The Effect of Socio-Cultural Context on Conceptualizing Autistic Disorder
In the People’s Republic of China

Correspondence:
Ching Hung Hsiao
227 Poucher Hall
Department of Modern Languages and Literatures
State University of New York, Oswego
Oswego, NY 13126

     

            The conceptualization of Autistic Disorder in modern psychiatry is an ongoing and dynamic process influenced by a range of discourses and research. From a socio-cultural perspective, an individual’s thinking is rooted in his or her culture and society (Bruner, 1986; Feldman, 1987; Stetsenko & Arievitch, 2004; Vygotsky, 1978), and as this applies to professional psychiatrists, their conceptualization of Autistic Disorder (AD) is necessarily entrenched in the society in which they reside. Psychiatric professionals apply a combination of scientifically based expertise and everyday thinking to link physical, psychological, and environmental factors to the cause, diagnosis, and treatment of AD. Furthermore, culturally produced sign systems, such as language and written texts, constantly reinforce the collective meanings that underlie the thinking of psychiatrists. Psychiatrists internalize collective meanings as cultural beliefs, daily practices, role expectations, and social justifications. Conversely, their thoughts about AD are transformed into public meanings, which are shared by their particular psychiatric community, and which fit specific social, cultural, and political milieus.

Knowing the effects of a particular social-cultural context on the causal explanation, diagnosis and treatment of AD as well as having performed a line-to-line investigation of the diagnostic criteria are prerequisites to understanding how AD is manifested in the People’s Republic of China (PRC). To this end, we explore how culturally based variations in thinking, expectations, and even norms of social behavior influence Chinese psychiatrists’ conceptions, diagnosis and treatment of mental illness, with a specific focus on AD. Our investigation of the socio-cultural and historic contexts for the construction of AD in China uses an ecological approach. We begin by briefly examining the history of mental illness in China, and tracing the development of thinking regarding its cause, diagnosis, and 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 diagnostic systems and conduct a qualitative analysis of the diagnostic criteria for AD in China. The investigation provides an opportunity to generate better conceptual framework and a more fruitful research outcome for a cross-cultural interpretation of diagnostic practice and treatment of AD.

Conceptualizing Mental Disorders in China

Conceptions of mental illness in China have evolved over centuries under the constant influences of the social, cultural and political environments. Thinking about the nature of autism, not the diagnostic term itself can be traced back to the beginning of Chinese history, and it is clear that this thinking has been based on Chinese society’s everyday understanding of mental disorders. Below, we describe how Chinese psychiatric societies have conceptualized mental disorder over time. An understanding of Chinese conceptualization of mental illness can further facilitate a cross-cultural understanding of mental disorders.

An absence of appropriate identification and treatment for individuals with AD (a term interchangeable with Childhood Autism) is the result of the religious practice and Traditional Chinese Medicine (TCM) of the 18^th century. First, the general perspective was that mental disturbances were the consequence of bad deeds perpetrated either by oneself or by members of one’s family. The religious nature of this conceptualization meant that blessings for individuals with a mental disorder were sought from the gods in local temples (Yip, 2005a). Second, based on the ancient doctrines of TCM, many Chinese attributed mental illness to an imbalance in vital forces -- a cause rooted, at least in part, in the physical world. According to Fàbrega (2001), TCM attributes the causes of illness to a complex relationship between impairments of the circulative function of “qi¹”and “blood” in an organ or in a stream across the body and, based on a philosophical understanding of phenomena among Heaven, the Earth, and Humanity, an imbalance of the forces of “Yin” and “Yang,” thus implying that both external/environmental and internal/personal factors influence the physical and mental functioning of individuals. A complicated metaphysics referring to the elements of Metal, Wood, Water, Fire, and Earth was also used to explain sicknesses and their treatments (Chan, Ying, & Chow, 2001).

            The understanding of mental disorders remained unchanged throughout the 19^th century. Individuals’ mental health problems were either unrecognized or identified as physical ailments by herbalist doctors. These herbalist doctors treated patients using single or compound ingredients of Chinese medicine, which they prescribed after a holistic assessment of the patient and the illness (Xu, 1982). Then, in 1898, an American missionary established the first psychiatric institution in Guangzhou (Liu, 1981; Yip, 2005b). Thereafter small asylums were founded in Beijing, Shengyang, and Suzhou (Yip, 2005a). Over time, a more westernized understanding of mental illness emerged in Chinese society. Even so, only a small number of individuals with mental illness were treated in hospitals. Others were confined in prisons, and the majority remained at home and cared for by their families.

