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Article 36

Culturally Effective Interventions for Chinese Children With Emotional Disturbance

Jiaqi Li and Janet Froeschle

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Emotional disturbance (ED) is the broad term encompassing many disorders such as anxiety, bipolar disorder, conduct disorder, and many other conditions. While specific terms are often used to describe children’s behaviors, this article utilizes the term, “Emotional Disturbance,” to coincide with special education law. The Individuals With Disabilities Education Act (IDEA; 2004) describes ED children as those who exhibit an inability to learn, build successful relationships with peers and teachers, exhibit inappropriate behavior or feelings, depressive mood, and physical symptoms associated with school/personal problems (National Dissemination Center for Children with Disabilities [NICHCY], 2010). Needless to say, this disorder can interfere with social functioning and performance of children in the home, school, and community (NICHCY, 2010). This is especially concerning since data from the U.S. Department of Education as well as estimates in China both indicate increases in the number of individuals identified with ED (Li & Wang, 2006; U. S. Department of Education, 2008). For example, from 1996 to 2006, the percentage of U.S. students with ED, aged 14 through 21, increased from 25.8% to 43.4%. In 2006, 7.5% of U.S. students (or as many as 456,142 students) between the ages of 6 and 21 were diagnosed with ED (U.S. Department of Education, 2008). Further, the estimated number of children with ED under 17 in China is nearly 30 million (Li & Wang, 2006).

Despite the data, few programs exist to address the needs of ED children in China or address the specific cultural needs of non-acculturated Chinese ED children living in the U.S. (Jia & Zhang, 2012). Consequently, this article: (a) reviews the definition and risk factors of emotional disturbance among Chinese children and Chinese American children, (b) introduces Chinese cultural characteristics, and (c) describes three culture- based intervention programs currently being used to assist children and adolescents with ED in China as well as in the U.S.

Emotional Disturbance in China

The history of psychology in China could be traced back 2,500 years (Thomason & Qiong, 2008). Both the teachings of Confucius on attaining the serenity of mind (Bankart, 1997), and the Chinese Taoists’ approach to maintaining the harmony of the cosmos (e.g., Yin & Yang) are important Chinese contributions to mental health. Additionally, ancient Chinese philosophers made significant contributions in the area of mental testing in applied psychology (Anastasi & Urbino, 1996; Thomason & Qiong, 2008). Recently, treatments originating in Western society have been adapted and modified for use in China. Nonetheless, while Western society offers many counseling theories, interventions, and practices, many of these are either not culturally appropriate or do not overcome the resistance Chinese Americans and the Chinese have about seeking mental health or medical help (Meyers, 2006).

Despite these influential and historical contributions, current mental health practices fall far short of sufficiently addressing issues such as ED or societal well-being among Chinese and Chinese American children. Programs are needed to assist the increasing numbers of Chinese children and adolescents currently identified with emotional disturbance in China and the U.S.

The Definition

Due to limited research and cultural differences, a clear worldwide definition of ED has not been established (Zhu & Li, 2010). As a result, the accepted definition of ED in the U.S. is very different from the diagnosis given in China. The following information describes the criteria used to diagnose ED within the U.S. and is followed by the distinct diagnosis given in China.

In 2004, the Individuals with Disabilities Education Act (IDEA) defined emotional disturbance as “a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s education performance.” These factors include: (a) an inability to learn that cannot be explained by intellectual, sensory, or health factors, (b) an inability to build or maintain satisfactory interpersonal relationships with peers and teachers, (c) inappropriate types of behavior or feelings under normal circumstances, (d) a general pervasive mood of unhappiness, and (e), a tendency to develop physical symptoms or fears associated with personal or school problems” (IDEA, 2004; Sect. 300.8[c]4[i.ii]).

Chinese researchers and doctors dispute the U.S. definition as well as the accompanying criteria used for diagnosis (Zhu & Li, 2010). Traditionally speaking, Chinese children and adolescents were given a diagnosis of ED if they exhibited emotional problems and inappropriate behaviors (Zhu & Li, 2010). Specific behaviors and emotions that might be displayed by someone with ED included aggression, resistance, impulsivity, learning difficulties, hyperactivity, withdrawal, fear, anxiety, and depression. These negative emotions and behaviors resulted in marked difficulties in living, studying, within relationships, and within the work environment (China Autism, 2007). As a result, many students with ED were rejected and discriminated against by family, school, and society, and even stereotyped as belonging to deviant groups who practiced behaviors such as drug-taking, stealing, and gambling (Zhu & Li, 2010).

