Table Of ContentPREFACE
There has been a major shift in the way we conceptualize and provide services to children and
adolescents with mental health needs. We are moving away from the traditional disorder-oriented
model of treatment to a child-centered, family-focused service delivery system that mandates mental
health services in the context of the child's family and social ecology. This new system of care has
spawned many variations of the model, including wraparound services, multisystemic treatment
(MST), futures planning, and person-centered planning.
As systems of care are different across countries and cultures, it is imperative that we share
our knowledge and make explicit the lessons we have learned in our attempts to provide services to
children and adolescents that focus on improving their quality of life rather than merely treating their
psychiatric disorders and psychological problems. Further, there is an urgent need to evaluate the
various treatments being offered to children and adolescents with mental health needs. Clearly,
empirical data on outcomes will determine the funding and delivery of services. As such, we need
to disseminate our latest research on treatment outcomes so that new and validated treatment
methods can be implemented rapidly.
The biennial Elsevier conference on Child and Adolescent Mental Health has been designed
to provide a forum for mental health experts from various disciplines and countries to discuss and
evaluate the current status of our knowledge in this field. The First International Conference on
Child and AdolescenMte ntal Health was held at the Chinese University ofHong Kong, on June 2-6,
1998, and was attended by scientists and practitioners from 32 countries. In all, 24 papers were
selected for this volume to highlight research and practice in child and adolescent mental health
around the world.
Nirbhay N. Singh
Jin Pang Leung
Ashvind N. Singh
vi
1
Mental Health Problems of
Chinese School Children
Qicheng Jing
Chinese Academy of Sciences
Qihua Zuo
Beijing Medical University
Qicheng Jing (cid:12)9 Institute of Psychology, Chinese Academy of Sciences, A01 Datun Road, De Wai, P.O. Box 1603,
Beijing 100101, China. Qihua Zuo~ Beijing Medical University, Beijing, China.
International Perspectives on Child and Adolescent Mental Health. Volume ".1 Proceedings of the First International
Conference, edited by N. .N Singh, .J .P Leung, and .A .N Singh. (cid:14)9 2000 Elsevier Science Ltd. All rights reserved.
The Beginning of the Mental Health Movement in China (1920-1948)
Although mental health is a relatively new concept in China, ancient Chinese sages have
always stressed the importance of harmony between mind and body in the treatment of diseases. In
Chinese medicine, mind and body are integrated into one unity, and a healthy mind is considered
just as important as a healthy body. Mental health is defined as a state of psychological equilibrium
where one' s behavior, emotion, and desire are be kept under control. The ancients advocated mental
self-recognition through exercises of the. Qi (breathing) and relaxation techniques enabling one's
behavior and psychological states to be kept in silence.
If we take Clifford W. Beers book A Mind that Found Itself (1908) as the beginning of the
mental health movement in the West, Chinese mental health was first made in 1920 by a group of
educators and psychologists. In 1920, Professor Yinian Zhang first taught the course of mental
health in Jinan University in Shanghai. Later, Nanxuan Wu and Randolph C. Sailer gave lectures
on mental health in Central University (Nanjing), Yenching University (Beijing) and Da Xia
University (Shanghai) respectively. In 1935, the Chinese Mental Health Association was founded
by Professor Nanxuan Wu. On it's agenda was the establishment of psychological counseling
centers and child guidance clinics. In the 61 years between 1920 and 1936, approximately 4 books
and 12 papers were published, dealing mostly with children' s mental health.
In 1937, Japan invaded China and occupied most of the eastern parts of the country. Many
universities and institutions were moved onto remote island cities where resources for research and
publication were scarce. Even under the difficult circumstances of wartime, 5 books and several
papers were still published. After World War II, Chinese universities and hospitals moved back to
their original sites in the southern and eastern parts of China and resumed teaching and research.
In 1948, the Chinese Mental Health Association resumed its activity.
