Professional Approaches Related to the Abuse Phenomenon
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Thus, we focus on the heterogeneity of the phenomenon (heterogeneity of the notion of "child maltreatment", heterogeneity of the classification criteria, heterogeneity of the different approaches that are related to maltreatment and the heterogeneity of the causes and consequences) and on the complexity that gives rise to that heterogeneity to define the child abuse and neglect.
In children and adolescents, child abuse and neglect can produce a decline in their biological, psychological and social functions. Child maltreatment in childhood and adolescence is recognised as an important psychopathological risk factor and is associated with poor psychological function in childhood and adolescence and adulthood. In this respect, we emphasise that it is wrong to believe that current knowledge has enabled the identification of clearly differentiated consequences for each type of child maltreatment. There is a high degree of co-morbidity among the different types, in such a way that many children experience more than one form of maltreatment and display common consequences. Moreover, it still needs to be clarified whether child abuse and neglect produces a general vulnerability towards psychopathology, in such a way that other factors would be responsible for the form finally adopted by psychopathology.
The first problem we encounter when studying child abuse and neglect is that of its definition [1-9].
Historically, the definition of child abuse has passed through different stages. At first, it was the academics and professionals attending the cases of child maltreatment who tried to define child abuse and neglect by focusing on the characteristics of the maltreated children [10]. At the beginning of the 1990’s, there was still a lack of consensus from the scientific community on a common definition of child abuse and neglect [11]. Despite vigorous debates on this matter, little has been achieved to provide a clear, reliable, valid and useful definition of child abuse and neglect [13].
Problems in proposing effective operational definitions include factors such as the lack of social consensus on unacceptable or dangerous parenting styles or actions; the lack of certainty on the appropriateness of defining child abuse and neglect according to the adults’ behaviour, to its effect on the children, or to a combination of both; the controversy over whether damage criteria should be included in the definition of maltreatment, and the confusion over whether similar definitions should be used for scientific, legal and clinical purposes [13].
Based on ideas set out by Aber and Zigler [1], Cicchetti and Barnett [3] and Zuravin [9], Palacios, Moreno and Jiménez [7] consider that main difficulty in defining child abuse lies in the
The generic label of maltreatment includes a significant variety of types (physical abuse, child neglect, sexual abuse, etc.) and subtypes (e.g. physical abuse would have subtypes like burns, blows with injuries, drowning, etc.) on which no unanimity exists between researchers [14,7].
Various authors [15-17] postulate that child abuse and neglect can be conceptualised as a continuum. Thus, in its most restricted form, we would encounter definitions of child abuse and neglect that only include intentional and severe physical abuse and, in its broadest form, we would have the definitions that include everything that could interfere in the child’s optimum development [18,19].
Initially, the concept of child maltreatment was restricted to the “severe physical harm generally caused by one of the parents or caregivers” [20]. This definition excluded other forms of maltreatment such as sexual abuse, cases of child neglect and emotional maltreatment, except when they led to physical injuries. This early research led to an increase in the scientific community’s interest in child abuse and neglect as a focus of study and concern. In a short time, the definition of abuse was extended to include emotional deprivation, malnutrition, child neglect and sexual abuse, and the consequences derived from physical and emotional abandonment were evaluated. This extension of the definition of child abuse and neglect contributed to consolidating the idea that not all abusive parents wanted to destroy their descendents and considered the social factors as determining factors in explaining the etiology of child maltreatment [3,21].
Based on research and studies carried out in the 1980’s, broader conceptualisation of child abuse and neglect has progressively been constructed [1,22, 23], defining it as all actions carried out by the caregivers, which significantly interfere in the child’s optimum development and do not adhere to social standards. This conceptualisation contemplates aspects such as neglecting the physical-biological, cognitive, emotional and social needs, and the different types of child maltreatment are also classified.
The heterogeneity of the phenomenon is not only related to the conceptualisation of the different types of child maltreatment, but also to the areas in which it takes place. Thus, we speak of child abuse and neglect in the family context, in the social context or in development contexts outside of the family microsystem and in the institutional area, as is the case of the context of schools or residential care centres, etc. [14].
Important discrepancies exist between the criteria on which the identification of child abuse and neglect should be based. According to Palacios, Moreno and Jiménez [7], "the presence of child maltreatment can be decided by considering the intentions or consequences; it may require evidence or be based on suspicions; it may or may not establish strict frequency of occurrence criteria, distinguishing between isolated episodes and recurrent behaviour; it may or may not be set against dominant social perceptions, which tend to establish borders between discipline and physical abuse, for example”. The use of one criteria or another would lead to essential modifications in the statistics, the conclusions on the etiology, the prevention models and the intervention guidelines in cases of child maltreatment [14].
