The Effect of
Socio-Cultural Context on
Conceptualizing Autistic Disorder
In the People’s Republic of China
Hung Hsiao, MA
Warner Graduate School of Education and Human Development
University of Rochester
Magyar, Ph. D.
Department of Pediatrics
University of Rochester
Hsiao, C.H. &
Magyar, C. (2006) The effect of socio-cultural context on
conceptualizing autistic disorder
in the People’s Republic of China International Journal
Rehabilitation. 11 (1), 51-60
of Modern Languages and Literatures
State University of New York, Oswego
Oswego, NY 13126
This essay reviews how
based variations in thinking, expectations, and even norms of social
influence Chinese psychiatrists’ conceptions, diagnosis, and treatment
mental illness, with a specific focus on Autistic Disorder (AD).
effects of the Chinese social-cultural context on the causal
diagnosis, and treatment of AD as well as conducting a line-to-line
investigation of the diagnostic criteria are prerequisites for the
understanding of how AD is manifested in the People’s Republic of China
(PRC). Whether an individual is less likely to be
having AD in the PRC because more criteria are required in the PRC, is
and should be the subject of future research. An understanding of that
diagnostic practice, as well as of the rationale and practice of
individuals with AD, would support the understanding of AD in a
study.<>Key words: Autistic Disorder; China;
Chinese Classification of Mental Disorders; Mental health;
conceptualization of Autistic Disorder in modern psychiatry is an
dynamic process influenced by a range of discourses and research. From
socio-cultural perspective, an individual’s thinking is rooted in his
culture and society (Bruner, 1986; Feldman, 1987; Stetsenko &
2004; Vygotsky, 1978), and as this applies to professional
conceptualization of Autistic Disorder (AD) is necessarily entrenched
society in which they reside. Psychiatric professionals apply a
scientifically based expertise and everyday thinking to link physical,
psychological, and environmental factors to the cause, diagnosis, and
of AD. Furthermore, culturally produced sign systems, such as language
written texts, constantly reinforce the collective meanings that
thinking of psychiatrists. Psychiatrists internalize collective
cultural beliefs, daily practices, role expectations, and social
justifications. Conversely, their thoughts about AD are transformed
meanings, which are shared by their particular psychiatric community,
fit specific social, cultural, and political milieus.
the effects of a
particular social-cultural context on the causal explanation, diagnosis
treatment of AD as well as having performed a line-to-line
investigation of the
diagnostic criteria are prerequisites to understanding how AD is
the People’s Republic of China
(PRC). To this end, we explore how culturally based variations in
expectations, and even norms of social behavior influence Chinese
psychiatrists’ conceptions, diagnosis and treatment of mental illness,
specific focus on AD. Our investigation of the socio-cultural and
contexts for the construction of AD in China
uses an ecological approach. We begin by briefly examining the history
mental illness in China,
and tracing the development of thinking regarding its cause, diagnosis,
treatment among psychiatric professionals and society in general. These
background details provide a context for understanding the very recent
classification of AD as a psychiatric diagnosis. We then analyze the
conceptualization of AD through its formal classification and
systems and conduct a qualitative analysis of the diagnostic criteria
for AD in
investigation provides an opportunity to generate better conceptual
and a more fruitful research outcome for a cross-cultural
diagnostic practice and treatment of AD.
Disorders in China
of mental illness in China
have evolved over centuries under the constant influences of the
cultural and political environments. Thinking
about the nature of autism, not the diagnostic term itself can be
to the beginning of Chinese history, and it is clear that this thinking
been based on Chinese society’s everyday understanding of mental
Below, we describe how Chinese psychiatric societies have
disorder over time. An understanding of Chinese
mental illness can further facilitate a cross-cultural understanding of
absence of appropriate identification and treatment for individuals
with AD (a
term interchangeable with Childhood Autism) is the result of the
practice and Traditional Chinese Medicine (TCM) of the 18th
century. First, the general
perspective was that mental
disturbances were the consequence of bad deeds perpetrated either by
by members of one’s family. The religious nature of this
meant that blessings for individuals with a mental disorder were sought
the gods in local temples (Yip, 2005a). Second, based on the ancient
of TCM, many Chinese attributed mental illness to an imbalance in vital
-- a cause rooted, at least in part, in the physical world. According
Fàbrega (2001), TCM attributes the causes of illness to a
between impairments of the circulative function of “qi1”and
in an organ or in a stream across the body and, based on a
understanding of phenomena among Heaven, the Earth, and Humanity, an
of the forces of “Yin” and “Yang,” thus implying that both
external/environmental and internal/personal factors influence the
mental functioning of individuals. A complicated metaphysics referring
elements of Metal, Wood, Water,
Fire, and Earth
was also used to explain sicknesses and their treatments (Chan, Ying,
The understanding of
mental disorders remained unchanged throughout the 19th
Individuals’ mental health problems were either unrecognized or
physical ailments by herbalist doctors. These herbalist doctors treated
patients using single or compound ingredients of Chinese medicine,
prescribed after a holistic assessment of the patient and the illness
1982). Then, in 1898, an American missionary established the first
institution in Guangzhou
1981; Yip, 2005b). Thereafter small asylums were founded in Beijing,
Shengyang, and Suzhou
Over time, a more westernized understanding of mental illness emerged
Chinese society. Even so, only a small number of individuals with
illness were treated in hospitals. Others were confined in prisons, and
majority remained at home and cared for by their families.