The Soviet Influence and the Cultural Revolution
In 1949 the People's Republic of China was founded. In the early years of the Republic,
Chinese psychologist Jiayin Huang published several books on the psychotherapy of children and
adolescents. These books include: Case Report of Prevention of Children' s Mental Disease (1951 ),
Psychotherapy Cases on Children's Behavioral Disorder (1952), and a book co-authored with
Zhonghua Su entitled The Girl who Thinks Herself a Queen: A Case of Abnormal Psychology
(1951). In his books, Huang tried to use treatment methods similar to supportive therapy which
3
stressed the collaboration of family members in the cure of mental disorders, giving encouragement
and positive reinforcement for good behaviors, and neglecting bad behaviors. This was a significant
advance in the utilization of therapy methods on children' s mental health problems in the history of
China (Qian, 1995).
Soon, after the founding of the People's Republic, a campaign was underway to learn from
the Soviet Union. As psychology in China before 1949 was mainly influenced by the West, a shift
was made toward Soviet psychology which centered on the physiological basis of human behavior.
Western psychology, psychological testing, counseling, and psychotherapy were all considered as
bourgeois ideology or practices, and were criticized. In effect, it became accepted that child and
adolescent health care could only be studied in their physical aspects, thus mental health was
eradicated from the agenda.
Following the Soviet tradition, clinical psychology was called medical psychology. From
1955 to 1964, Chinese medical psychologists were involved in a unique kind of psychotherapy
called "Speedy Synthetic Therapy of Neurasthenia" in which neurasthenia was treated by a
combination of medical treatments and traditional Chinese exercises such as Qi Gong, Taijiquan,
meditation, and rational explanation of the nature of disease. Patients attended lectures and were
arranged into small groups to participate in discussion sessions. The method was later extended to
the treatment of other chronic diseases, including schizophrenia, hypertension, and peptic ulcers.
The general theory was that the cognitive understanding of the nature of the disease would enable
patients to mobilize his or her own "subjective initiative" (Tzedong Mao's term) to develop self-
confidence for curing the disease. Hallucinations and delusions were described in relation to the
specific instances that could be tested against reality; paranoid symptoms were explained in such a
manner that patients began to doubt their own false beliefs. The results had been quite successful,
as evidenced by a 7-year follow-up study of patients who received the treatment. In 1991, Li
summed up this treatment and renamed it Comprehensive Practice Psychotherapy. This was the first
indigenous Chinese psychotherapy developed after the founding of the People's Republic of China.
However, with the onset of the Chinese Cultural Revolution in 1966, psychology was the
first scientific discipline to be attacked by the "Gang of Four" as a so-called bourgeois
pseudoscience. This time, psychology and mental health wei'e uprooted completely as scientific
disciplines. Psychological research was abandoned, teaching institutions were dissolved, and
psychologists were dispatched to remote areas of the country to work in the farms and factories;
mental health cares ceased to exist. The Cultural Revolution ended in 1976, and several years later
the rehabilitation of science and education took place.
The Revival of Mental Health Practices (1976-present)
In the two decades after the Cultural Revolution most acute and infectious diseases have been
controlled. This is primarily due to social economic development and improved health care. Aside
from physical health, the importance of children's mental health is being recognized, child and
adolescent mental health problems are being studied and placed on the Chinese governments agenda.
In 1978, the Chinese Psychological Society resumed its activity, and in 1979 a division of
medical psychology was established. In 1985, the Chinese Association of Mental Health was
established as an inter-disciplinary organization, and branches existed in most provinces.
Subsequently, 11 sub-divisions were established, among which were the divisions of children's
mental health, adolescent mental health, and university students psychological counseling. Three
journals were published: (1) Chinese Journal of Mental Health (1987); (2) Chinese Journal of
Clinical Psychology (1993); and (3) Health Psychology Journal (1992).
In 1976, the Child and Adolescent Research Institute was founded under the Chinese
Academy of Social Sciences. Later, Beijing Medical University also established a Child and
Adolescent Research Institute. In 1981, the World Health Organization (WHO) organized the
National Symposium on Children's Mental Health in Nanjing, in which the most urgent problems
of child mental health in China were identified. This led to the WHO/China Workshop on the
Psycho-social Aspects of Primary Health Care, which took place in Beijing in 1983. From then on,
pediatricians, psychiatrists, psychologists, and public health workers joined hands to study not only
the physiological aspects of child and adolescent health, but also mental health problems in school
and at home. At present, a movement of mental health guidance for primary and secondary school
children is underway.