An adequate approach to the definition of child abuse and neglect should take into consideration the concept of intentionality [21]. Kempe, Silverman, Steele, Droegemueller, & Silver [20] recognise the importance of this aspect in their definition of abuse (“… any child who receives non-accidental physical harm as a result of actions or omissions by their parents or caregivers”). Another significant aspect of the criteria to be considered when defining child abuse is the aspect regarding the consequences that the child maltreatment would have on the child. According to De Paúl [24], we would have to consider three basic issues when defining child abuse:
The frequency of abusive behaviour and the chronicity of such conduct are important factors when considering behaviour to be abusive or not, as well as their severity [25]. Moreover, as it is a phenomenon that is defined in the community, an adequate definition of child abuse and neglect must implicitly recognise the importance of community and cultural standards [26-27]. It is impossible to discriminate between abusive and non-abusive parents, if you do not take into account the standard community values or the social representation of the abuse. For this purpose, it is necessary to consider that cultures are substantially different from each other in the guidelines for bringing up children, the degree in which childhood is recognised as a stage of development that deserves special attention, the conditions considered necessary for healthy development and the rights recognised to children [28].
Five approaches or perspectives are distinguished, which have had a notable influence on the definition of child abuse and neglect: The medical approach, the legal approach, the sociological approach, the research perspective, the subjective approach and the ecological perspective. Table 1 combines the determining factors and the essential objective of each of these approaches.
The
The definition of the medical approach on child abuse and neglect is closed and essentially limited to the most severe cases of abuse, documented with x-rays that provide proof of injuries such as multiple fractures and subdural haematomas. From this perspective, the treatment of the disorder from which the abusive parents are believed to suffer takes on great importance. According to Barnett, Manly, & Cicchetti [31], by grouping child abuse with other children’s illnesses, the medical community releases society from any responsibility in the etiology of the abuse and provides an optimistic view of the problem which is conceived as a phenomenon that can be resolved through research and treatment focused on the abusive parents.
In the
The theorists of the sociological perspective stress the importance of counting on public opinion and the professionals’ opinion when defining what unacceptable parental behaviour should be and they emphasise the importance of knowing society’s role in the perpetuation of child maltreatment. Furthermore, the sociological perspective proclaims a more open definition of child abuse and neglect which includes a wide range of parental actions that have negative consequences on the child, such as child neglect in all its forms.
Medical | Parents’ characteristics, adjustment of the parents or caregivers. | To identify and cure the abuser’s psychopathology. |
Sociological | Actions of the parents or caregivers. | To label and control the social deviation. |
Legal | Evidence of physical and psychological harm on the child. | To create a legal child protection system. |
Research | Environment. | To guide the research on multilevel processes that determine the child’s development and promote social programmes and policies that favour adaptive human development. |
Subjective | Perception of the actions. | To discover the subjective experience of the victims of maltreatment and promote the necessary therapeutic actions for their treatment. |
Professional Approaches Related to the Abuse Phenomenon
In the
From the
Lastly, from the
Taking into account the number of approaches that exist, it is not surprising that different professionals access the problem of maltreatment along different routes, either by using their own classification criteria and/or their own detection procedures and placing more emphasis on some aspects rather than others [1,4,36]. In this way, the researchers, social workers, health workers, educators and the Child Protection Services frequently have different and often contradictory views about the diverse aspects regarding abuse, which substantially respond to their own objectives. Thus, the child abuse and neglect can be considered as a medical problem, which needs to be diagnosed and treated; as criminal conduct that needs to be defined in legal terms and punished; as a social problem that needs to be analysed as a social phenomenon; as a problem of child protection, which requires the resources and intervention of the Child Protection Services; and as a family problem, which needs to be understood in the context of the family dynamics [37-38].
Zuravin [9] suggests that, insofar as research is concerned, the studies that focus on specific acts that harm the child may be the most appropriate. The challenge of researchers is to develop a precise operational definition that minimises the lack of agreement among professionals. This lack of consensus on what constitutes maltreatment greatly obstructs the communication and collaboration between the respective fields of intervention.
According to Zigler and Hall [18], the absence of a consensus on the definition of child abuse and neglect could be explained, at least in part, by the lack of agreement to accept that one single definition is not capable of meeting all the aspects that the social scientists and the social services professionals consider relevant in order to conceptualise the maltreatment. Aber and Zigler [1] propose the development of three different categories of definitions: legal definitions, definitions for the management of cases and definitions for research. In any case, the way in which child maltreatment is defined can affect factors such as the classification of the cases and their severity, decision-making regarding the legal and social actions that must be undertaken (by whom, how and at what time) and even the perception of who is maltreating, who is maltreated, either by themselves or by others [18]. According to Giovannoni and Becerra [5], the lack of definition can lead to the situation of some children and adolescents who require protection not being detected, whilst other children or adolescents, who have not been maltreated, are inadequately classified and subjected to unnecessary treatment and intervention.
