AUTISM IN CHINA: FROM ACUPUNCTURE TO APPLIED BEHAVIOR ANALYSIS

ELAINE CLARK

University of Utah

ZHENG ZHOU

St. John’s University

It has been only in the past decade that autism has been widely recognized among Chineseservice providers. As a result, there are few professionals who are trained to treat the disorder.Although efforts are currently under way to determine the prevalence of autism in China, to datethere are no reliable data that indicate the magnitude of the problem. There are no formalizededucation programs for children with autism and only a handful of treatment programs in largercity hospitals and private schools. Treatments range from herbal medicines and acupuncture tosensory integration training and, in rare instances, applied behavior analysis (ABA). This articleprovides an update on what is taking place in China for autism treatment, and the challenges thatlie ahead as the Chinese Ministry of Education struggles to address the needs of children iden-tified with the disorder. © 2005 Wiley Periodicals, Inc.

Historically, in comparison to Western societies, there has been a dearth of scientific litera-ture in China regarding the diagnostic features and treatment of “autism” (a term used interchange-ably in this article to denote the full range of autistic spectrum disorders; ASD); however, severalarticles have been published in the last 5 years in Chinese medical journals (e.g., Chinese Journalof Psychiatry, Chinese Mental Health Journal, and Journal of Clinical Psychological Medicine).Although autism has not had anywhere near the publicity in Chinese newspapers as it has had inthe United States, autism became the focus of China’s popular press in 2002 when a 21-year-oldcollege student gave a mixture of sulfuric acid and caustic soda to bears at the Beijing Zoo toassess the bears’ intelligence. The man was described in the news as autistic, raising questions asto how China’s elite educational system could permit a student with a disability to gain entranceinto college and complete a degree. Although some questioned whether the man had autism at all,the issue garnered national attention and raised the level of awareness among citizens of thePeople’s Republic of China (PRC). The fact that so little has been written about autism is notsurprising given that the disorder was not recognized by mental health professionals in China untilafter the second edition of the Chinese Category of Mental Disease (CCMD-2) was published in1995 [and included criteria from the American Psychiatric Association’s (1994) Diagnostic andstatistical manual of mental disorders (4th ed.)].

Putting Autism in Perspective

Historical Background

Despite the fact that the first special schools in China were established by Western mission-aries in the 19th century, as a result of continual turmoil (politically and economically), it was notuntil the 1980s that special education began to develop. Since that time, services for disabilitieshave been continuously offered. Although there are six disability categories [visual, hearing, intel-lectual, physical, mental (i.e., emotional and behavioral), and multiple impairments], due to lim-ited resources and ideological beliefs, the majority of resources have been put into programs forchildren with physical disabilities; that is, disabilities that do not prevent a person from contrib-uting to society. Examples of the programs that have received funding include vocational training

Correspondence to: Elaine Clark, Department of Educational Psychology, University of Utah, 1705 Campus CenterDrive, Room 327, Salt Lake City, UT 84112–9255. E-mail: clark@ed.utah.edu

Psychology in the Schools, Vol. 42(3), 2005 © 2005 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pits.20079

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for hearing-impaired individuals to work as artists and for the blind to work as massage therapists).The emphasis on physical (sensory) disabilities in China is not new. In fact, it appears to date backto the Zhou Dynasty (800–1100 BC), a period where symbols denoting blindness as a disability werescripted on bronze objects. Intellectual disabilities have never received as much attention, and indi-viduals with this impairment have not been able to access as much of the nation’s educational resources.Although services have improved (e.g., there were only four schools that served children withintellectual disabilities in 1984 and 370 in 1994), a substantial number of these children do notreceive educational services and remain dependent on their families for their care (Y. Chen, 1996).

Service Needs and the Government’s Response

Once identified, individuals with autism can be expected to be added to the already largegroup of people with disabilities in China who are dependent on families and society for theircare—a number that is estimated to be 67% of the “disabled” population living in China (Y. Chen,1996; Stratford & Ng, 2000). Although there have not been any long-term follow-up studies ofchildren with autism to know what can be expected in terms of long-term outcomes (e.g., level ofindependent functioning as adults), there are no data to suggest that outcomes would not be thesame or that the variables predicting outcomes would be anything different (e.g., children doingmore poorly as adults when intellectual ability is markedly impaired and language skills are sig-nificantly delayed (Howlin, Goode, Hutton, & Rutter, 2004).

