: 2019  |  Volume : 17  |  Issue : 1  |  Page : 103--108

Psychological first aid for children during the Kumamoto earthquake disaster response in Japan

Miyuki Akasaka1, Yuzuru Kawashima2,  
1 BA, Save the Children, Japan
2 MD, PhD, Clinical Research Institute at the National Disaster Medical Centre, Disaster Medical Assistance Team Secretariat, Disaster Psychiatric Assistance Team Secretariat, Tokyo, Japan

Correspondence Address:
Miyuki Akasaka
Save the Children Japan, 2-8-4-4F Uchikanda, Chiyoda-ku, Tokyo 101-0047


The following field report is based on lessons learned from the adaptation and utilisation of the Psychological First Aid for Child Practitioners (Save the Children, 2013) materials in Japan. Psychological first aid (PFA) is a set of skills and competencies that help reduce the initial distress of children and caregivers due to accidents, natural disasters, conflicts or other critical incidents. The manual was developed by Save the Children based on Psychological First Aid: A Guide for Field Workers (World Health Organization, War Trauma Foundation and World Vision International, 2011). National capacity-building in PFA was focused in Japan on mental health professionals and emergency responders to enhance mental health and psyschosocial support in times of disaster. In April 2016, during the Kumamoto earthquake, emergency disaster responders in Japan learned PFA and worked at child friendly spaces for children and caregivers.

How to cite this article:
Akasaka M, Kawashima Y. Psychological first aid for children during the Kumamoto earthquake disaster response in Japan.Intervention 2019;17:103-108

How to cite this URL:
Akasaka M, Kawashima Y. Psychological first aid for children during the Kumamoto earthquake disaster response in Japan. Intervention [serial online] 2019 [cited 2023 Feb 5 ];17:103-108
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Mental health and psychosocial support in Japan

The Great East Japan Earthquake and Tsunami (GEJET) of 11 March 2011 was the most powerful earthquake recorded in Japan. It triggered a massive tsunami which struck Japan’s north-east coast. There were more than 15,000 deaths, 3000 homes were totally destroyed and 47,000 people became evacuees (Cabinet Office, Government of Japan, 2018a). Lifesaving relief operations were delivered to the affected areas, which included mental health and psychosocial support (MHPSS). The Ministry of Health, Labour and Welfare dispatched 57 mental healthcare professional teams called ‘kokoro-no care teams’ comprised of psychiatrists, nurses, psychologists or psychosocial workers and logisticians to the affected areas (Ministry of Health, Labour and Welfare, 2018). ‘Kokoro’ in Japanese means ‘heart, mind, emotions, thoughts and feelings’, and the term ‘kokoro-no care’ has the same meaning as MHPSS as described in the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Suzuki, Fukasawa, Nakajima, Narisawa, Asano, & Kim, 2015). The term ‘kokoro-no care’ itself is widely known among mental health professionals as well as community members; however, misunderstandings can occur and the IASC guidelines are very helpful in this regard. The IASC guidelines recommend a multi-layered support approach, including provision of basic needs and security, and specialised support. These layers are designed to complement each other to best respond to a diverse variety of needs. The guidelines emphasise the importance of cross-sectoral collaboration and inter-agency coordination in times of emergency (IASC, 2007). These points have been generally understood among Japanese mental health professionals, but have not been widely integrated into practice (Kim, 2011). Different professions have different point of views on MHPSS in emergency settings. For example, healthcare professionals tend to identify and address pathological mental health issues in times of crisis. Community members often think that the ‘kokoro-no care’ approach does not include specialised mental healthcare (Suzuki et al., 2015). In the GEJET response, varied responders who had different backgrounds or expertise were involved in the relief operation, and everyone was in a position to be provided with psychosocial support. However, it is important to note that improperly providing psychosocial support itself can cause harm, as we deal with highly sensitive isues (Inter-Agency Standing Committee, 2007). It was therefore necessary to increase awareness of ‘kokoro-no care’ in order to have a common understanding to reduce the risk of harm. The national level of capacity-building effort was made by the mental health professionals and partners by introducing psychological first aid (PFA). PFA is a popular evidence-informed approach based on international expert consensus. It provides ‘a humane, supportive and practical response to a fellow human being who is suffering and may need support’ (Shultz & Forbes, 2014). The Japan National Information Centre for Disaster Mental Health (NICDMH) and partners translated Psychological First Aid: A Guide for Field Workers (World Health Organization, War Trauma Foundation and World Vision International, 2011) into Japanese and started training in PFA in 2012. In 2014, Save the Children with support from NICDMH introduced Psychological First Aid for Child Practitioners (Save the Children, 2013) and started disseminating the training.