Early research developed to clarify the etiology of child abuse focused on the abusive parents. Thus, numerous authors have suggested that child abuse and neglect is produced as a result of the actions of perverse parents with mental health problems [39-41]. Other authors have emphasised the importance of the stressful interactive role between the environment, the abuser and the abused child [30,42-44]. Several authors have focused on the children’s characteristics (age, physical health, behaviour, etc.) as factors that can provoke the maltreatment from caregivers [45]. Multi-factor models have also been developed, such as the Integrative-Ecological Model [33], the Transactional Model [25] and the Ecological-Transactional Model [13] which represented a considerable advance in knowledge on the etiology of child abuse and neglect.
As regards the consequences of child abuse and neglect, it is not surprising that, depending on the perspective adopted for its definition, the professional approach and the explicative model on the causes of the maltreatment, the results found are also diverging.
Based on this context, the following definition of child abuse and negelct is proposed:
One of the most important aspects in the detection and prevention of maltreatment is the social representation that the members of a particular society have regarding this problem. The social representation of child abuse and neglect has also experienced an evolution in which ideas, beliefs and distortions have gradually been ruled out which would explain seminal aspects of child abuse and neglect. We will now take a look at them:
Children in a situation of vulnerability constitute a social problem that affects all societies of the world. Throughout history, violence against children has been practiced in many ways: physically and emotionally, through sexual and labour exploitation. Therefore, child maltreatment is not a new phenomenon; it has been around since the beginning of time. History documents that the problem of child abuse and neglect is present from the start of civilisation and that, despite this, abusive conducts have for a long time gone “unnoticed” for families and for communities [58-60].
From the social discovery of the abuse phenomenon, different governments and societies have aimed to carry out research to discover the real scope of the problem.
The most contrasted data on this matter comes from the United States and Great Britain. For instance, according to the governmental statistics published in the United States [12,61], it is estimated that 1.8 million U.S. children may be the victims of child maltreatment every year, of which around 800,000 are cases that are actually confirmed. This data was collected from the Child Protection Services, to which we should add the cases that are not detected by these sources and/or are not reported.
In the United States, the rate of victimisation for every 1000 children is 12.4, whereby it is children under three who display the highest rates of victimisation; that is to say, 16 children are maltreated per 1000 [62]. In Great Britain, the rate of child abuse and neglect, in children under 18 years of age is 2.8 children per 1000, whereby the highest percentages are found in children under one (7.1 per 1000) [63].
Besides the negative consequences it has on the victim, child abuse and neglect also has important consequences for society. The price paid for child maltreatment is very high; it has a direct cost (e.g. hospitalisations, social and judicial action, victim support programmes, child protection measures, etc.) and an indirect cost (pain, decrease in the quality of life, a less healthy and positive society, etc.). For instance, it is estimated that in the United States, child maltreatment annually generates costs to the value of 56 billion dollars [12].
Child maltreatment can produce a decline in biological, psychological and social function in children and adolescents. Maltreatment in childhood and adolescence is recognised as an important psychopathological risk factor and is associated with poor psychological function in
As we have already mentioned, many different difficulties exist to adequately classify the phenomenon of child abuse and neglect. In this respect, it would be wrong to think that current knowledge has allowed us to identify clearly differentiated consequences for each type of child maltreatment. There is a high degree of co-morbidity between the different types, to the extent that many children experience more than one form of maltreatment and demonstrate common consequences [79-80]. Furthermore, it still needs to be clarified whether child maltreatment produces psychopathology in children or whether it generates general vulnerability towards psychopathology in such a way that other factors would be responsible for the type of psychopathological deviation eventually adopted.
Despite these limitations, many studies have found an association between different types of child maltreatment and various psychopathological symptoms in adolescence and at the beginning of adulthood. We will now briefly focus on the psychopathological consequences associated with each type of maltreatment.
Being physically abused in childhood is a risk factor associated with psychopathological problems in adolescence and adulthood. Numerous research studies have demonstrated that physically abused adolescents and adults who were subjected to physical abuse in childhood have a high risk of displaying mental health problems [81-88].
By way of example, various studies have found that children and young people who are the victims of physical abuse and children and young people who are part of a violent family context, in comparison with children and young people who do not display these characteristics, display more emotional problems [69,84,89-91]. The research reveals that physical abuse is associated with a variety of emotional problems such as somatisation, depression, anxiety, hostility, paranoid ideation, psychosis, posttraumatic symptoms and dissociative disorder. This relationship is moderated by aspects such as the presence of multiple types of abuse and the gender of the perpetrator. The data obtained in the various research studies indicates that the combination of physical and sexual abuse has greater emotional consequences for the victims, generating above all, depression and anxiety [92-94].