in the conceptualization
of mental disorders in the PRC were slowed by the unstable social,
political milieus of the early 20th century. China
was preoccupied with multiple distressing large-scale events: the
of the empirical Qing dynasty, devastating losses in the Sino-Japanese
revolution and the establishment of the PRC. Of particular significance
decade-long Cultural Revolution, during which collective political
replaced a more westernized treatment of mental disorder. As Yip
states, “Medical professionals identified clients with mental illness
brother’ to fight against ‘mental illness’ which originated from ‘evil
Capitalistic think’” (p.28). Mental illness was thus not thought of as
problem. As Allodi and Dukszta (1978) explain, “the official line is
mental illness is rare in China since the Revolution because of the
accomplishments of the preventive public health programs in controlling
parasitic, infectious and venereal diseases, and alcoholism, and
because of the
lack of social stress, (unemployment), and the ‘fine moral and social
tradition’ of the country” (p. 365). It was thought that political
and healthy life practices were the basis for preventing mental
illness. As a result,
discussions about, and investigations of, mental illness were limited.
was not until the nation
regained its strength in the late 1970s, that scientific thinking and
into mental disorders emerged and were integrated into an international
perspective. More specifically, with the Reform and Opening policy3
of 1978, the articulation of westernized thinking and psychiatric
once again reappeared, and with it, the establishment of an
discourse, a gradual shift in the understanding of mental disorder, and
diagnostic system and treatment modalities that had elements common to
psychiatric communities around the world began to be established in
individuals with mental disorders, however, were treated at a primary
level or at home due to the lack of psychiatric professionals (Chen,
of Autistic Disorder in the PRC
changes in the social and
political climates and the opening up to international discourse
Chinese psychiatric community and the public to construct an objective
of AD in the 20th century, although multiple political
continued to impede the recognition of AD. In 1982, Tao reported four
IA (Infantile Autism) in the PRC that supported the definition
developed by the
US National Society for Autistic Children (and subsequently approved by
American Psychiatric Association) that “autism has been found
world in families of all racial, ethnic, and social backgrounds” (Tao,
289). Moreover, Tao (1987) compared the
clinical features of IA found in fifteen Chinese individuals to the
in Kanner’s 1943 cases, suggesting that his findings “replicated those
Kanner and of Cantwell, Rutter, and Baker (1976) on the subject of
socioeconomic status of parents” (p. 289). He further suggested that
findings heralded the opening of a discourse between the United
States and the PRC. Both Chinese
and, at this stage, the urban public began to hear the term “Infantile
Autism.” It remains common, however, for
the public to form a direct sense of IA from its translation in
is “gu du zheng” (孤独症)
or “zi bi zheng” (自闭症). For many, the referential and
representational meanings of “gu du” and “zi bi” are “aloneness” or
“self-shut-off,” thereby suggesting a personality type rather than a
behavioral descriptions as suggested by Kanner (1943).
the philosophy of TCM and notions of Western psychiatry suggest two
causal interpretations of AD. As already explained, TCM implies a
mental illness related to vital and spiritual forces, as well as to
life practices in the social, cultural, and political milieus. The
that claim is related to the function of the total well being of the
individual, rather than of the brain (Chan et al., 2001).
However, the causal interpretation of AD
based on the Western psychiatric system is quite different. Certain
psychiatric professionals have adopted the research framework of
studies to conduct their research and to generate empirical findings
articulate the possible causal explanations of AD in the PRC. Samples
Lu and Yang (2004), who argue that children with AD have a neurological
mal-development in the embryonic stage; Guo and Liu (2003), who suggest
possible genetic abnormality of twin brothers; and Ke and her
colleagues, who conclude
that sensory integration dysfunction is related closely to Pervasive
Developmental Disorders (Ke, Wang, Chen, Zhou, Jiao, Wang, Jin, &
classification and categorization of mental disorders has been
meet current socio-cultural needs in China.