Despite past failures to adequately diagnose and assist Chinese children, much has improved in recent years. Within the past 10 years, an infusion of foreign literature as well as increases in ED research have led to improved clinical understanding and treatment for those living with ED in China. For instance, Liao (2004) recently defined children with ED by their inappropriate behaviors, including: (a) depression, (b) an inability to build and maintain interpersonal relationships, (c) learning disabilities, (d) reluctance to participate in social activities in the presence of peers, (e) aggression, headache, stomachache, and upset stomach.

Despite these recent breakthroughs, the cause of emotional disturbance has still not been adequately defined in China and much additional research is needed to further improve diagnosis and intervention for emotionally disturbed Chinese children. Further improving treatment for ED children within China requires overcoming obstacles such as lack of information and governmental restrictions, while also adhering to cultural traditions. For instance, researchers must contend with a lack of national ED statistics (Jiang, 2005; Thomason & Qiong, 2008), the one-child policy, and the traditional Chinese values (as described in a later section of this article). Nonetheless, an increasing number of Chinese researchers have overcome this lack of information and identified certain risk factors that contribute to the development of ED.

Risk Factors

Risk factors for ED in China include: low socioeconomic status (Zhang, Kang, Chen, & Zhou, 2009), family structure (e.g., parental separation, family conflicts, living in a single parent household, or with a grandparent as caregiver), dysfunctional parenting (e.g., child abuse, over-indulgence, over-expectancy, ignorance and bigotry, lack of basic parenting knowledge), and school related issues (e.g., cultural pressure to succeed leading to little free time and constant study as well as bullying; Cheng & Zhang, 2009; Du, 2005; Guo, 2005; Liao, 2004; Wang & Luo, 2011). Jiang, Wu, Xu, and Wang (2008) investigated 244 children and adolescents and reported that cultural pressure to succeed leading to little free time and constant study (22.13%) was one of the most significant triggering factors for ED in China. Further, gender posed another risk factor. Mei, Wang, Yang, and Wei (2011) found childhood emotional and behavioral disorders were more common among girls (59.8%) and teenagers (51.1%). Further, these Chinese researchers contended that not only were females more likely to experience the symptoms of emotional disturbance, but they were also more likely to have experienced dysfunctional parenting, the main risk factor for ED among children and adolescents aged 3-17 in China. As such, culture, family values, and ED are interrelated.

In the U.S., risk factors for ED are much like those in China. For example, issues such as poverty, stress, diet, and family function have been noted as possible causes for ED in the U.S. (Duke Medicine News & Communications, 2004; NICHCY, 2010). Risk factors for Chinese American children include family stressors and cultural pressures. Chinese American children display a greater incidence of emotional disturbance than did their parents and are less likely to seek or receive help than those in the mainstream U.S. culture (Meyers, 2006). These risk factors make it crucial that counselors consider cultural differences when working with Chinese or non-acculturated children living in the U.S. Consequently, the next section describes Chinese culture so counselors can take into consideration these factors when assisting children residing in both countries.

Chinese Cultural Characteristics

Harmony and face-saving are two important characteristics within the Chinese culture (Lin, 2001). Both factors can be traced to Chinese traditional philosophies, including Confucianism, Buddhism, and Taoism (Leung & Lee, 1996). In particular, harmony is deeply imbedded into almost all aspects of Chinese culture and consistently influences the understanding of psychological problems. Generally, harmony refers to emotional restraint and self-control (Lin, 2001). In contrast, people with mental illness are usually considered to have lack of self-control and loss of harmony. Kung (2003) concluded that psychological problems in Asian countries are explained as a result of “malingering bad thoughts,” “a lack of will power,” and “personality weakness” (p. 29). For instance, people with mental disorders are labeled as having “inherited weakness, spiritual unrest, bad karma or a character weakness” (ChinaSource, 2010). As a result, Chinese people have negative attitudes and misconceptions about individuals diagnosed with mental illness. Rather than understanding the phenomenon as an illness, the Chinese often believe the disorder to be a certain personality deficit.