An important association exists between being physically abused in childhood and an increase in the manifestation of self-harming behaviour and suicides in adolescence and adulthood [94-101]. However, different research studies have demonstrated that this correlation varies depending on the victim’s gender, the type of abuse and the level of parental conflict. For instance, it has been suggested that physical abuse in itself does not produce suicidal behaviour; however, when physical and sexual abuse are experienced together, this behaviour seems to be produced more frequently [102].
Much of the literature on child abuse and neglect has related physical abuse with delinquency and aggressive behaviour in adolescence. A close relationship has also been found between physical abuse and conduct disorder which, in turn, has been associated with delinquency and aggressive behaviour [84].
Having suffered child neglect in childhood has been associated with poor psychological function in childhood, adolescence and adulthood.
The results of studies such as the
Research on sexual abuse suggests that children and adolescents who develop in an abusive environment run the risk of suffering psychological difficulties that are characterised by emotional dysregulation. In particular, it has be found that children who are the victims of sexual abuse show internalising and externalising difficulties, posttraumatic stress disorder symptoms, personality disorders and problems in interpersonal relations with peers [61,106-110].
One of the most worrying aspects for the physical and mental health of the abused adolescent in their childhood is the strong association that exists between sexual abuse and suicidal conduct in this evolutionary stage [99]. The percentage of attempted suicides in the adolescent population of victims of sexual abuse ranges between 7.3 and 11.2% in girls and 3.2 and 4.5% in boys [99,112].
By way of example, in one of the most relevant research projects carried out recently in this field by Martin et al. [112], in which 2,485 adolescents participated, of which 7.4% had been the victim of sexual abuse, they discovered that 27.1% of the sample admitted having suicidal ideation (21.8% of boys and 33.6% of girls); 13.7% had planned to commit suicide (11.3% of boys and 16.4% of girls) and 4.5% of boys and 7.3% of girls had attempted suicide.
At present, sufficient evidence is available to confirm that emotional maltreatment in childhood is associated with mental health problems and adaptation problems in adolescence and adulthood [95,113-116].
Emotional maltreatment has been identified as a strong predictor of most psychological problems including personality disorders, anxiety, depression, dissociative symptoms, posttraumatic stress, physical symptoms, suicidal behaviour, sexual dysfunction, eating disorders and low self-esteem [32,74-75,95,114-123].
In Japan, the number of older adults requiring medical and nursing care is increasing, constituting a super-aged society [1]. This trend is exacerbated by the decrease in the active working population and is accompanied by a declining birth rate [2]. This situation in Japan and other countries, including for current and future rehabilitation services, increases the demand for nursing care of older adults. With that as a result, nursing staff shortages are becoming more serious [3, 4]. Therefore, it is necessary to bridge the gap between human resources and demand for services in health care. In addition, the number of patients with dementia is also increasing especially among the older adult population who need more engaged medical and nursing care [5].
There are plenty of reports on the benefits of animal therapy, which began in the USA in the 1970s [6]. One study conducted in patient with schizophrenia found that showed cortisol level was significantly reduced after participating in an animal assisted therapy session, which could indicate that interaction with the therapy dogs reduced stress [7]. Another study reported that measuring actigraphy increased sleep duration (min) when visitors were accompanied by a dog rather than the robot seal or soft toy cat [8]. Another study reported that animal therapy is associated with decreased impulsivity, aggression, and anxiety, and increased sociability [9].
Meanwhile, several studies have suggested that the robots used in robot therapy can improve the cognitive level and reduce the Behavioral and Psychological Symptoms of Dementia (BPSD) in patients [10, 11]. However, none of the studies have tested the robots on a large sample, meaning that their findings have limited generalizability [12]. Yokoyama reported the caregiver must play an intermediary role during robot therapy for older people with dementia [13]. For such therapy to be effective, it must be evaluated from the perspective of the user (an older adult with dementia) and the caregiver (a nurse or other professional caregiver).
Osaka and other studies [14, 15, 16] analysed Heart Rate Variability (HRV) and accelerometer data in two-second increments and showed real-time results. As such, changes in autonomic activity and the intensity of physical exercise could be determined during the implementation of robot therapy. This device sensor was designed to be small size and thus carry only minimal burden for older persons. Another advantage was that it could transmit data to a computer wirelessly, allowing the tested subjects to move freely. It is also possible for an observer to supplement the data by recording through the participant observation of the relationship between the older person and the caregiver during the intervention.
Limited study on robot therapy in older adults with dementia has assessed the intervention objectively and comprehensively by using participant observation and HRV and accelerometer data. The study by Osaka et al. [14] is valuable in that it provides objective data to those involved in caring for older adults with dementia (caregivers and health care professionals involved in rehabilitation), thereby allowing them to review their interventional approaches in relation to standard. Moreover, if it can be demonstrated that low-cost robot therapy is effective, then the study will offer valuable data for developing policies on cost-effective robotics in dementia care.
This chapter explains the robot therapy program for patients with dementia from the viewpoint of its framework and effectiveness.