In the late 1970's, psychological testing and counseling were rehabilitated after some 30 years
since the founding of the People's Republic. Today, most hospitals, universities, and high schools
in big cities have mental health clinics. Psychological tests are widely used in the medical field for
diagnosis, counseling, and psychotherapy. In 1990, over 80 tests were used in China. Most of these
are revisions of Western tests, with the most common being intelligence and personality test;,
projective tests are rarely used. Counseling for college and high school students is becoming
common in China. Some of the most common complaints of Chinese students are obsessive-
compulsive behavior, interpersonal relationship problems, anxiety, inferiority, and pessimism.
Recent shifts in the conceptualization of health has increased the involvement of psychology
in the study of human development. The traditional medical model of physical health has been
replaced by a more holistic social-behavioral model of psychological health. Health is not only a
medical problem, but a social behavioral problem as well. With this shift comes a corresponding
shift in focus from the sick person to the individual's personality, and from the treatment of disease
to its prevention, with a stress on the environmental conditions that bring about morbidity. This new
perspective requires a more holistic psychological conceptualization of human development,
stressing the complex interactions between the individual and their environment, including family,
community, and cultural factors which affect the individual's life-span development.
Current Mental Health Problems of School Children
Mental Retardation
From epidemiological studies, one of the most pressing mental health problems of children
and adolescents is mental retardation. A nationwide survey conducted in 1987 (CDCC, 1996) by
Chinese government agencies on 460,613 children aged 0-14 showed that 12,242 children were
disabled, yielding a prevalence rate of 2.66%. The children population was 307.5 million at that
time, and it was projected that there were 8.17 million disabled children. Among these disabled
children, 66% were mentally disabled, i.e. mentally retarded, amounting to 5.39 million children;
the male to female ratio was 1.18:1. The prevalence rate was found to increase with age, 1.42% for
2 year olds increasing to 3.76% for 21 year olds. The prevalence rate for big cities (Beijing 1.67%,
Shanghai 1.59%) was found to be lower than for remote inland provinces (Guangxi Province 4.34%,
Yunnan Province 4.44%), and in general, lower than rural areas (city 1.46%, village 2.82%).
Another national survey conducted in 1988 in 8 regions of China on 85,170 children aged 0-14
showed a mental retardation prevalence rate of 1.2%, with 0.70% for cities, and 1.41% for rural
areas, male 1.24% and female 1.16%. The distributions of mental retardation were mild 60.6%,
moderate 22.7%, severe 9.6%, and profound 7.1% (Zuo et. al., 1994). The main cause for mental
retardation in cities was prenatal, while for rural areas was postnatal.
Table .1 Proportion of Chinese Children's Disabilities
Disability Proportion Male/Female Ratio (M:F)
Mental Disability 66.0% 1:81.1
Speech Disturbance 14.2% 1:84.1
Motor Disability 7.5% 1:52.1
Visual Impairment 2.2% 1:32.1
Psychiatric Disorder 0.2% 0.61:1
Combined Disabilities 9.9% 1:63.1
School children with a mild degree of mental retardation attend ordinary classes, however,
in some primary schools special classes were established for mild cases of mental retardation. Only
children who are severely mentally handicapped attend special schools. In the past two decades,
special education services in China have rapidly increased. In the first 53 years after the founding
for the People's Republic, there were almost no schools for mentally retarded children, only schools
for the blind existed. In 1983, China established the first mentally retarded rehabilitation center.
By 1985, the number had reached 446; the most noted one being the Xin Yun Mentally retarded
School founded by the psychologist Yuyan Mao in Beijing.
Prevalence Rate of Behavioral Problems
From 1985 to 1995, the physical development indices of Chinese children, such as height and
weight, increased markedly, and there is a trend of advanced development of puberty. However,
there is also an increase in the number of psycho-social problems. Tang and Xin (1993) used the
Chinese version of Achenbach's Child Behavior Checklist (CBCL) to screen 2,432 cases of 7-14
year old primary school children in Beijing, and obtained similar results showing a total prevalence
rate of 13.16%; the teachers questionnaire for school behavioral problems was 6.95%. Prevalence
rates found by other researchers usually fall between 8.72% and 14.89%. The results of some recent
investigations are listed in Table .2
Table 2. Prevalence Rate of behavioral Problems of Chinese Children.