Although the personnel in the Ministry of Education in the PRC may not be aware of theresearch on adult outcomes of autism, these individuals are aware that the educational needs ofthese children are not being met in the public schools. The Ministry acknowledges that there areno public education programs (including special education) for children in China who have autismand point to private programs such as Beijing’s Xingxingyu Education Institute for Children withAutism (referred to as Stars and Rain, the direct translation of Xingxingyu) as an example of anexemplary program where children with autism can receive services, including applied behavioranalysis (ABA). Despite the appearance of not caring enough about autism to provide publiceducation programs, it is important to keep in mind that it has been only in the last 15 years thatchildren in the PRC were ensured a public education at all (And only in the last 11 years havechildren with disabilities been protected under this law.) (Chinese Ministry of Education, 2004).

Unfortunately, there have not been enough programs or teachers to provide an education for chil-dren with disabilities. This is not surprising given estimates that 2,000 children are born each day inChina with some form of disability (Stratford & Ng, 2000).As a result of service-delivery problems,the Ministry of Education has had a number of initiatives to improve services for these children,initiatives referred to as the Five-Year Plans. Some goals of the initiatives include an increase inthe number of school programs and an increase in the number of qualified teachers (ChineseMinistry of Education, 2004). Although the shear number of school-age children in China (esti-mated to be 210 million) makes any special initiative difficult, the fact that 80% of the populationlives in rural areas makes it that much harder. Adding any other disability group will strain analready stressed system. Although it is not entirely clear how many children in China have autism,using estimates from Western nations would suggest that well over 1 million children have autism.

Assessing the Magnitude of the Problem for Children with Autism

Prevalence Data

Getting accurate prevalence data in China is difficult given the size of the country (estimatedto be 3.7 million square miles) and its vast rural areas. One report in 2001 by the Xinhua News

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Agency estimated that the number of children with autism was between 400,000 and 500,000.This rate is about two or three times lower than what would be expected using prevalence esti-mates from Western nations such as the United States. Using the U.S. rate of 6 in 1,000 (Yeargin-Allsopp et al., 2003), the number of children in China estimated to have an ASD (i.e., bothhigh- and low-functioning autism) would be 1.2 million. No nationwide epidemiological study hasbeen conducted as yet; however, two studies in provinces in East China reveal quite discrepantresults. Data collected in Changzhou indicate that 7 of 3,978 children have autism (W.H. Wanget al., 2002) whereas a study in the province of Anhui showed that 420 of 3,559 children haveautism, or 11.8% of the population (Ren & Duan, 2002).

Referral Patterns and Personnel Issues

According to data from a study by H. Guo, Zhang, and Liu (2002), the number of referrals forsuspected ASD have dramatically increased over the past decade. These researchers studied thepattern of first visits to the Mental Health Institute of Beijing University in 1999 and found that“autism” was the primary reason that children were referred that year. Before that time, datarevealed that children were referred more often for questionable “mental retardation” (in 1986)and earlier on for Attention Deficit Hyperactivity Disorder (in 1980). Apparently, prior to the1980s, little attention was paid to mental health issues in China, let alone a condition that manyhad never heard of—autism; however, as seen in the Mental Health Institute data, there was athreefold increase in the number of overall referrals in just 19 years. Whereas in 1980 there were386 referrals for psychiatric evaluations, in 1999 there were 1,198. Some suspect that this wasrelated to the end of the Cultural Revolution in 1976 and the start of a new era in terms of mentalhealth concerns. During the 10-year Revolution, physicians were not allowed to practice medicineas they had once practiced; the same was true of the schools. Although many schools in Chinawere open during that time, the curriculum was dramatically changed (e.g., greater political con-tent, bringing classrooms to the factories and countryside to teach students practical skills). AlthoughChina has made considerable progress since 1976, there are still a number of problems such as anextreme shortage of mental health professionals, including psychologists and psychiatrists. Theshortage of psychiatrists is especially critical for the identification of children (and adults) withautism in China. Psychiatrists are the only professionals at this time licensed to provide a ChineseCategory of Mental Disease, third edition (CCDM-3; Chinese Medical Association–Mental HealthDivision, 2001) diagnosis, and therefore the only ones who can make an autism diagnosis.