The American Veterinary Medical Association (AVMA) defined Animal Assisted Therapy (AAT) as one of the Animal Assisted Intervention (AAI) [17]. There are various animals are used for AAT, such as canines, felines, and equines, depending on purpose of treatment, but the most frequently used animal for AAT is the dog [18]. The AAI for older people can be expected to have the effect of suppressing the decline in cognitive functions and improving the peripheral symptoms (depression, agitation, aggression) and insomnia associated with dementia [10] .
The number of robot therapy articles for rehabilitation or recreation that include communication is increasing. Considering the entity of a care robot, several definitions are recently offered [19]. However, there is no consensus about their findings. The devices and applications in those studies have yet to be integrated into widespread clinical use [20]. Robot therapy functions include providing therapy, educate, enable communication, and so on [21]. A pilot study showed that by interacting with Paro, a seal-like robot, the communication and interaction skills, and activity participation of older people improved [22]. Another study reported that the use of Paro is associated with improvement in emotional state and social interaction and reduce the challenging behaviours among older people [23]. Research showed that robot therapy has the same effect on people as animal therapy [21]. The effects of robot therapy and animal therapy influence the physical, cognitive, and mental conditions of the users, especially the older people.
The Model for the intermediary Role of nurses in Transactive relationships with Healthcare robots (MIRTH©) [24] explains the engagement processes that are characteristic activities of older adults with dementia, the nurse as mediator, and the communication robot (Figure 1). Healthcare robots` function in transactive relationships among patients and nurses. The nurses\' role as intermediaries is integral to facilitating the interaction between these robots and the older adult patients who are in transactive relationships. The effects of the intermediary role are especially prominent with low-fidelity robots in use today. The functional abilities of the nurse as intermediary include knowledge of advancing technologies regarding robots that foster quality care.
Illustration of MIRTH©.
Nurses as intermediaries should: (1) have an accurate awareness of each of the functions of robot performance and the usefulness of each function relevant to patient care situations; (2) create relationships with healthcare robots so that they can promote the health and safety of older adults while increasing their enjoyment through physical and social activities; and (3) seek safe, secure, and competent ways to facilitate using healthcare robots for healthcare. In essence, intermediaries should prepare the environment for using healthcare robots. In doing so older adults can use healthcare robots for complicated operations, with the nurse as intermediary monitoring the effective use of robots and identifying clinical problems while working with healthcare institutions to address preventable healthcare problems.
The MIRTH© model has five assumptions:
It is the responsibility of nurses as professionals to practice nursing grounded in discipline-related knowledge of nursing. The most important attribute in nursing is the relationship expressed as caring. Robot performance requires an intermediary for their effective and safe use [14, 15]. This assumption expresses the importance of the functions of intermediaries in robot-human situations. The intermediary is inextricably linked with the patient and the healthcare robot;
Robots are used for rehabilitation, recreation, and caring of older adults [16]. This assumption describes the variety of functions of robots specifically for older persons;
High-quality care with robot-human relationship is guided by ethical and moral standards of nursing [25]. With human beings as patients and robots as integral to human health care, this relationship must be linked with considerations of beneficial effects founded on justice and goodness;
Technologies of health and nursing are elements for caring [26].
The utility of advancing technologies founded on competent expressions of caring provides opportunities for innovating human caring practices;
Nursing is both a discipline and a profession [27].
It is the responsibility of nurses as professionals to practice nursing grounded in discipline-related knowledge of nursing. The interactive engagement, the lived experience of the caring between patients and nurses, gives meaning to the nursing relationship, the most important attribute in Nursing.
Framework for robot therapy program.
It has been reported that therapies using animals have a healing effect on patients and an improvement in motivation for performing activities [28, 29]. Park et al. performed a meta-analysis on animal assisted and pet robot interventions which suggested that AAI and Pet Robot Intervention (PRI) significantly reduce depression in patients with dementia. It report, nine studies were analysed and seven of them showed confirming results. The outcome measurements used scales such as functional tests and depression scales. In the two studies, pulse oximetry, pulse rate or galvanic skin response (GSR) (electric skin response) were combined and evaluated as physiological indicators [10].
Intervention therapies using animals for hospitalized patients is not uncommon. Studies by Osaka and others [14, 15, 16] suggest that robot therapy is expected to have a more healing effect on patients and improve motivation for activities for older people by using an expensive humanoid robot such as Pepper from an inexpensive communication robot.
Figure 2 shows the framework of the effectiveness using robot therapy by Osaka. Robot therapy uses humanoid and animal-like robots. The robot therapy is expected to affect the therapeutic goals, including physical effect (e.g., relaxation, motivation), physiological effect (e.g., improvement of vital signs), and social effect (e.g., stimulation of communication among inpatients and caregivers) [30]. By interaction with humanoid or animal-like robot, the older adults who are not physically active may have the improvement of their physical condition [31], such as hugging and stroking them, talking with them, and participating in any activity involving the robot.
