Previous research has found that victims of child abuse are more likely than nonvictims to suffer from mental and chronic illnesses, behavioral problems, interpersonal problems, and decreased productivity, with effects that continue into adulthood [1
]. The economic losses from child abuse are $
120 billion per year in the United States [2
], while the social costs (e.g., costs of child social welfare services, medical costs) are $
16 billion in Japan [3
]. Child abuse is associated with public health problems.
Early intervention is essential to prevent the negative influences of child abuse, and child guidance centers play an important role in early intervention in Japan. Sixty percent of the consultations at child guidance centers in Japan are related to inadequate child care, such as abuse and neglect [4
], and it is thought that child guidance center workers have many opportunities to come into contact with parents who are perpetrators of abuse and children who are victims. Contact with parents who cannot afford to obtain childcare may lead to a high frequency of work-related traumatic events, such as verbal abuse and violence, leading to post-traumatic stress disorder (PTSD) in workers. Previous research has shown that as the level of PTSD among child welfare workers increases, the child’s risk becomes increasingly underestimated [5
]. PTSD may reduce the staff’s ability to judge risk and may hinder early intervention for abuse. However, few previous studies have examined PTSD among child welfare workers.
To date, previous research has revealed that the intensity of experiences and the length of exposure are associated with PTSD in single traumatic events [6
]. Furthermore, previous studies in civil populations affected by war have shown dose–effect relationships between the cumulative number of traumatic events experienced and PTSD symptoms, pointing to the need to examine the effects of cumulative traumatic experiences as well as single traumatic events for people in settings with the potential for many different types of experiences [9
]. Therefore, the effect of work-related traumatic events on PTSD among child guidance center workers may also need to be assessed for the cumulative effects of traumatic events, and not only to determine which type of traumatic event has a stronger effect. However, to the best of our knowledge, very few studies have assessed the effects of work-related traumatic events on PTSD among child welfare workers, and no previous studies have evaluated the cumulative effects of traumatic events.
The purpose of this study was to examine the association between the single and the cumulative number of types of work-related trauma events experienced by child guidance center workers and PTSD symptoms in Japan.
shows the demographics and characteristics of the participants. The mean age and years of work experience were 43.98 (SD = 12.34) and 4.86 (SD = 4.17), respectively. Of the total number of participants, 25.7% were male and 74.3% were female, and 54.3% qualified for welfare. The mean PCL-5 and TRS scores were 10.75 (SD = 13.17) and 44.98 (SD = 10.01), respectively.
and Table 3
show the percentages of each traumatic event experienced. The most experienced traumatic event was, “Repeatedly heard detailed stories about abuse during work” (70.0%), while 12.9% of the workers had no experience with work-related traumatic events, and 87.1% had at least one event.
shows the results of the univariate and multivariate analyses. In the first multivariate analysis, the event, “During work, witnessed a parent violently beat, hit, kick, or otherwise injure a child or the other parent” (β = 11.96; 95%CI, 2.11–21.80; p
< 0.05) and TRS (β = −0.60; 95%CI, −0.84 to −0.36; p
< 0.01) were significantly associated with PCL-5 scores. In the second multivariate analysis, TRS (β = −0.60; 95%CI, −0.84 to −0.36; p
< 0.01) was significantly associated with PCL-5 scores. The association between the cumulative number of event types and PCL-5 scores was not significant, but it was stronger when the cumulative number was four or more.
This was the first study, to the best of our knowledge, to examine the association between PTSD symptoms and the single and the cumulative number of types of work-related trauma events experienced by child guidance center workers. The single traumatic event significantly associated with the severity of PTSD symptoms was, “During work, witnessed a parent violently beat, hit, kick, or otherwise injure a child or the other parent”.
A previous study of child welfare workers indicated that indirect traumatic events (working with children in distressing circumstances and being unable to do enough for the client, both specifically and generally) were more highly associated with trauma effects than were direct events (spoken abuse by a client to a worker and being placed in fear of personal safety by a client) [20
]. This suggests that indirect events may be more toxic because they reflect workers’ lack of control and inability to impact clients’ lives adequately. A possible explanation is that these are assumed strength differences of peri-traumatic emotional responses noted as risk factors for PTSD [19
] between indirect events and direct events. The event, “During work, witnessed a parent violently beat, hit, kick, or otherwise injure a child or the other parent”, seems an indirect event and made workers feel that their capacity to prevent abuse was ineffective, which might lead to workers’ feelings of inability.