Fortunately, China has adopted the same diagnostic criteria as Western nations, and studieshave shown that the characteristics associated with autism are essentially the same. Althoughrelatively little research has been conducted on higher functioning autism, studies that have beenpublished further suggest that the features of children with greater cognitive ability and betterlanguage development also are the same as those found in other countries (e.g., Li, Liu, & Fang,2001).

Classification of ASD

The CCMD-3 is currently being used to diagnose children with autism. The criteria for ASDin the CCMD-3 were drawn from the criteria for pervasive developmental disorders (PDD) foundin the fourth edition of the Diagnostic and statistical manual of mental disorders (DSM-IV;American Psychiatric Association, 1994). There are six categories under PDD: Infantile Autism,Asperger’s Disorder, PDD-Not Otherwise Specified, Other or Yet to be Specified PDD, HellerSyndrome, and 3 Rett (Y.Z. Liang, personal communication, June 29, 2004, Beijing AndingHospital).

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Infantile Autism

In the CCMD-3, the criteria for Infantile Autism is the same as the DSM-IV criteria forAutistic Disorder; that is, it involves qualitative impairment in social interaction (e.g., markedimpairment in the use of nonverbal behaviors such as eye contact, failure to develop appropriatepeer relationships, lack of spontaneous sharing of enjoyment, and lack of social or emotionalreciprocity). Social impairments that have been reported in the Chinese literature include behav-iors such as alienation from peers, lack of eye contact, flat affect, indifference and lack of warmthtoward parents, and an inability to engage in role-play during games. Infantile Autism also involvescommunication impairment such as a delay or lack of appropriate expressive language, or ifverbal, a marked impairment in the ability to initiate or sustain conversations, stereotyped use oflanguage or idiosyncratic speech, and lack of varied and spontaneous imaginative play, or nosocial imitation. Examples of the types of problems among the Chinese in this area include non-responsiveness to greetings or commands, mumblings, “self-invention” of words, inability to usepronouns, and abnormal pronunciation and intonation. Finally, children diagnosed with InfantileAutism have restricted repetitive and stereotyped patterns of behavior, interests, and activities(e.g., have an intense focus, an inflexible adherence to nonfunctional routines, repetitive behav-iors, or mannerisms, and a persistent preoccupation with parts of objects). These “autistic-type”behaviors are reported in the Chinese literature to include attachments to select objects, preoccu-pation with certain activities, and interests in spinning objects. Like the DSM-IV, CCMD-3 crite-ria require that these impairments be apparent in preschool (e.g., by the age of 3 years) and thatchildren have developmental delays or abnormal functioning in one or more of the core areas(social interaction, language used for social communication, and symbolic or imaginative play).

Asperger’s Disorder

Asperger’s Disorder is distinct from Infantile Autism in the CCMD-3 in that children musthave normal cognitive and language development. Although communication styles may be some-what unusual (e.g., formal speech patterns), the primary characteristic of Asperger’s Disorderinvolves severe impairment in social functioning and stereotypies. Children in China are describedas failing to develop age-appropriate peer relationships, lacking social and/or emotional recip-rocity, inflexible adherence to routines, and having circumscribed interests that are oftenall-encompassing.

Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)and Other or Yet to Be Specified PDD)

Often considered a mild variant of autism, PDD-NOS has not been well researched, espe-cially in comparison to other autism conditions (e.g., Infantile Autism and Asperger’s). No studywas found in the Chinese literature that specifically addressed PDD-NOS (And only a coupleaddressed Asperger’s.) This is not surprising since the diagnosis of PDD-NOS is made for childrenwho do not meet the full criteria for either Infantile Autism or Asperger’s Disorder (or the tworegression developmental disorders, Heller’s and 3 Rett) since the other CCMD-3 category, “Otheror Yet to be Specified PDD,” is more of a default; that is, a category reserved for cases whereindividuals are showing signs of ASD, but do not have even enough features to make a PDD-NOSdiagnosis. Unlike the “Other” category, a PDD-NOS requires that the individual manifest somedistinct features of an ASD (e.g., severe and pervasive impairments in reciprocal social inter-actions and serious communication problems or idiosyncratic behaviors that involve patterns ofrigidity and/or stereotypies).