Changes in the conceptualization of mental disorders in the PRC were slowed by the unstable social, cultural and political milieus of the early 20^th century. China was preoccupied with multiple distressing large-scale events: the dramatic end of the empirical Qing dynasty, devastating losses in the Sino-Japanese war, the revolution and the establishment of the PRC. Of particular significance was the decade-long Cultural Revolution, during which collective political education² replaced a more westernized treatment of mental disorder. As Yip (2005a) states, “Medical professionals identified clients with mental illness as ‘class brother’ to fight against ‘mental illness’ which originated from ‘evil Capitalistic think’” (p.28). Mental illness was thus not thought of as a social problem. As Allodi and Dukszta (1978) explain, “the official line is that 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 education and healthy life practices were the basis for preventing mental illness. As a result, discussions about, and investigations of, mental illness were limited.

It was not until the nation regained its strength in the late 1970s, that scientific thinking and research 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 knowledge once again reappeared, and with it, the establishment of an international discourse, a gradual shift in the understanding of mental disorder, and a diagnostic system and treatment modalities that had elements common to psychiatric communities around the world began to be established in China. Most individuals with mental disorders, however, were treated at a primary care level or at home due to the lack of psychiatric professionals (Chen, 2002).

The Construction of Autistic Disorder in the PRC

The changes in the social and political climates and the opening up to international discourse enabled the Chinese psychiatric community and the public to construct an objective picture of AD in the 20^th century, although multiple political issues have continued to impede the recognition of AD. In 1982, Tao reported four cases of IA (Infantile Autism) in the PRC that supported the definition developed by the US National Society for Autistic Children (and subsequently approved by the American Psychiatric Association) that “autism has been found throughout the world in families of all racial, ethnic, and social backgrounds” (Tao, 1987, p. 289).  Moreover, Tao (1987) compared the clinical features of IA found in fifteen Chinese individuals to the individuals in Kanner’s 1943 cases, suggesting that his findings “replicated those of Kanner and of Cantwell, Rutter, and Baker (1976) on the subject of socioeconomic status of parents” (p. 289). He further suggested that the findings heralded the opening of a discourse between the United States and the PRC. Both Chinese physicians 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 Chinese, which 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 set of behavioral descriptions as suggested by Kanner (1943).

            In China, the philosophy of TCM and notions of Western psychiatry suggest two distinct causal interpretations of AD. As already explained, TCM implies a causality of mental illness related to vital and spiritual forces, as well as to healthy life practices in the social, cultural, and political milieus. The causality of 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 Chinese psychiatric professionals have adopted the research framework of Western studies to conduct their research and to generate empirical findings that articulate the possible causal explanations of AD in the PRC. Samples include: 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 the 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, & Lin, 2004).

            The contemporary classification and categorization of mental disorders has been constructed to meet current socio-cultural needs in China. Throughout the profound social reforms and the rapid development of the economy of the last two decades, China has moved towards becoming a modern nation. A set of operational criteria for diagnosing IA was established in the Chinese Classification of Mental Disorders 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 a significant milestone inasmuch as it indicated the achievement of a momentous understanding, an acceptance, and an acknowledgment of the applicability of diagnostic practice in Chinese psychiatry (Zhang, Yang, Jin, Wu, & He, 1994). A national field trial of the CCMD-2, however, found that having IA in the diagnostic manual did not have a positive impact on diagnostic practice in the early 1990s. According to Zhang and his colleagues, “childhood disorders were a somewhat weaker classification because a great proportion of its content was introduced directly from foreign systems of diagnosis, and in addition, 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. 127). In 1995, the Chinese Classification of Mental Disorders and Diagnostic Criteria, Second Edition, Text Revision (CCMD-2-R; Chinese Medical Association, 1995) was published to reflect a classification of mental disorders similar to those in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) and the International Classification of Diseases, Tenth Revision (ICD-10; World Health Organization [WHO], 1990). In the CCMD-2-R, Childhood Autism was classified as a mental 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 meet the needs of (our) society, (2) fit in with Chinese cultural background and tradition, (3) maintain the superiority of CCMD previous versions, (4) match ICD and DSM systems, and (5) be concise and manipulative” (CCMD-3, 2001, p. 173). The diagnostic criteria of AD were satisfied in a national field trial (Li, Su, & Luo, 2002), and the term AD gradually gained publicity in Chinese clinical practice and research. Accordingly, the number of referrals for suspected AD increased dramatically. In 1999, AD became the most common consultation and diagnosis of clinical cases in the Institute of Mental Health at Peking University (Guo, Zhang, & Liu, 2002). 