Face-saving is another significant factor that influences Chinese perceptions of mental illness. In South Asian countries, face is considered a symbol of dignity, honor, and prestige (Ho, 1976). Saving face refers to maintaining one’s reputation and the respect of other people (Lin, 1935). In China and Japan, saving face plays a vital role in keeping the interpersonal harmony in a social network. Recent studies and literature indicate that face-saving associated with mental illness is a critical factor influencing a Chinese citizen or Chinese American’s decision to seek professional mental health services (Kam & Bond, 2008; Leong, Kim, & Gupta, 2011; Sue & Sue, 2007). Sue and Morishima (1982) explained loss of face as the threat or loss of social integrity in interpersonal relationships. This is particularly true for Chinese and Japanese Americans. For instance, an individual deeply influenced by traditional Chinese culture will view a psychological problem as a loss of face caused by personality weakness (Kung, 2003). The aforementioned person will likely not expose a mental health issue for fear of losing face. As a result, seeking counseling services and receiving psychological therapy is often correlated with bringing shame to oneself and the family (Lin, 2001).

Level of Acculturation

Acculturation refers to the Chinese child’s individual relationship with Chinese culture. Berry (2005) identified four levels of acculturation including: assimilation, separation, integration, and marginalization. Chinese individuals in the assimilation level identify with mainstream society and do not maintain their cultural identity. Those at the separation level preserve their original culture and avoid interactions with those of the larger culture. Integration refers to Chinese individuals who maintain their original culture yet attempt to integrate with the mainstream society. Those in the marginalization level lose connections with both the Chinese and mainstream culture. For sake of clarity, this article refers to “non-acculturated Chinese children living in the U.S.” as those in the separation and integration levels. Since these children maintain connections with their original Chinese culture, interventions that promote cultural Chinese values can assist those in China and as well as “non-acculturated” children in the U.S.

Interventions for Children of the Chinese Culture With ED

Historically, a dearth of interventions has been utilized for children and adolescents with psychological problems in China. However, with the advent of National Professional Standards for Counseling Therapists as issued by the Ministry of Human Resources and Social Security of the People’s Republic of China in 2001 (Zhang, 2007b), the number of researchers, counselor educators, and practitioners in the mental health field has greatly increased. As a result, more studies have been conducted and interventions developed for students with ED. Meanwhile, China’s rapidly growing economy and open-door policy is improving perceptions toward mental health and psychology (Clay, 2002).

At the same time, ED remains a concern for Chinese American children as well as Chinese children living in the U.S. Chinese American children who immigrate at a young age are more likely to show signs of ED than their parents and are less likely to receive help than those in mainstream society (Meyers, 2006). Because Asians are less likely to ask for help with mental health or medical issues, it is important for counselors to reach out and develop helpful interventions that take into consideration Chinese culture (Meyers, 2006).

Consequently, three intervention programs have been developed to assist Chinese and Chinese American children diagnosed with ED and will be described as follows. The first intervention details a doctor-parents-teacher team approach while the second intervention consists of filial therapy. The third program utilizes art as a medium to improve Chinese children’s behavioral and emotional problems. Each program is described as follows.

Doctor-Parents-Teacher Team Work

A review of the literature published in the Chinese language revealed a unique intervention aimed at assisting the needs of ED children in Mainland China. According to Du (2005), this commonly used intervention, the Doctor-Parents-Teacher team (DPT) program, provides a structure for parents, teachers, and doctor(s) (e.g., psychologist, school counselor, or psychiatrist) to work as a team in identifying goals and implementing effective treatment plans. In short, DPT team work is based on effective family-school collaboration and involves intensive individual intervention. The purpose of the program is to help children who demonstrate inappropriate behaviors in school address the problem systemically. One positive cultural advantage of the DPT program is that it resembles a hospital-family-school focused intervention and as such, coincides with the Chinese education focus.

For non-acculturated Chinese children living in the U.S., DPT allows a school counselor to take the leadership role and design a treatment plan tailored for the individual child based on a physician’s diagnosis. Accordingly, parents and teachers are expected to provide the maximum support and participation desired by the school. School counselors may also consult with and educate parents throughout the process. The end result is a treatment specifically tailored to meet the individual and cultural needs of each student.

Filial Therapy

Filial therapy was first developed by Drs. Bernard and Louise Guerney in the 1960s, and is considered an effective parenting program for Chinese American children with ED (Chau & Landreth, 1997; Guo, 2005; Yuen, Landreth, & Baggerly, 2002). Landreth defined filial therapy as “a unique approach used by counseling professionals trained in play therapy to train parents to be therapeutic agents with their own children…” (Watts & Broaddus, 2002, p. 372). Based on the principles of play therapy, filial therapy is aimed at developing a strengthened relationship bonding between parents and child (Garza, Watts, & Kinsworthy, 2007). For example, the counselor trains parents to use play therapy techniques with their own children. Doing this helps parents develop competence and confidence via improved communication skills. The counselor also monitors play sessions, helps parents understand their child’s feelings and behaviors, and provides feedback on use of play therapy skills.

