substantially through initiatives such as the “Comprehensive Reinforcement Plan for Child Abuse Prevention Systems.” Yet the situation remains no more than a drop in the bucket. For municipal consultation staff, staffing standards have not even been codified.

Securing professional expertise is also an urgent task. It is said that at least ten years of practical experience are required to become proficient in child abuse response. However, child welfare officers, as civil servants, are subject to short rotation cycles, and according to a national survey, nearly half have less than three years of experience*². The lack of assessment capacity noted earlier is itself a problem of professional expertise. In order to enhance professionalism, urgent measures must be taken to enable personnel to accumulate expertise. This includes promoting the appointment of specialists and establishing personnel rotation rules different from those for general administrative staff, such as extending rotation cycles. To ensure the recruitment and retention of high-quality personnel, it is also essential to improve working conditions commensurate with the demanding nature of the work, enhance supervision, and implement measures for mental health support.

For specific measures to secure professional expertise at child guidance centers and municipalities, see my previous article in this journal (EN-ICHI FORUM, November 2023)*³.

To move closer to zero child abuse deaths, above all, it is vital to reflect on the deep regret of children who were forced to leave this world at such a young age and to fully make use of the lessons of the past.

(First published in "EN-ICHI FORUM" February 2025 issue)

References

*1 “Results of Reviews of Fatal Child Abuse Cases, etc.” 20th Report of the Expert Committee on Reviews of Child Abuse and Other Cases Requiring Protection, Child Abuse Prevention Measures Subcommittee, Children and Families Council (September 2024).（「こども虐待による死亡事例等の検証結果等について」こども家庭審議会児童虐待防止対策部会児童虐待等要保護事例の検証に関する専門委員会第20次報告（令和6年9月））.
*2 As of April 1, 2023 (Children and Families Agency, Support Bureau, Abuse Prevention Measures Division).
*3 才村純「児童虐待予防に向けた提言-法整備、専門人材育成を中心に」圓一フォーラム、2023.11.

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