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Heller Syndrome and 3 Rett

Heller Syndrome is the same disorder in the CCMD-3 as the DSM-IV category for ChildhoodDisintegrative Disorder. Other names that have been used for this disintegrative disorder includedementia infantilis and disintegrative psychosis. Heller’s has the essential feature of marked regres-sion in multiple areas of functioning after a period of at least 2 years of normal development ofcommunication skills, social interaction, play, and adaptive behaviors (American Psychiatric Asso-ciation, 2000, p. 79). Although to be diagnosed with Heller’s children must display regression inonly two areas, often skill loss occurs across all domains (e.g., expressive and receptive language,social interaction, adaptive skills, bowel and bladder control, play, and motor skills). In addition tohaving regression of previously acquired skills and areas of functioning, the diagnosis of Heller’srequires that the child manifest at least two of the following abnormalities: qualitative impairmentin social interaction, qualitative impairment in communication, and restricted repetitive and ste-reotypes behaviors, interest, and activities. Regressive behaviors typically begin between the agesof 3 and 4 years (and must occur before the age of 10 years). The disorder can begin abruptly orhave an insidious onset where normal periods of development are marked by multiple transientperiods of regression.

3 Rett is the Chinese equivalent of the DSM-IV’s Rett’s Disorder. Although Rett’s and Heller’sshare a number of features, most notably regression in normal development and behavior, the twodiffer in a number of important ways. Rett’s is only found in females whereas Heller’s is morecommon in males. Further, the onset of Rett’s is much earlier than Heller’s, usually between 1 and2 years of age, and as early as 5 months. Rett’s also has the characteristic feature of deceleratedhead circumference (after at least 5 months of normal head growth) and loss of purposeful handmovements that is replaced by stereotyped hand movements (i.e., hand wringing and washing). Inaddition, children with Rett’s have poor coordination of gait or truck movements and tend tomanifest severe psychomotor retardation. These children also lose functional communication skillsand disengage from their social environments. Although a small number of children with Rett’shave been found to show increased social interest during late childhood and adolescence, their lossof communication skills and behavioral difficulties typically cause severe permanent disability(CCMD-3, 2001).

Similar Manifestations of Autism and Similar Assessments

Research in China has not only demonstrated similarities in the core symptoms of autism(i.e., social impairment, communication delay, and restricted and repetitive behaviors; Jiang, Wang,Yang, & Yang, 2001; Lin & Peng, 2002; Song & Ji, 1995) but also has shown that many of theassociated features and symptom presentation and report are quite similar to Western nations. Forexample, researchers have found that it takes, on average, 31 months from the time parents firstobserve problems to the time of their first reporting to physicians (Xue, Han, & Xi, 2001). Xueet al. (2001) also found that the parents’ first concern is similar to that in other countries—delayedspeech and language, followed by social delays (Ozonoff, Rogers, & Hendren, 2003). Other com-mon features of autism that appear to be shared by Chinese children include rare “savant” skills(i.e., unusual proficiencies); however, researchers have noticed this phenomenon in China, andfound that it presents in a similar fashion as elsewhere in the world (e.g., extraordinary ability toremember dates from the Gregorian calendar (Ho, Tsang, & Ho, 1991).

Other features that have been found in Western research include difficulty understandingabstract concepts, a tendency to become overly focused on nonessential details, inflexible in think-ing and behavior, and inability to generalize from one situation to the next. Another significantfinding in China is that children with autism have problems with the “theory of mind,” or the

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ability to take another person’s perspective and understand their intentions. Jiao (2001) found thatchildren with autism were capable of understanding the physical and social needs of anotherperson, but could not understand the other person’s intentions or their thoughts and emotionalstates. Other researchers have noted similar findings (e.g., Frith & Happe, 1999; Landa, 2000).