There is a paucity of empirical research on the effectiveness of PFA. However, mental health experts and global humanitarian guidelines recommended PFA as an appropriate support for an individual experiencing acute mental distress following a disaster (Child Protection Working Group, 2012; Morris, Ommeren, Belfer, Saxena, & Saraceno, 2007). In Japan, both training in relation to the PFA Guide for Field Workers and PFA for Child Practitioners were successfully disseminated to various people, including fire fighters, medical responders, local prefecture, city and town officials, school teachers, local organisations and non-governmental organisations, company workers, media people and students from universities and colleges. Two governmental disaster medical response teams, the Disaster Medical Assistance Team and Disaster Psychiatric Assistance Team, started introducing PFA in their official trainings. The Board of Education in Miyagi Prefecture, a prefecture affected the by GEJET in 2011, has also adopted the PFA for Child Practitioners training into their official annual teachers training since 2016.

Psychosocial support for children in emergency settings

Children’s responses to the emergency events may cause caregivers or adults around them to feel confused or nervous, because children display unique reactions. For example, they may exhibit regression to younger behaviours (e.g. bedwetting) or socio-dramatic play with content related to the disaster or some children may appear as if they are not registering a response. Most children affected by disasters experience distress, but do not develop mental illnesses and the distress tends to diminish with time (Pfefferbaum, Newman, Summer, & Nelson, 2014). However, some may face post-disaster mental health problems such as depression, somatic symptoms and posttraumatic stress disorder, and may need additional support resources. In an emergency, different socio-ecological levels, family, peers, school and community, are all important factors to protect and promote children’s mental health and psychosocial wellbeing in disaster settings (Betancourt, Meyers-Ohki, Charrow, & Tol, 2013; Norris, Friedman, & Watson, 2002). A report about children after the GEJET said that there were not many children’s cases referred to the mental health professionals in Miyagi Prefecture. The reason may be related to the fact that caregivers may lack information or knowledge on the children’s reactions to disasters, and as a result, they were not aware of the changes in the children (Miyagi Prefecure Kodomo Sogo Center, 2016). A survey conducted by the Ministry of Education, Culture, Sports, Science and Technology, Japan, on 5075 kindergarten to high schools with 33,700 classroom teachers and 3408 school nurses from the seven GEJET-affected prefectures showed that half of the teachers felt that they did not have enough basic knowledge on children’s mental health. School nurses with more knowledge of mental health than teachers identified more stress reactions, had more mental health referral information and referred more children’s cases to mental health professionals (Ministry of Education, Culture, Sports, Science and Technology Japan, 2013). If caregivers and school teachers understood children’s views on disasters and were aware of the children’s distress, they might have normalised less serious distress in children’s psychological reactions and referred children with severe distress (Norris, Friedman, & Watson, 2002). For these reasons, appropriate trainings should cover all sensitive issues of child development and children’s emotional and behavioural reactions to disasters (Pfefferbaum & North, 2013). This information will be beneficial for adults to better respond to children’s behavioural changes in disasters and provide age-appropriate PFA.