The framework for robot therapy program.
The intermediary role of the nurse involves mediating and connecting patients with robots. It also involves a focus on ethical and moral issues inherent in nursing situations that include activities by healthcare robots [25]. Specifically, the intermediary person was in charge of connecting the subject with the robot. An intermediary can support older persons to interact well with the robot according to their physical condition. Also, they can provide joy for older adults when interacting with the robot, and among other persons. Moreover, in this interaction, the cognitive function of older persons with dementia may improve as they are able to communicate or have a conversation with robots [32]. Thus, intermediary can ask older adults if they are having fun, and if they feel like they have a companion in their daily life.
In Japan, various robots are produced and introduced for robot therapy in hospitals and other health care facilities. However, the performance and functions of these robots are often of lesser fidelity and functionality than expected by some facilities, thereby preventing their continued use after the initial introduction [33, 34]. The dialogue between healthcare robots and older adults was difficult without an intermediary role because of the difficulty for older adults to understand the robot because of the speed of its speech and tone of vocalization [15]. Oftentimes, because of this robot inefficiency, it is essential to consider instituting the intermediary role of nurses to engage the robot with the older adults. This nurses’ role can enhance utility and instigate efficiency even if the robot is not sophisticated enough to be useful for rehabilitation and dialogue with older adults.
The subjects of the study were two female older persons who were diagnosed with dementia using the Hasegawa’s Dementia Scale-Revised (HDS-R) [35] instrument. Both were in their 80s and met the following inclusion criterion (diagnosed with dementia with a certain score): the HDS-R between the score range of 3-20 points. Exclusion criteria included older people who could not communicate verbally, those who could not interact with dogs and small stuffed toy robots, those who could not wear a portable electrocardiogram, and those who could not consent from their families.
Subject A received the animal therapy intervention. She was in her 80’s and diagnosed with dementia with a HDS-R score of 8 points.
Subject B received the robot therapy. She was in her 80’s and diagnosed with dementia with a HDS-R score of 10 points.
Data collection occurred on a single day, in a single observation period for each person; data collection for animal therapy was on October 10, 2017, and for robot therapy was October 25, 2019.
As a prediction of the data comparison results, both animal therapy and robot therapy have the same effect on the physical, mental, and cognitive functions of the older person. Each subject data was extracted from animal and robot therapy, and both effects were compared. Data extraction methods were indicated in Figures 3 and 4.
Animal therapy protocol. Animal therapy data extraction method. Before therapy 10:24:00 ~ 10:28:58 (5 minutes in total); During therapy 11:32:00 ~ 11:36:58 (5 minutes in total); After therapy 11:37:00 ~ 11:41:58 (5 minutes in total). As described above, a total of 5 minutes of data was extracted before, during, and after the therapy.
Robot therapy protocol. Robot therapy data extraction method. Before therapy 10:05:00 ~ 10:09:58 (5 minutes in total); During therapy 10:26:16 ~ 10:27:58 (1 minute 41 seconds in total); After therapy 10:27:58 ~ 10:28:40 (42 seconds in total). As described above, it was set to extract a total of 5 minutes of data before, during, and after the therapy. However, due to data constraints, data during and after the therapy was less than 5 minutes. The measurement time was sometimes short because the measurement was performed according to the procedure of robot therapy in the clinical setting. In addition, an artifact was included in the electrocardiogram due to the subject’s movements, so it was not possible to obtain all the data for 5 minutes. This was the limitation of this clinical study.
The data collection procedure was performed following the Private Information Protection Law, with approval from the Tokushima University Hospital Ethics Board (approval number 2039) and Mifune Hospital (approval number 20170201-1). The purpose and methods used in the study were explained to all subjects and their guardians. Subjects were assured that their personal information would be protected and would only be used for research purposes, and that anonymity would be maintained in the report.
As described below, a total of 5 minutes of data was extracted before, during, and after the therapy (Figure 3). In the animal therapy, the subject was an older person with dementia who was admitted to the facility. Animal therapy was performed by a therapist after music therapy. The animal used was a dog.
As described below, robot therapy was set to a total of 5 minutes of data before, during, and after the therapy. However, due to data collection constraints, it could not obtain data for 5 minutes during and after the therapy (Figure 4). In the robot therapy procedure, the subject was an older person with dementia. The robots used were Kabo-chan (W23×H28×H28 (sitting high), weight 680g) and Mi-chan (W25×D20×H 30 (sitting high) 30cm, weight 390g). These robots can talk, sing, and slightly nod charmingly in response to touch and spoken words. These robots have sensors that are installed in the mouth, head, hands, feet, and main body. These sensors allow the robots to verbally respond to any sounds and movements.