Special Assessments for Screening Autism

Many of the same screening measures that are used throughout the Western world are used inChina today. Although some studies suggest that some rather outdated screening instruments arestill used (e.g., Clancy Autism Behavior Scale, mentioned in Ren & Duan, 2002), for the mostpart, the Chinese are using recent measures. Although there are no data to indicate how closelymatched the Chinese translations of these measures are to English, there are indications that themethods are psychometrically sound; however, there is some question as to how the content of themeasures capture the influence of culture—an important consideration for a disorder such asautism in which social interactions, language, and behaviors are so severely affected (Brown &Rogers, 2003).

One of the “gold standard” measures being used today in China is the Autism DiagnosticInterview-Revised (ADI-R; Rutter, LeCouteur, & Lord, 2002). Despite the lack of the aforemen-tioned information on the Chinese version of the ADI-R, according to research by H. Guo, Yang,Liu, and Jia (2002), the inventory was found to have adequate reliability and validity when studiedwith a group of 50 autistic children and 32 controls); however, the ADI-R does not appear often inthe research literature, perhaps due to the scale’s relative newness and the fact it takes much longerto administer than other screening devices. This includes the Autism Diagnostic Observation Sched-ule (ADOS; Lord, Rutter, DiLavore, & Risi, 2003). Whereas the ADOS can take less than 1 hr, theADI-R typically takes 2 or 3 hr to administer; however, there was no indication in the research thatthe ADOS is being used to screen for ASD. Although this may mean that professionals in Chinarecognize that this structured observation scale requires considerable training and supervision toadminister reliably. There also were no indications that the Social Communication Questionnaire(Rutler, Bailey, & Lord, 2003) or the Gilliam Autism Rating Scale (Gilliam, 2001) are being usedin China. This is somewhat surprising since the items in both measures are based on DSM-IVcriteria, and are therefore consistent with the CCDM-3 that is used to diagnose ASD in China.

Measures that are found most often in the Chinese research literature include: the ChildAutism Rating Scale (Schopler, Reichler, & Renner, 1988) and the Autism Behavior Checklist(Krug, Arick, & Almond, 1980). Both of these translated measures have been reported to havesatisfactory psychometric properties (Yang, Huang, Jia, & Chen, 1994). Researchers and clini-cians also are using a Chinese version of the Psychoeducational Profile (PEP; Schopler, Reichler,Bashford, Lansing, & Marcus, 1990), the C-PEP (for a review, see Yu, 2001). Although Sunet al. (2000) described the measure as having adequate reliability and validity, it is not clearfrom the literature if the measure is being used to identify or treat autism. The PEP was intendedto help in the development of treatment plans using TEACCH’s (Schopler, Lansing, & Waters,1983) emerging skills strategy. It was not intended for diagnostic purposes. There also are indi-cations that another useful measure for planning treatment programs (for young children, ages1– 60 months) is being used in China, the Mullen Scales of Early Learning (Mullen, 1995).

Status of Treatments for Autism

Traditional Chinese Medicine

Treatment studies found in the scientific journals are a fascinating mix of the old (traditionalChinese medicine using herbs and acupuncture, e.g., Wong, 2002; Zhang, 1988) and the new

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(sensory integration training, e.g., Lin & Zhang, 1995; Wang, 2000) and ABA. Traditional Chinesemedicine views autism, like any other disease, as an imbalance in energy (Yin and Yang). Unlikeexternalizing disorders that involve aggression (or what traditional medicine refers to as the“Yang”), autism is a “Yin” disorder manifested by social isolation, lack of communication, andapathy. According to traditional medicine, both Yin and Yang conditions are treated similarly;that is, with methods intended to reduce accumulated phlegm (or what is considered the coreroot of problems) (Zhang, 1988). For this, herbal and nutritional remedies and acupuncture areused. Whereas herbs and nutrition are intended to treat phlegm, acupuncture is intended to recon-nect neural circuits that have been disrupted and disconnect vital areas of the brain (Wong,2002). For autism, the focus is on areas thought to be involved with the disorder itself (i.e.,frontal lobe and cerebellum connections). According to Wong (2002), who studied acupuncturein 30 children with autism, regular treatments can reduce both the core symptoms of autism (i.e.,social and communication impairments) and associated problems (e.g., inattention, hyperactiv-ity, and temper tantrums). Although no studies were found in the scientific literature examiningthe effectiveness of acupuncture with autistic traits, Wong claimed that acupuncture is gaining inpopularity in China as a way to treat autism. Many other studies reported that Chinese scientificliterature includes continuing to use interventions that have not been proven effective, such assensory integration training. The studies reported by the Chinese rarely mentioned the use ofABA, which has been shown to be the most effective if applied early and intensive (Weiss,1999).