Researcher No. of Cases Age of Subjects Scale Prevalence Rate
Tang, et. al. (1993) 24013 4-13 Yrs. CBCL* 12.97%
Li, et. al. (1993) 8644 4-16 CBCL 14.89%
Su, et. al. (1993) 2522 3-16 CBCL 8.72%
Yu, .te al. (1994) 1414 12-18 CBCL 13.50%
Guo, .te al. (1995) 2941 6-11 CBCL 13.81%
Wang, et. .la (1989) 2432 7-14 Rutter BRS** 13.16%
Qiao, et. al. (1995) 4433 7-12 Rutter BRS 14.20%
Li, et. al. (1995) 1151 7-15 Rutter BRS 9.60%
Hu (1994) 500 14-17 SCL-90*** 10.80%
* Achenbach's Child behavior Checklist
** Rutter's Behavioral Rating Scale
*** Derogatis' Symptom Checklist 90
The results of the study by Li .te al., (1993) using the CBCL on 8,644 children aged 4-16 in
Hunan Province showed that: (1) the prevalence rate of behavioral problems of Chinese children is
quite high, averaging 14.89%; (2) mental health problems are positively related to age, older children
having a higher prevalence rate that younger children; (3) the prevalence rate is lower in cities
(14.18%) than in rural areas (16.13%) suggesting that children's mental health problems are
positively related to economic development; (4) generally, there is a higher prevalence rate for male
children (18.49%) than female children (10.80%), except for emotional disorders where female
children have a higher prevalence rate; and (5) for young children of 4-6 years, the most frequent
problems are developmental disorders, for 6-11 year olds, both developmental and behavioral
problems become frequent, while for 12-16 year olds, behavioral and emotional problems become
prominent. Wang and Shen (1989) found that of the behavior problems most identified in children,
anti-social behavior occurred more frequently, and at a higher rate among male children than female
children. The results were correlated with school performance using standardized Chinese ratings
and it was found that low performance children have markedly higher rates of behavior problems
than high performance children.
Among anti-social disorders, the most frequent complaint raised by parents and teachers in
China concerns Attention Deficit Hyperactivity Disorder (ADHD), occupying about half of the total
behavior problems. The high rate of ADHD may be attributed to the one child family program; the
only child being the focus of attention of parents and teachers. In Chinese classrooms, children have
to sit quietly 45 minutes, so any overt movement can be easily noticed. In Chinese child psychiatric
and counseling clinics, hyperactivity has been the most common problem awaiting treatment.
However, surveys conducted in Beijing, Shanjhai, Guangzhou, Nanjing, Xian, Moudanjiang, and
other cities vary greatly in prevalence rate, ranging from %1 to 14%. Zhang, Song, and Cui (1986)
conducted a survey in 71 primary schools on 9,966 cases using a series of psychological tests
(Children Activity Scale Test, Attention Cancellation Test, Bender Gestalt Test, Benton Test, WISC-
R, and Draw A Person Test). The results showed a prevalence rate of 2.25%. These authors also
compared 200 ADHD children with 200 normal children, and showed that parents behavior and
family education had a great influence on ADHD morbidity. Also, Gonner's Inventory and Hsu's
Children Behavioral Assessment Inventory have been used, all showing that ADHD children had
lower intelligence scores than normal children. An EEG study comparing normal children and
ADHD children during different mental performances showed that there are differences in alpha
rhythms in the left and fight hemispheres (Kuang &Chen, 1985). Lin and Tang (1985) studied
family environment, attention tests, and peripheral adrenaline secretion in hyperactive children and
found these children were significantly disadvantaged by family environment. They also found that
some ADHD children exhibited a specific pattern of adrenaline excretion during rest-test-rest
periods. The authors maintain that adrenaline analysis might be a useful guide for the diagnosis of
ADHD.
Recently, special attention has been paid to Autism. In 1994, the Bureau of Education of
Beijing Municipal Government initiated experimental studies on autistic children. It is estimated
that among the 5.1 million children and adolescents in Beijing, there are 300-600 autistic children.
Beijing Medical University made systematic observations on 80 autistic children and published a
guidebook on the education and training of autistic children. In 1995, an Association for
Rehabilitation of Autistic Children was established in Beijing. In Shanghai and Nanjing, there are
similar organizations.