            Given that Chinese health professionals did not recognize AD until the late 20^th century and the continuing lack of resources, funding, and trained professionals, the development of diagnostic tools and treatments programs for AD remains limited in the PRC. A decade after Tao’s report of four cases with IA, Western diagnostic tools such as the Autism Behavior Checklist, the Psycho-Educational Profile, and the Childhood Autism Rating Scale, were adapted for AD assessment in the PRC (Lu, Yang, Shu, & Su, 2004; Sun, Wei, Yu, Yuan, Yang, Jia, & Yan, 2000; Wong, Hui, Lee, Leung, Ho, Fung, & Chung, 2004; Yang, Huang, Jia, & Chen, 1993). Not until the 21^st century, Chinese psychiatric professionals developed their own screening and assessment tools that are reliable and valid for the conditions of Chinese individuals with AD (Liu, Wang, Guo, Yang, & Jia, 2004). However, advancement in the diagnosing of individuals with AD was not accompanied by development of effective treatments. Many individuals with AD do not have the benefit of appropriate intervention programs at the public school (Clark & Zhou, 2005). According to McCabe (2003), “educational opportunity and experiences for children with autism vary as a function of parent advocacy and a school’s willingness and ability to serve these students” (p. 20). Parents and professionals who are aware of Western psychiatric practice implement various types of intervention program for individuals with AD without any funding support. Treatment programs that include applied behavior analysis (ABA), discrete trail training (DTT), and sensory integration training, as well as acupuncture and herbal medicine (Clark & Zhou, 2005), are selected based on the parents’ beliefs and the philosophy of the organizations or commercial sectors. For instance, the Beijing Xingxing Yu Education Institute for Children with Autism was established under such initiative. The organization and parents of individual with AD work together to provide ABA and DTT to individuals with AD (McCabe & Tian, 2001). There remains a pressing need for legislative support and effective treatment programs for individuals with AD.

The Diagnostic Criteria of Autistic Disorder in the CCMD-3

The effect of socio-cultural context on the conceptualization of AD can be demonstrated by examining the construction of diagnostic criteria. The Chinese psychiatric community has created reliable and culturally valid diagnostic guidelines for AD. We present a Chinese-English translation of the Chinese version of the diagnostic criteria for AD in the CCMD-3 to reveal how professionals assess behavioral functions or characteristics associated with AD in the PRC and to better portray how Chinese psychiatric professionals conduct their diagnoses, since the English-language and the Chinese-language versions of the diagnostic criteria for AD in CCMD-3 are not identical (See Table 1).

Table 1

Diagnostic Criteria of Autistic Disorder/ Childhood Autism in the CCMD-3

A. At least seven items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3).

(1) Qualitative impairments in social interaction: 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 confusions. 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 style: Preoccupation with one or more patterns of restricted interest. For example, the spinning of an electric fan, a single musical rhythm, commercials, weather forecasts, etc. 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 experiencing them. Inflexible adherence to specific, nonfunctional routines, or ritualistic movements or activities.

B. Severity criteria: The impairment of social function. C. Course criteria: The onset is usually prior to 3 years of age.

            The diagnostic criteria listed in the CCMD-3 are not only a direct translation from the DSM-IV and the ICD-10, but also include material obtained from Western diagnostic resources, tools and/or scales, as well as information on Chinese social needs that present comprehensive features for diagnostic purposes. The topography of core symptoms in the CCMD-3 include: (1) qualitative impairments in social interaction; (2) qualitative impairments in communication; and (3) restricted interests, stereotyped and repetitive activities, requiring an unchanging environment and life style. The CCMD-3 requires seven behavior criteria within three core symptoms to conclude that an individual has AD. A total of seventeen associated diagnostic criteria are listed. Among them, six under the impairment of social interaction, six under the impairment of communication, and five under the restricted repertoire of activity and interests. Examples are used to describe a diagnostic criterion in order to help Chinese professionals reach an understanding.

Descriptive statements of behavior criteria within the diagnostic guidelines reflect an identification of AD in terms of its impairments and behavior patterns within three core symptoms. Some interesting descriptions are noted. In the diagnostic criteria for qualitative impairment in social interaction, inability to apply skills for interaction was specified with three criteria. Profound aloneness was highlighted in two criteria with such descriptions as: lack of interest in group-play, aloneness, and engaging in self-entertainment. The individual’s behavior pattern related to its surrounding environment is mentioned in one criterion. In the diagnostic criteria for qualitative impairment in communication, impairment in language comprehension, expression and exchange is included. Language features, such as semantic, syntactic, and pragmatic elements were explicitly described with four criteria. Abnormalities of speech, such as the pitch, intonation, rate, and rhythm, were noted as a criterion. In criteria for restricted, repetitive, and stereotyped patterns of behavior, an anxious tenseness is suggested in one criterion. Sensory dysfunction, hyperactivity and self-stimulation are described in four criteria.