Contemporary Treatments

Based on a review of the treatment literature and the treatment protocols used in psychiatriccenters in Beijing and Shanghai, it appears that much of the treatment for autism involves sensoryintegration therapies and relaxation types of therapies (i.e., massage, music, and play therapies)(e.g., Lin & Zhang, 1995; L. Su, Zhang, & Gao, 1999; L.P. Wang, 2000). Researchers in Chinawho have studied these treatments report limited, but positive, findings (i.e., treatment improvingthe child’s adaptation to the environment). Although ABA is provided in rare instances, the scien-tific literature did not adequately assess the effectiveness of ABA. In fact, most of the studies thatexamined behavioral treatments used combined treatments (i.e., combined behavior training withsensory integration training and medications) (e.g., Jiang et al., 2001); however, as with much ofthe treatment (and other) research, more often than not there were no control groups to compareresults. J. Chen, Zhang, and Li (2003), for example, found that behavior therapy and social skillstraining improved social communication, oral communication, and behavioral control in 37% ofthe children with autism, but failed to provide the same treatment for nonautistic children.

Critiquing the Scientific Literature

The lack of control groups is only one of many methodological concerns that seems to plaguecurrent research in the PRC. Although most of the studies that were found were clinical casestudies or small-scale investigations (e.g., studies of risk factors and the feasibility of certainassessment tools and treatments; S.T. Li et al., 2002; J.H. Li, Liu, & Fan, 2001), many had eitherserious methodological problems or failed to provide sufficient information to interpret the results.This included information about subjects (e.g., how children were identified and diagnosed ashaving autism), the treatments being provided and the level of training of those who were provid-ing the treatment, and the methods used to assess the outcomes (e.g., the psychometric propertiesof the scales and limitations given the use of translated versions of tests). The research also is verylimited in scope (i.e., primarily addresses children with severe types of autism such as InfantileAutism and Rett’s).

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It was apparent from the literature that several issues that have been of great interest toresearchers in Western societies were not considered. For example, although aggression is a majorconcern of parents and teachers of children with autism in the West, little concern was noted inChinese literature. It is not clear whether aggression is not reported that often for children withautism or whether the issue has not as yet been addressed. Similarly, studies seemed to neglectissues pertaining to the course of the disorder (i.e., how symptoms are manifested over time).Research in the West has shown that social interactions increase for children as they move intoadolescence and adulthood (Seltzer, Krauss, Shattuck, Orsmond, & Lord, 2003; Szatmari, Bryson,Boyle, Streiner, & Duku, 2003). Whether this is the case for Chinese children would be importantinformation for educators and parents alike. It also would have been significant if more studies hadbeen conducted on children with high-functioning autism. Knowing more about milder forms ofautism is critical, especially in light of the large number of children who are typically diagnosedwith the disorder and who are often identified much later than children with low functioningautism. It would be important, for example, to know if the same variables, such as IQ and func-tional language utility, predict outcomes for children with Asperger’s as well as other forms ofautism (Howlin et al., 2004). In another study that addressed Asperger’s, researchers did show thatthe children were less aggressive and had fewer repetitive movements (Xi, Hua, & Zhao, 2002).Knowing about probable outcomes for these children, as well as children with PDD-NOS, canhelp educators and parents set appropriate goals and plan interventions.

Ongoing Challenges for China

Improved Research Methods

One critical challenge that China faces has to do with the research methods that are beingused. For the data to be meaningful, improvements in the design and the implementation of thestudies are needed. Researchers in China also need to expand the topics that are being covered. Alarge portion of the literature seems to pertain to risk factors for developing autism. Perhaps thisis a function of China’s efforts to determine if there are any preventable causes. Although under-standable as a motivation for research, many of the studies conducted are no different from thosethat have been conducted in the Western world and have failed to provide any clear direction as toways to prevent autism (e.g., studies of obstetrical complications and pre- and perinatal risk fac-tors; Tan, Ke, & Lin, 2000; S.T. Li et al., 2002; R. Chen, Lin, & Luo, 1997); however, research isunder way that is examining the role that genetics plays (e.g., S.S. Li, Yang, & Jia, 1997) andneurobiology (e.g., neuroanatomical structure and neurotransmitters) (e.g., Hu, 1998; Shu, Zhang,& Jia, 2001; Tsai, 2000).