Psychological first aid for child practitioners training manual

In 2013, Save the Children (SC) developed a PFA for Child Practitioners manual which trained people to support and communicate with children in distress and caregivers in emergency settings. The core actions in PFA aimed to encourage children’s positive coping skills by offering safety and comfort, connecting to social support, providing practical support and link children with serious distress to more professional resources. The PFA for Child Practitioners training manual adopted the PFA principles, ‘look, listen and link’ (World Health Organization, War Trauma Foundation and World Vision International, 2011). The training manual was originally designed to be a two-day programme and potentially complemented a one-day training on stress management for staff. The training programme included information on general child cognitive development, general child stress reactions, practice on child age-appropriate communication techniques, communication with caregivers in distress, PFA action principles and key actions [[Table 1]]. The training was combined with lectures, group activities and role-play exercises.{Table 1}

PFA for child practitioner’s training adaptation in Japan

SC condensed the two-day programme on PFA for Child Practitioners into a single day to adapt it to the Japanese context [[Table 1]] due to time constraints. In condensing the training, the important element, ‘communicating with caregivers’, unfortunately was left out. Moreover, the one-day training on stress management for staff was not disseminated in Japan, as they already had the same topic available by mental health professionals. There were two animated movie clips from the original training material that described PFA for children and PFA for caregivers with a child in a disaster setting. The scenes in the movie clips looked very different from Japanese cultural contexts, but they were very much welcomed by Japanese trainers as a training tool.

The first PFA training of trainers (ToT) for Child Practitioners was held in Tokyo from 8 to 11 July 2014. It was organised by SC with support from the NICDMH. The training was conducted by two authors of the PFA for Child Practitioners manual from Denmark. The four-day ToT on PFA for Child Practitioners consisted of a two-day ToT, a one-day training for community members, which was conducted by the ToT participants, and a one-day feedback session. There were 24 people who participated in the ToT with the majority of the participants from medical teams or MHPSS who had already taken the PFA Guide for Field Workers ToT in Japan. According to the feedback from the ToT participants and NICDMH, the training methodology of PFA for child practitioners was highly relevant to the Japanese cultural context, particularly for disaster preparedness as well as actual disaster responses. Many of the ToT participants expressed eagerness to introduce the training to their agencies or communities. Together with the trainers and support from NICDMH, Save the Children delivered the training to more than 2000 people by 2016.

Save the Children’s Kumamoto earthquake response

The Kumamoto earthquake comprised a series of shocks, including one that registered a magnitude of 7.0. Evacuees peaked at 183,882 on 17 April 2016 (Cabinet Office, Government of Japan, 2018). After the first shock, SC dispatched an emergency response team on 15 April to Mashiki town in Kumamoto Prefecture, which was heavily damaged. SC opened and operated five child friendly spaces (CFSs) from 16 April to 13 May at five different evacuation centres. The CFSs were open seven days a week and run by fifteen SC staff with support from affected community members such as teachers, after-school programme staff and caregivers. The CFSs operated three to four hours a day, either in the morning or afternoon, with some open for a full day. A total of 1234 children attended the CFSs, and their average age was 6.44 years old.

 Materials and methods


Fifteen participants, ten females and five males, were all working for the CFSs as staff. The participants worked in rotational shifts with an average of 8.4 working days from 16 April to 13 May. Most worked for two different CFSs in one day. Three participants were SC’s full-time staff members and the remaining were temporary emergency response team staff members. Six participants received a one-day training in PFA for Child Practitioners prior to the Kumamoto earthquake between July 2014 and December 2015 as part of the disaster preparedness training at SC. Nine participants who did not take the one-day training had received one to 1.5 hours of briefing in PFA for Child Practitioners orientation, either at the accommodation or on the way to the site from an experienced PFA trainer. The brief orientation focused on ‘what is PFA for children’, ‘children’s reactions to crisis’, ‘action principles of PFA’ and an ‘active listening’ practice. Ideally, it was the best way to provide the one-day training; however, it was very difficult to do within the chaos of the emergency response. Five out of the fifteen participants were previous workers at CFSs as CFS staff in SC’s GEJET emergency response in 2011. All of the participants had either current or prior working experience with children at schools, after-school programmes, medical facilities or at SC’s child participation activities.