Throughout the profound social reforms and the rapid development of the
of the last two decades, China
has moved towards becoming a modern nation. A set of operational
diagnosing IA was established in the Chinese Classification of Mental
and Diagnostic Criteria, Second Edition (CCMD-2; Chinese Association of
Neurology and Psychiatry, 1989). Although qualified by the questionable
inclusion of IA within the category of Childhood Schizophrenia, it was
significant milestone inasmuch as it indicated the achievement of a
understanding, an acceptance, and an acknowledgment of the
diagnostic practice in Chinese psychiatry (Zhang, Yang, Jin, Wu, &
1994). A national field trial of the CCMD-2, however, found that having
the diagnostic manual did not have a positive impact on diagnostic
the early 1990s. According to Zhang and his colleagues, “childhood
were a somewhat weaker classification because a great proportion of its
was introduced directly from foreign systems of diagnosis, and in
most of the participants in the field trial were not engaged in child
psychiatry and they were not familiar with it” (Zhang et al., 1994, p.
1995, the Chinese Classification of Mental Disorders and Diagnostic
Second Edition, Text Revision (CCMD-2-R; Chinese Medical Association,
published to reflect a classification of mental disorders similar to
the Diagnostic and Statistical Manual of Mental Disorders, Fourth
(DSM-IV; American Psychiatric Association [APA], 1994) and the
Classification of Diseases, Tenth Revision (ICD-10; World Health
[WHO], 1990). In the CCMD-2-R, Childhood Autism was classified as a
disorder under the category of Pervasive Developmental Delay.
The CCMD-3 is the
current diagnostic guideline that includes psychiatric perspectives on
AD in China.
It is utilized to: “(1) improve the service for the patients, and to
needs of (our) society, (2) fit in with Chinese cultural background and
tradition, (3) maintain the superiority of CCMD previous versions, (4)
ICD and DSM systems, and (5) be concise and manipulative” (CCMD-3,
173). The diagnostic criteria of AD were satisfied in a national field
(Li, Su, & Luo, 2002), and the term AD gradually gained publicity
Chinese clinical practice and research. Accordingly, the number of
for suspected AD increased dramatically. In 1999, AD became the most
consultation and diagnosis of clinical cases in the Institute
of Mental Health at Peking
University (Guo, Zhang,
Given that Chinese
health professionals did not recognize AD until the late 20th
century and the continuing lack of resources, funding, and trained
professionals, the development of diagnostic tools and treatments
AD remains limited in the PRC. A decade after Tao’s report of four
IA, Western diagnostic tools such as the Autism Behavior Checklist, the
Psycho-Educational Profile, and the Childhood Autism Rating Scale, were
for AD assessment in the PRC (Lu, Yang, Shu, & Su, 2004; Sun, Wei,
Yuan, Yang, Jia, & Yan, 2000; Wong, Hui, Lee, Leung, Ho, Fung,
2004; Yang, Huang, Jia, & Chen, 1993). Not until the 21st
century, Chinese psychiatric professionals developed their own
assessment tools that are reliable and valid for the conditions of
individuals with AD (Liu, Wang, Guo, Yang, & Jia, 2004). However,
advancement in the diagnosing of individuals with AD was not
development of effective treatments. Many individuals with AD do not
benefit of appropriate intervention programs at the public school
Zhou, 2005). According to McCabe (2003), “educational opportunity and
experiences for children with autism vary as a function of parent
a school’s willingness and ability to serve these students” (p. 20).
and professionals who are aware of Western psychiatric practice
various types of intervention program for individuals with AD without
funding support. Treatment programs that include applied behavior
(ABA), discrete trail training (DTT), and sensory integration training,
as acupuncture and herbal medicine (Clark & Zhou, 2005), are
on the parents’ beliefs and the philosophy of the organizations or
sectors. For instance, the Beijing Xingxing Yu Education Institute for
with Autism was established under such initiative. The organization and
of individual with AD work together to provide ABA and DTT to
individuals with AD (McCabe & Tian, 2001). There remains a pressing
for legislative support and effective treatment programs for
Criteria of Autistic Disorder in the CCMD-3
effect of socio-cultural
context on the conceptualization of AD can be demonstrated by examining
construction of diagnostic criteria. The Chinese psychiatric community
created reliable and culturally valid diagnostic guidelines for AD. We
a Chinese-English translation of the Chinese version of the diagnostic
for AD in the CCMD-3 to reveal how professionals assess behavioral
characteristics associated with AD in the PRC and to better portray how
psychiatric professionals conduct their diagnoses, since the
and the Chinese-language versions of the diagnostic criteria for AD in
are not identical (See Table 1).