Heart Rate Variability (HRV) data were assessed at various frequency bands using an HRV software tool (MemCalc/Bonaly Light: GMS, Tokyo, Japan). The low frequency (LF) and high frequency (HF) bands in heart rate variability (HRV) reflect sympathetic and parasympathetic nervous systems which is commonly accepted as the activities of the autonomic nervous system [36, 37]. In a continuously recorded data, inter-beat (R-R) intervals were obtained for a 1-min segment using the maximum entropy method. In this study, the two major spectral components of HRV, the variances of the Low-Frequency (LF: 0.04 - 0.15 Hz) band and High-Frequency (HF: 0.15 - 0.4 Hz) band, were calculated. The HF data can be used as an index of parasympathetic nervous activity, and the LF/HF ratio can be used as an index of sympathetic nervous activity.
An optimal level of variability within an organism’s key regulatory systems is critical to the inherent flexibility and adaptability or resilience that epitomizes healthy functioning and well-being [38]. HRV is the change in the time intervals between adjacent heartbeats. It is an emergent property of interdependent regulatory systems that operate on different time scales to adapt to environmental and psychological challenges. The heart’s rhythms are characterized as reflecting both physiological and psychological functional status of internal self-regulatory systems. Lowered parasympathetic activity, rather than reduced sympathetic functioning appears to account for the reduced HRV in aging [39]. This can be observed when persons engage in meeting a challenge that requires effort and increased sympathetic activation. Alternatively, it can indicate increased parasympathetic activity as occurs during slow breathing [40]. With psychological regulation, lower HF power is associated with stress, panic, anxiety, or worry [41].
In this study, the use of HRV was critical in measuring the psychological functional status and emotional experience of older persons particularly those with dementia. Changes in autonomic nervous activity were determined using HRV. Heart Rate (HR) -mean, HF, LF/HF, NU % (ratio of sympathetic nerve components), and body movement (acceleration) are shown in the graph, it shows the relationship between subjects’ interaction with dog or robot doll during intervention. The results were recorded graphically, enabling visual assessments and measurements (Figure 5).
Heart Rate Variability (HRV) data were assessed at various frequency bands using an HRV software tool (MemCalc/Bonaly Light: GMS, Tokyo, Japan).
The data were visually recorded enabling graphic visual assessments and measurements. The analysis of the HRV allowed the evaluation of autonomic nervous function.
After the movement of the dog (animal) trunk, the sympathetic nerve recordings became predominant. Afterwards, it was the parasympathetic nerve that became predominant. Changes in autonomic nervous activity can be confirmed from the data recorded in the accelerometer and the results of heart rate variability analysis as the body moves (Figure 6).
The experimental data before the animal therapy (Subject A). Note: HR-mean; Heart Rate mean, HF; High Frequency, LF/HF; Low Frequency / High Frequency, NU; Normalized Unit, Movement; the body movement. The unit of vertical axis. HR-Mean; Beat/min, HF; msec2, LF/HF; Nothing, NU (%), Movement; G. The unit of horizontal axis; hour: min: second.
Subject A\'s HRV data showed sympathetic nerve predominance after touching the dog, after which it showed a sympathetic nerve predominance. Before touching the dog for the second time, the pulse rate decreased, and the parasympathetic nerve became predominant. By interacting with the dog, fluctuations in heart rate were observed, and a balance between sympathetic and parasympathetic nerve activities was observed. Therefore, it was considered that effective stimulation could be provided by contact between the subject and subject A through interaction with the dog (Figure 7).
The experimental data during animal therapy (Subject A).
Figure 8 shows the alternating sympathetic and parasympathetic activities before the robot therapy.
The experimental data before robot therapy (Subject B).
After holding the robot, it was observed that the parasympathetic nerve activity became predominant, and then subsequently, the sympathetic nerve became predominant. In addition, after holding the robot for the second time, the parasympathetic nerve became predominant.
Sympathetic nerve activity was predominant before the start of the therapy. However, during the therapy, the sympathetic nerve activity predominance continued immediately after holding the robot was observed. Autonomic nervous activity was stable at the end of the therapy (Figure 9).
The experimental data during robot therapy (Subject B).
In both animal therapy and robot therapy, stable heart rate and body movements were confirmed in all processes before, during, and after therapy. These were during the awake state, and the awakening could be confirmed visually by participant observation and recorded video data.
In the animal therapy, the LF/HF value was high even before the start of therapy, and the predominance of sympathetic nerve activity was confirmed. During the therapy, the LF/HF value increased immediately after the first touch of the dog, immediately before the second touch of the dog, and immediately after the touch. These activities confirmed that the sympathetic nerve activities were dominant. At the end of the therapy, the LF/HF value was high for about one minute, confirming the predominance of sympathetic nerve activity.