The data were collected from daily CFSs feedback forms filled by each of the participants. The participants were asked to provide basic information about their CFSs, and describe good practices or lesson learned, any concerns, impressions or suggestions, and to report the use of any of the PFA principles, ‘look, listen and link’, if used. A total of 116 daily feedback reports were collected from the fifteen participants from 17 April to 13 May 2016.

 Findings and discussion

The outcome of the PFA training and brief orientation of child practitioners provided key lessons about how PFA prepared the participants to work with children in distress and face challenges.

How PFA prepared participants to work with children in distress

Having prior information on children’s reactions to crisis prepared the staff in observing children. Many participants reported their observation of common distress reactions displayed by children in the CFSs, including recreating their experiences through play. For example, the participants reported that in a socio-dramatic play, one child exclaimed, ‘Earthquake, earthquake is coming’ while playing, and another child said, ‘My house collapsed and my car collapsed’ while she smashed play dough. Some participants who worked for the first time in the CFSs in a disaster setting wrote, ‘When I saw children role playing in the socio-dramatic play about the earthquake, I thought “this is actually happening”. I did not interrupt them; I just kept my eyes on them’ (Male, PFA orientation participant). Other children were aggressive or regressed to younger behaviours: ‘Younger children (boys) wanted to climb on me several times. So, I suggested to them to play tag with me’ (Male, PFA orientation participant). They knew the children’s reactions were normal to the abnormal situation. They, therefore, did not interrupt the children’s natural coping process, instead they facilitated. This is an important step in taking care of distressed children. This information will also be beneficial for caregivers to better understand, accept and respond to children’s behavioural changes in disasters.

Active listening

The second PFA principle, ‘listen’, involves actively listening to children and caregivers if they want to talk. The active listening practice with role playing in the training process prepared the staff. The participants often used active listening when the children spontaneously talked about their disaster experiences. Some participants recalled key elements of active listening while they listened to the children.

‘A younger child started talking to me while we were playing. He was talking about how scared he was when the earthquake occurred. I focused on his story, nodding, and kept repeating key phrases when he spoke.’ (Male, PFA orientation participant)

Moreover, many participants reported stories from a variety of caregivers at CFSs.

‘When a mother and her baby were playing at the CFS, she started talking to me. She was talking about how her child lost her appetite after they evacuated to a car and was sleeping in the car. I was just listening to her and I did not ask her anything.’ (Male, PFA orientation participant)

The findings suggested that the practice should focus not only on children but also on communication with caregivers in distress, which helps PFA providers to deliver safe and practical support to caregivers. Unfortunately, this very important topic had to be left out during the process of condensing the original two-day PFA for Child Practitioners into a one-day training. It is recommended that the training should always touch upon the topics. The active listening practices should have cases about caregivers and referral exercises that have topics on caregivers or caregivers with children.


The last PFA action principle is ‘link’. The findings showed that staff helped children and caregivers to access to basic needs and services; some staff recalled the key elements in the link; and some linked affected children’s behavioural concerns to caregivers or community members in the actual disaster setting. It showed the important points that staff linked them with social support or loved ones rather than trying to solve all the problems by themselves.

‘A younger child was very cranky at CFS today, so I asked her father who was in the evacuation centre, to come and pick her up. It is very important not to try and solve the problem all by myself. It is very important to link, for example, her father or other staff. If there are more needs, we can link the school counsellor.’ (Female, PFA orientation participants)

‘A middle school aged child was not engaging in play. He said “I cannot play, I am busy with taking care of my grandmother”. I became concerned that he seemed potentially overwhelmed by the responsibility of caring for her and I was concerned about the risk of play deprivation. At the end of the day, I had mentioned this to a teacher who was working with evacuees at the centre. As it turns out, the teacher knew him very well and offered to keep him under careful observation by working with a school counsellor. I felt relieved.’ (Female, one-day PFA participant)

Some participants wrote about their concern for the children’s behaviour in the daily feedback report, but they neither linked nor reported their actions further.