In addition, some descriptions within the diagnostic systems reflect particular attention to and views of behaviors that indicate impairment of social and communicative functions. The CCMD-3 categorizes “lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level” as an indication of qualitative impairment in social interaction. It is not considered one of the diagnostic criteria for qualitative impairments in communication. The CCMD-3 did not emphasize that the delays or abnormal function must be socially oriented and, hence, in the context of symbolic or imaginary play. It indicates that the impairment of social function is an indicator for severe cases.

The diagnostic criteria for AD in the CCMD-3 are based on both observable behaviors and inner characteristics, such as aloneness, that was proposed by Kanner in 1943. We can only guess at the rationales for the descriptions, and many questions remain unanswered. For 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: why do Chinese professionals share Kanner’s (1943) observation of this behavior? Do more Chinese individuals diagnosed with AD prefer self-isolation than do Americans with the same diagnosis? If individuals like to socialize, but lack the skills for appropriate social behaviors and language, are they less likely to be diagnosed with AD in the PRC than in the United States?  When “aloneness” is considered a legitimate diagnostic criterion, the diagnostic outcomes for AD might be different. (2) Another unanswered question stems from the fact that “a lack of spontaneous seeking to share interests or achievements with other people⁴” is less explicitly described in the CCMD-3.  Further investigation is required to understand what prevents Chinese professionals from considering 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 phenomena and norms that regulate daily practices and social interaction? Do most Chinese parents encourage their children to share their interests and talk about whatever they want? Or are children more likely to internalize adults’ interests while listening to their conversation? Do most Chinese parents encourage their children to share their achievements? Or are their children taught to be self-effacing and not become a person who talks more while doing less? This raises fundamental questions about how Chinese parents view and treat their children.  (3) Another interesting description is the specification of the abnormality of speech. “Tone of voice may be monotonous” is highlighted in the CCMD-3. But why do Chinese professionals choose the word “monotonous” to describe a possible speech abnormality? Is a “sing-song” quality characteristic of normal Chinese speech? We note that tones, along with the other two pronunciation elements, initials and finals, are considered sufficient and necessary for accurate speech in Chinese language. There are various tones in Chinese, and every Chinese syllable has an assigned tone. The same syllable with different tones can have different meanings (Yao, Liu, Ge, Chen, Bi, & Wang, 2005). Abnormalities in use of speech elements such as tone all have consequences for the accuracy of spoken language when the language being spoken is Chinese. The CCMD-3 considers it important to list pronunciation of speech as a main criterion in the diagnostic menu. To date, these questions remain unanswered. We know that Chinese professionals have particular views about certain behavior features, and that these criteria are reflected in their subjective judgments and decisions regarding establishing a unified and culturally embedded diagnostic tool. But we do not know how these criteria are arrived at. This remains the subject of future research.

Conclusion

Thinking about a psychiatric phenomenon is greatly related to social, cultural, and political practices that influence everyday and scientifically based thinking. Culture is seen as a mediator that constantly provides resources for psychiatrists to construct 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 interactions. They both influence and are influenced by their external environments. The development of their thoughts about mental disorders and AD is both manifested within the self and changed by the socio-cultural context over their lifetimes.

 As a product of everyday thinking and psychiatric thought, autism is a dynamic social phenomenon that is constructed in specific socio-cultural contexts. It is not solely for Western society, but is a global construct. Chinese psychiatric communities share the construct of AD in their own social cultural milieu. Both behavioral descriptions and terms that represent inner status are embedded in the diagnostic criteria of AD in the CCMD-3. Whether an individual is less likely to be diagnosed as having AD in the PRC because more criteria are required in the PRC, is unclear, and should be the subject of future research. An understanding of that diagnostic practice, as well as of the rationale and practice of treatment for individuals with AD, would support the understanding of AD in a cross-nation study.

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Footnotes

1 Qi 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.

2 Suggesting that “self criticism” and “mutual criticism” are the most effective ways to regain mental health through eliminating Capitalistic thinking and class evil.

3 A policy adopted by the Communist Party of China that involves a more positive attitude towards all other countries than previously.

4 It is one of the diagnostic criteria for qualitative impairment in social interaction in DSM-IV.