In addition, such violence also seems to be a direct event. The event is likely to occur in a closed space where the consultation takes place, such as a consultation room or the client’s home. Witnessing the violence in a closed space might lead the worker to fear being caught up in that violence. These are also assumed peritraumatic emotional responses. Thus, this event might create more stronger peritraumatic emotional responses than other events.
However, the estimated value had a wide 95% confidence interval range. This may be due to the small number of workers who had experienced this event (n = 8). Further research of a longitudinal design with random sampling and a large number of participants will be needed to validate this result.
Although the association between the cumulative number of event types and the severity of PTSD symptoms was not significant, it was stronger when the cumulative number was four or more. This is partly consistent with previous studies’ findings, which showed dose–effect relationships between the cumulative number of types of traumatic events experienced and lifetime PTSD symptoms [9
]. A similar relationship pattern was also seen in child guidance center workers.
In professions that may experience many types of work-related traumatic events, such as child guidance center work, we may need to pay attention to the cumulative number of events and not just single events. Further research among the occupations likely to experience various types of work-related traumatic events will be needed to validate this result.
It may be important to reduce the experience of witnessing violence or other types of traumatic events in child guidance center workers to avoid having the negative effects of PTSD symptoms affect their performance. A previous study of child welfare workers suggested that consideration of the causes and effects of violence, reflecting support for planning and a commitment of agencies to worker safety, is essential to prevent violence of clients [21
]. A study of healthcare workers in emergency departments found that training (focused on constructing a relationship with the patient, improving the worker’s communication skills, and accurately reporting violent incidents) and implementing workplace design effective in minimizing stressful conditions of patients should be prioritized to prevent and manage patient violence [22
]. Further research may be needed to assess the commitment and measures of child guidance centers to prevent work-related traumatic events and to determine how effectively they work.
Resilience had a significant negative association with PTSD symptoms. This is consistent with previous studies showing resilience to be a protective factor against PTSD, especially among the occupations that are likely to experience work-related traumatic events (e.g., firefighters, police officers, and intensive care unit nurses) [23
]. On the contrary, another previous study suggested that there is no ultimate resilience to traumatic stress, and that the repeated occurrence of traumatic stress has a cumulative damaging effect on the mental health of the victim, because all develop PTSD once the trauma load reaches a certain threshold [10
]. Therefore, to prevent PTSD in child guidance center workers who may experience various types of traumatic events, it may be essential to reduce even one traumatic event.
These results were obtained from workers in six centers in one prefecture, which is one of the most populous, and the number of abuse consultations was higher than the national average in Japan. Although the number of abuse cases handled by each worker was on par with other prefectures with a large population, the number of workers per center was greater than that of other prefectures. For these reasons, participants might be more likely to experience traumatic events, especially indirect events, such as witnessing and learning their colleagues’ traumatic events, compared to other prefectures. Thus, workers’ characterization of traumatic events may differ depending on the prefecture and workplace. To confirm this study’s results, further research is needed to investigate the differences in traumatic events experienced by workers in each prefecture and workplace and how they affect PTSD symptoms.
This study has some limitations. First, the response rate was low (15.2%), and the sample size was modest (n = 140). There was the possibility of selection bias. Participants may have been biased toward those interested in their mental health. As a result, the association between traumatic events and PTSD symptoms might be overestimated. Second, generalization was limited because the results were obtained from workers in six centers in one prefecture in Japan, due to the possibility of the difference in workers’ traumatic event experiences in each prefecture. Third, there were other confounding factors for PTSD symptoms for which we did not collect information from participants (e.g., history of psychiatric illness and peritraumatic factors). Failure to adjust for these confounding factors might have influenced the results. Fourth, PTSD symptoms might be associated with other lifetime traumatic events rather than work-related events. In this case, the effect of work-related traumatic events on PTSD symptoms might be overestimated. Fifth, the work-related traumatic event checklist was created based on interviews with child guidance center staff and previous studies, but there is a possibility that the checklist might not be comprehensive and might not cover some work-related traumatic events. Therefore, there might be traumatic events for which the impacts on PTSD symptoms were not assessed in this study. Sixth, because this study was a cross-sectional study, it was impossible to determine a causal relationship.