Criteria of Autistic Disorder/ Childhood Autism in the CCMD-3
(1) Qualitative impairments in social
- Lack of interest in group play,
aloneness, inability to share group enjoyments.
- Lack of skills to interact with
others, inability to apply age appropriate skills to develop peer
relationships. For example, interacting with peers mainly by pulling,
pushing, or hugging them as means of interaction.
- Engaging in self-entertainment,
inadequate interaction with surrounding environment, lack of related
observation and presupposed emotional response (e.g. oblivious to the
presence of parents).
- Marked impairment in the use of
appropriate eye-to-eye gaze, facial expression, gestures, and body
postures while interacting.
- Marked impairment in
make-believe play and social imitative play (e.g. inability to play
“each family” game).
- Inability to seek sympathy and
relief of physical discomfort or distress, unable to express care and
sympathy for others’ physical discomfort or distress.
(2) Qualitative impairments in communication:
- Delay in the development of, or
total lack of, spoken language, and inability to communicate through
gesture or imitation.
- Marked impairment in language
comprehension, frequent inability to understand directions, inability
to express one’s own needs and distress, reduced tendency to ask
questions, and lack of response to others’ speech.
- Difficulty with language
acquisition, use of meaningless mimic language or echolalia, pronoun
- Repetitive use of words and
phrases inappropriate to context or making unintelligible sounds.
- In individuals with adequate
speech, marked inability to initiate or sustain a conversation or
engage in simple verbal exchanges.
- Abnormalities in the pitch,
intonation, rate, and rhythm of speech. For example, tone of voice may
be monotonous, stereotyped use of language.
(3) Restricted interest, stereotyped and
repetitive activities, resistance to change in environment and life
- Preoccupation with one or more
patterns of restricted interest. For example, the spinning of an
electric fan, a single musical rhythm, commercials, weather forecasts,
- Hyperactivity, excessive walking
back-and-forth, running, self-spinning, etc.
- Resistance to changes in
stereotyped, repetitive motor mannerisms or body postures, and shows
irritation and anxiety over changes.
- Persistent preoccupation with
odors, objects, or parts of toys, such as special odors, a piece of
paper, smooth cloth, wheels of toy cars, and obtains gratification from
- Inflexible adherence to
specific, nonfunctional routines, or ritualistic movements or
B. Severity criteria: The impairment of
C. Course criteria: The onset is usually
prior to 3 years of age.
listed in the CCMD-3 are not only a direct translation from the DSM-IV
ICD-10, but also include material obtained from Western diagnostic
tools and/or scales, as well as information on Chinese social needs
present comprehensive features for diagnostic purposes. The topography
symptoms in the CCMD-3 include: (1) qualitative impairments in social
interaction; (2) qualitative impairments in communication; and (3)
interests, stereotyped and repetitive activities, requiring an
environment and life style. The CCMD-3 requires seven behavior criteria
three core symptoms to conclude that an individual has AD. A total of
associated diagnostic criteria are listed. Among them, six under the
of social interaction, six under the impairment of communication, and
under the restricted repertoire of activity and interests. Examples are
describe a diagnostic criterion in order to help Chinese professionals
behavior criteria within the diagnostic guidelines reflect an
AD in terms of its impairments and behavior patterns within three core
symptoms. Some interesting descriptions are noted. In the diagnostic
for qualitative impairment in social interaction, inability to apply
interaction was specified with three criteria. Profound aloneness was
highlighted in two criteria with such descriptions as: lack of interest
group-play, aloneness, and engaging in self-entertainment. The
behavior pattern related to its surrounding environment is mentioned in
criterion. In the diagnostic criteria for qualitative impairment in
communication, impairment in language comprehension, expression and
included. Language features, such as semantic, syntactic, and pragmatic
elements were explicitly described with four criteria. Abnormalities of
such as the pitch, intonation, rate, and rhythm, were noted as a
criteria for restricted, repetitive, and stereotyped patterns of
anxious tenseness is suggested in one criterion. Sensory dysfunction,
hyperactivity and self-stimulation are described in four criteria.