Accessible Treatments

Psychiatric hospitals. Although some psychiatric hospitals in some of the larger cities (e.g.,Beijing and Shanghai) have programs for children with ASD, many of these offer only limitedservices. For example, at Shanghai’s Institute for Mental Health, the services are more diagnostic,and the treatment is focused on developing motor skills and typically does not focus much onsocial skills and communication.

Private schools. For parents that have financial resources, one of the best options is to placechildren in private programs that offer comprehensive, state-of-the-art services. The most widelyknown is Beijing’s “Stars and Rain” Education Institute for Children with Autism.

“Stars and Rain” has been reported to have served nearly 500 children (3– 6 years of age)across China since it was founded in 1993. A parent of a child with autism, Tian Huiping, was the

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founder. Unlike many of the other programs for children with autism in China, Stars and Rain usesbehavioral principles (e.g., ABA) and parent training models to enhance children’s independenceand increase their social interactions (Xinhua News Agency, 2001; H. Tian, personal communication,June 29, 2004, Stars and Rain Education Institute for Children with Autism). The treatment pro-gram consists of 10 weeks of behavior therapy. The treatment costs 3000 yuan (about $361.), andfamilies are responsible for these costs as well as the costs for travel and accommodations whilein Beijing. For most families, this is not feasible, and the treatments are not provided in the cityhospitals.

Public school programs. To date, there are no special education programs specifically designedto address the needs of children with autism and no guidelines for these children’s educationalexperiences. Although children with autism who have serious cognitive deficits may find servicesavailable in programs for students with “intellectual impairments,” there is no indication that theseservices will be appropriate for the unique educational and social needs of these children (evenwith intellectual impairments). Although some of these programs may implement ABA, there is noindication that it is used early enough or is intensive enough to make a significant impact onchildren’s educational outcomes.

Although children with milder forms of ASD, including Asperger’s Disorder, may do betterin terms of academic work, research outside China has shown that the majority still have seriouslearning problems and poor adult outcomes despite more normal intellectual skills (see Howlinet al., 2004). Clearly, the severe social impairments that these children have and their autistic-typebehaviors (e.g., restricted interests, repetitive behaviors, and unusual preoccupations) make itdifficult for them to learn or adapt to the social environment, including the school. These childrenmay have even more adjustment problems as their disorder is so poorly understood and theircognitive deficits not so severe as to warrant special education in programs for students withintellectual impairments. In a recently published study, J.H. Li et al. (2001) studied 3 children withAsperger’s who were attending public schools in China. The 3 boys were reported to have beensubjected to severe peer rejection because of their limited social skills and communication prob-lems; however, the only intervention that was provided was a change in context. In other words,the children were moved from one classroom to another and from one school to the next in hopesof improving their chances of success, but no other help was offered.

Conclusion

Perhaps one of the greatest challenges for China is to address the severe shortage of ade-quately trained personnel to address the needs of children with autism across this vast nation.There already is a serious shortage of special education teachers and mental health professionalsto work with students with disabilities (Zhou, Bray, Kehle, & Xin, 2001), and identifying morechildren with autism will only add to this limited supply of professionals. Although the Ministry ofEducation seems to be aware of the situation, combined with the fact that no programs exist in theschools, there are not enough university training programs to adequately prepare personnel ineducation and mental health. Hopefully, the Ministry’s Five-Year Plan (2004) will accomplish thegoal of creating more training opportunities and more programs for children with such complexneeds. What influence the rapidly changing economy in China (i.e., open market and capitalism)will have on the distribution of resources for this Plan is unclear. What is clear is that China cansoon expect a dramatic increase in the number of children identified with autism as more knowl-edge about the disorder is made available and the public becomes more aware of what it means tobe “autistic.”

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