In the robot therapy, the subjects had high LF/HF values and predominant sympathetic nerve activity before the start of the therapy. In addition, during the therapy, high LF/HF values that continued immediately after the robot was first held were observed, confirming the predominance of sympathetic nerve activity. After the therapy, the autonomic nervous activity became stable.
Animal therapy was conducted by the therapist and pianist in the healthcare institution. After music therapy, the therapist brought a dog to the older person (Subject A). Her expression can be seen from Figure 10. From the observation, it was evident that the older person spontaneously touched and stroked the dog. Subject A seemed happy touching the dog and intermediary bring the dog near her.
Subject A’s scene during the animal-assisted therapy. During animal therapy: she spontaneously stretched her arms, stroked dog’s body, and smiled from beginning to end.
The nurse intermediary was in charge of connecting Subject A with the dog. The intermediary asked Subject A some questions: “Do you like dogs and animals” and “Have you ever owned a dog?” Subsequently, the intermediary asked, “May I bring the dog closer to you?” Since Subject A’s mobility requires a cane when walking, and her daily activities is slow due to old age, the intermediary held on to the small dog, and brought it near to subject A\'s chest (Figure 10) to make it easier for her to touch the dog. Subject A replied that she had a dog, and that she liked dogs and had many dogs, and that one of her dogs was as small as the size of dog used for animal therapy. Then the intermediary picked a conversational topic, and the dog waved its tail seemingly to mean that “This dog seems happy.”
Subject B was in the robot therapy section. It was observed that older persons seemed happier during their interactions with robots. Subject B touched and held the robots. She stroked their legs and arms, and head as if the robots were her grandchildren. When the older person saw the pictures displayed in the television screen, they turned the robot to see the TV screen and she exclaimed to the robot “Look at the TV!” After that, she asked the robot some questions like “Do you like animals?” And she stroked the robot’s head. When the robot said, “Thank you”, she laughed. When the robot sang, she clapped her hands and said, “You’re so good!” (Figure 11).
Subject B′ scene during robot therapy. During robot therapy: she hugged robot, smile and talked to the robot.
The intermediary asked subject B about her impression of robots and if she was interested in the robot. Subject B was interested in the robot and listened to what the robot had to say. She replied, “around 80 years old” to the robot question, “How old are you?” However, there were some occasions when she could not hear what the robot said. Therefore, the intermediary had to repeat what the robot said. Since the inexpensive robot used had limited conversational word content, the intermediary supplemented the conversation content and enhanced the interval in the conversation. Also, since the robot can sing songs, the intermediary tried to sing thereby illustrating that it was the robot that was singing. Subject B listened intently while the robot was singing, and she enjoyed singing to the tune along with the robot. On one occasion, the intermediary informed subject B that she could touch the robot. She asked. “Would you like to pick up robot Mi chan?”
Conversations with the robots illustrated that nurses as intermediaries can show that emotional conversations establish effective transactive engagements between subjects and robots.
The comparison of AAI and Robot therapy showed that each method has its benefits and shortcomings indicating that the two methods could potentially complement each other. Both therapies were shown to have a possibility of beneficial effects on the emotional wellbeing of patients with dementia. There is a possibility that if robot therapy using an inexpensive robot such as used in this study might be obtain the same effect as AAI, barriers peculiar to AAI such as zoonotic diseases, animal bites, and allergies can be avoided. In addition, it will be possible to use AAI and robot therapy properly while taking advantage of their respective characteristics and advantages.
This chapter explained the robot therapy program for patients with dementia from the viewpoint of its framework and effectiveness.
The electrographic data provided neurophysiological evidence of the influence of robot utilization on the autonomic nervous system activity of older adults with dementia. The examples described were demonstrations of studies, which captured how data were collected through different devices and specific procedures to describe, explain, predict, and prescribe phenomena, as evidenced from a rigorous analysis of data regarding human-robot interaction with nurses as intermediaries.
The typical examples show that animal therapy has almost the same effectiveness as robot therapy among older people. It is clarified that robot therapy can be expected to have a healing effect on patients, improve motivation for activity, and increase the amount of activity, similar to animal therapy. Furthermore, it was essential to consider the intermediary role of nurses for connecting the robot and older adults and their role, even if the robot is not sophisticated enough to be useful as a humanoid nurse robot for rehabilitation and dialogue with older adults.
Thus, robot therapy could be considered another important intervention in the challenging health and innovative care practices needed in the care of older persons. Nevertheless, two issues were realized regarding living with a human-type communication robot as a strategy for rehabilitation care and to improve cognitive functions and prevent cognitive decline in the older adults. In this regard, robot therapy has not been generalized, and more analysis, descriptions and discussions about its practical utility are required.
This work was supported by JSPS KAKENHI Grant Numbers JP17K17504. We would like to express our sincere appreciation to all the patients and participants who contributed to this article. With many thanks to Dr. Savina Schoenhofer for reviewing this chapter prior to its publication.
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