While filial therapy has been used effectively with children overall and was developed as part of conventional Western psychology, it may be particularly helpful with children from the Chinese culture for a number of reasons (Guo, 2005). First, it complements Chinese parenting concepts and practices (Huang, 2012). According to Huang (2012), fundamental Chinese parenting values include: (a) education as a first priority, (b) discipline, (c) filial piety, (d) lack of boundary in the relationship between parent and child, and (e) strong family ties. Further, filial therapy helps parents attain greater understanding, acceptance, and greater empathy for the child’s needs and perceptions (Garza et al., 2007). Consequently, filial therapy not only matches Chinese parenting values but also enhances the parent-child relationship. The result is the facilitation of personal growth for both the Chinese and non-acculturated Chinese child and parent living in the U.S.

Art Therapy

Drawing has been considered one of the most important ways in which children can express their feelings and thoughts. Art facilitates children’s inherent creativity and reflects their emotions, experiences, and memories in ways that language cannot (Malchiodi, 1998). Further, drawing is a natural communication that children seldom resist and is less threatening than any other traditionally verbal psychotherapeutic approach (Malchiodi, 2001). Consequently, drawing is often used as a therapeutic activity and is effective for children diagnosed with autism spectrum disorder (Martin, 2008), emotional disorders (Jia & Zhang, 2012), depression (Silver, 2009), sexual abuse (Katz & Hershkowitz, 2010; Pretorius & Pfeifer, 2010), and trauma and loss (Malchiodi, 2001).

Additionally, art therapy can easily be adapted for use with children from around the world (Hocoy, 2002; McNiff, 2009). According to McNiff (2009), art therapy has “definite characteristics of cross-cultural interchangeability” and involves the least amount of verbal communication (p. 102). Art, therefore, imposes fewer personal cultural biases and values on clients. As a result, art therapy is widely used and has become an effective psychotherapeutic approach in China as well as in the U.S. (Dreikurs, 1986; Li, 2006).

One specific method of art therapy being utilized effectively with Chinese children is paint therapy. In paint therapy, children are asked to paint feelings, thoughts, or depictions of events using paper, paintbrushes, and paints. Emotions are released in a non-verbal, culturally appropriate manner in a way that encourages harmony and saves face. Children are not asked to verbalize emotions but rather, experience past events and perceptions through art. It is no surprise, therefore, this method has shown positive results in assisting Chinese ED children (Jia & Zhang, 2012; Li, 2006; Zhang, 2007a). For example, Jia and Zhang (2012) conducted a study of examining the effect of paint therapy on 32 Chinese children diagnosed with emotional disorders. These researchers reported decreases in neuroticism and psychoticism in children after a 6-month treatment. The children learned to not only control inappropriate emotions and behaviors but to some extent improve their self-esteem and self-concept. It would seem the children learned to release culturally inappropriate behaviors and emotions via art.

Applications for Chinese Children in the U.S.

The aforementioned treatments were originally used in the U.S. and later adapted and used effectively by health practitioners in China. Because each method takes into consideration the previously described Chinese cultural characteristics of harmony and face-saving, they may be helpful interventions for U.S. counselors working with non- acculturated Chinese American children or Chinese children living in the U.S.

Conclusion

Emotional Disturbance is an often misunderstood disorder that is increasing within both the U.S. as well as in China. Non-acculturated Chinese children with ED living in the U.S., as well as those living in China, need culturally appropriate, effective treatments that do not bring a perception of shame upon the individual and the family. Further, these treatments must take into consideration the importance of family, education, and harmony within the Chinese culture. A review of the literature reveals three culturally appropriate interventions that can be effectively used with children from the Chinese cultures as well as with non-acculturated Chinese children living in the U.S.: the DPT Program, filial therapy, and art therapy. Counselors can overcome cultural barriers and assist Chinese children and non-acculturated Chinese children with ED living in the U.S. if they understand not only the risks and diagnoses of emotional disturbance but also have the cultural knowledge and skills to implement culturally effective programs.