‘A boy went to the restroom four times this morning. The last time I remember, he went to the restroom three times. I am not sure why he goes to the restroom so frequently.’ (Male, PFA orientation participant)

PFA providers need to use their best judgement about when to link for further assistance or end (World Health Organization, War Trauma Foundation and World Vision International, 2011). If there are continuous concerns about a child, the PFA provider should at least link them to their team members and not leave the child alone. This should be explained in the training or orientation to prevent further harm. It was also important to make the participants aware that improperly providing PFA or psychosocial support itself can cause harm (Schafer, Snider, & Sammour, 2016).


Some CFSs staff found it challenging to take care of children who displayed aggressive and regressive behaviour; they climbed on the backs of the staff or tried to hug them, which is highly unusual in Japanese culture.

‘She (younger child) was clinging to me and she did not want to let go of me. So I had to hold her, while I was playing with the other children.’ (Female, PFA orientation participant)

Although providing practical support is a part of PFA for Child Practitioners, the training did not provide full child care skills. A previous study of 50 emergency responders who were trained using the PFA manual, which was developed by National Child Traumatic Stress Network, and utilised in Hurricane Gustav and Ika, showed that PFA training increased confidence in responders to work with disaster-affected people. Yet, they were less confident in providing PFA for children than adults. The study suggested that it may be more practical to focus on topics of communication with children in different developmental stages and families (Allen et al., 2010). For staff who lack work experience with children, follow-up training or additional training in child development, children’s play or communication practices at different developmental stages and caregivers with children in distress may be helpful to reduce their stress [[Table 2]].{Table 2}

Limitations of findings

The findings of this study have significant limitations. The findings are based on a small number of samples and do not represent all trained people. The participants had a variety of professional skills which may have affected the results of the study. The data collection and translations were not systematic. Moreover, the results reflected perceived information from PFA providers, not from the affected people who received the PFA.


The PFA for Child Practitioners training in Japan indicates important lessons for further training improvement. The staff who took the one-day training or brief orientation on PFA recalled the simple PFA action principles, ‘look, listen and link’, and applied it with the key elements in Kumamoto earthquake response. Prior learning about child development and children’s reactions to crisis helped the staff observe situations calmly and enabled them to provide age-appropriate care and empowering approaches. Linking children’s needs to further MHPSS demonstrated how PFA helps in strengthening an important part of the support network to facilitate recovery. PFA is not a stand-alone approach but an integral component of MHPSS system in affected communities. Future studies should explore how national PFA can influence collaboration and cooperation in the field to create MHPSS system.

National capacity-building should continue as different stakeholders at all levels are key players in protecting and promoting children’s mental health and psychosocial wellbeing in a disaster setting. Moreover, it is important to raise the awareness of ‘kokoro-no care’ and to have a common understanding among all to do no harm.


We would first like to express our sincere appreciation to Dr. Leslie Snider for all her help and guidance. We would like to acknowledge our gratitude to her for introducing the materials in Psychological First Aid: A Guide for Field Workers in Japan, and for inspiring us to work more on cross-sectoral collaborations and inter-agency coordination. We would also like to express our appreciation to Dr. Yoshiharu Kim and his team, for all their support in introducing and disseminating PFA for Child Practitioners training in Japan. Finally, we would like to thank Ms. Anne-Sophie Dybdal, the Senior Child Protection Adviser at Save the Children in Denmark. She is the expert who created the PFA training manual for child practitioners and introduced it in Japan.

Financial support and sponsorship


Conflicts of interest

Miyuki Akasaka is a Child Protection Programme Coordinator for Save the Children Japan. Yuzuru Kawashima is a Medical Doctor for the Clinical Research Institute at the National Disaster Medical Centre. He is also the member of the Japan Disaster Medical Assistance Team Secretariat and is on the Japan Disaster Psychiatric Assistance Team Secretariat. They both provide and are paid to deliver the PFA training to other organisations. No other potential conflicts of interest were disclosed. [19]


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