addition, some descriptions
within the diagnostic systems reflect particular attention to and views
behaviors that indicate impairment of social and communicative
CCMD-3 categorizes “lack of varied, spontaneous make-believe play or
imitative play appropriate to developmental level” as an indication of
qualitative impairment in social interaction. It is not considered one
diagnostic criteria for qualitative impairments in communication. The
did not emphasize that the delays or abnormal function must be socially
oriented and, hence, in the context of symbolic or imaginary play. It
that the impairment of social function is an indicator for severe
The diagnostic criteria for AD in the
CCMD-3 are based on both observable behaviors and inner
as aloneness, that was proposed by Kanner in 1943. We can only guess at
rationales for the descriptions, and many questions remain unanswered.
example, (1) in keeping with the literal meaning of the Chinese name
for AD (孤独症 or自闭症),
the CCMD-3 explicitly highlights the aloneness
feature in its
diagnostic criteria. This inclusion raises several questions, such as:
Chinese professionals share Kanner’s (1943) observation of this
more Chinese individuals diagnosed with AD prefer self-isolation than
Americans with the same diagnosis? If individuals like to socialize,
the skills for appropriate social behaviors and language, are they less
to be diagnosed with AD in the PRC than in the United
When “aloneness” is considered a legitimate diagnostic
diagnostic outcomes for AD might be different. (2) Another unanswered
stems from the fact that “a lack of spontaneous seeking to share
achievements with other people4” is less explicitly
described in the
CCMD-3. Further investigation is
required to understand what prevents Chinese professionals from
that to be an indicator for quality of social interaction, and thus
list it as
a diagnostic criterion. Is it related to certain social-cultural
norms that regulate daily practices and social interaction? Do most
parents encourage their children to share their interests and talk
whatever they want? Or are children more likely to internalize adults’
interests while listening to their conversation? Do most Chinese
encourage their children to share their achievements? Or are their
taught to be self-effacing and not become a person who talks more while
less? This raises fundamental questions about how Chinese parents view
treat their children. (3) Another
interesting description is the specification of the abnormality of
“Tone of voice may be monotonous” is highlighted in the CCMD-3. But why
Chinese professionals choose the word “monotonous” to describe a
speech abnormality? Is a “sing-song” quality characteristic of normal
speech? We note that tones, along with the other two pronunciation
initials and finals, are considered sufficient and necessary for
speech in Chinese language. There are various tones in Chinese, and
Chinese syllable has an assigned tone. The same syllable with different
can have different meanings (Yao,
Liu, Ge, Chen, Bi, & Wang, 2005). Abnormalities in use of speech
such as tone all have consequences for the accuracy of spoken language
language being spoken is Chinese. The CCMD-3 considers it important to
pronunciation of speech as a main criterion in the diagnostic menu. To
these questions remain unanswered. We know that Chinese professionals
particular views about certain behavior features, and that these
reflected in their subjective judgments and decisions regarding
unified and culturally embedded diagnostic tool. But we do not know how
criteria are arrived at. This remains the subject of future research.
about a psychiatric
phenomenon is greatly related to social, cultural, and political
influence everyday and scientifically based thinking. Culture is seen
mediator that constantly provides resources for psychiatrists to
their thinking. By sharing cultural resources, psychiatrists construct
acceptable behaviors, perform joint activities, and build an
understanding of a
mental disorder. Psychiatrists develop their thoughts in their specific
socio-cultural contexts by actively participating in social
both influence and are influenced by their external environments. The
development of their thoughts about mental disorders and AD is both
within the self and changed by the socio-cultural context over their
As a product of everyday thinking and
psychiatric thought, autism is a dynamic social phenomenon that is
in specific socio-cultural contexts. It is not solely for Western
is a global construct. Chinese psychiatric communities share the
AD in their own social cultural milieu. Both behavioral descriptions
that represent inner status are embedded in the diagnostic criteria of
the CCMD-3. Whether an individual is less likely to be diagnosed as
in the PRC because more criteria are required in the PRC, is unclear,
should be the subject of future research. An understanding of that
practice, as well as of the rationale and practice of treatment for
with AD, would support the understanding of AD in a cross-nation study.
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is a life energy that flows through the human body.
From a Traditional Chinese Medicine perspective,
the human body is nourished by, and depends on, its flow.
that “self criticism” and “mutual criticism” are the most effective
regain mental health through eliminating Capitalistic thinking and
3 A policy adopted
by the Communist Party of China that involves a more positive attitude
all other countries than previously.
4 It is one
of the diagnostic criteria for qualitative impairment in social