China

China has a long and complex 5000-year history. It was one of the first areas of human civilization and the Chinese were one of the first to invent and use a standardized writing system. The society produced incredible sculptures and art to depict their culture. Over centuries, it was ruled by 23 dynasties.

The last dynasty was the Qing Dynasty, which ended in 1912 with the establishment of the Republic of China under Sun Yat-sen. Internal and external conflict continued to persist within China during the subsequent decades, with a civil war between the growing political parties (Nationalists and Communists) and the Japanese invasion from 1937-1945. After the Japanese were defeated, the civil war resumed and the Nationalists, led by Chiang Kai-Shek were defeated by the Communists, led by Mao Zedong. Chiang Kai-Shek and his Nationlist followers retreated to Taiwan, where he assumed leadership.

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Religion

The People's Republic of China is officially atheist, although many religions and ritualistic practices are evident in Chinese traditions. It is estimated that approximately half of the population considers themselves non-religious. The remainder of the population practices one or more religion simultaneously, including folk religions or Taoism (approx. 30% of the pop.), Buddhism (approx. 15%), Ethnic minority indigenous religions (4%), Christianity (4%), and Islam (2%). Practitioners of these various religions can be found throughout the country, however some regions of China are dominated by a particular religion. Various forms of Buddhism are seen and practiced throughout the country (in Tibet, the vast majority are practitioners); Taoism, too, is seen throughout the country, but is particularly strong in Sichuan; Christians are mostly found in the eastern areas of China (a remnant of missionaries' arrival to the eastern seaboard); and the population in northwest China is primarily Muslim. The teachings of Confucianism, better described as an ideology rather than a religion, are guiding principles which have heavily influenced traditional (Han) Chinese values. A number of holidays are specifically centered on honoring and making prayers to deceased ancestors, including Tomb-Sweeping Day (also known as Qingming Jie or Clear and Bright Festival).

View of Death

In China, death is a public affair. There is no time limit on the grieving process and the degree of elaborateness of the funeral is a symbol of status. According to traditional beliefs, the dead continue to live in another world amongst the living. If the dead person is unhappy with the burial process it is believed that the family may be plagued with bad luck. It is this association of death with bad luck that makes the topic of death taboo. For this reason, the number 4 (四, pronounced 'si', 4th tone) is an unlucky number because it sounds like the word for death (死, pronounced 'si', 3rd tone). It is particularly shameful to experience the death of a child. It is considered an unnatural death and the parents may be viewed to have done something to receive bad luck.

Holidays

Numerous official and traditional holidays are celebrated in China. Various minority groups celebrate additional holidays unique to their specific traditions. Many holidays have prescribed food that is traditionally eaten, as well as certain celebratory activities. Nearly all holidays prioritize spending family time together, and involve lighting a lot of firecrackers and fireworks.

Official Holidays: (Western) New Year’s Day – January 1, Chinese New Year (also known as Spring Festival) - 1st day of 1st lunar month (usually January or February), Qingming Festival (Clear and Bright Festival, or Tomb-Sweeping Day) - Early April, Workers' Day (or Labor Day) - May 1, Dragon Boat Festival - June, Mid-Autumn Festival - September, National Day (founding of the People's Republic of China) - October 1.

In addition, International Women's Day is celebrated on March 8 and Children's Day is on June 1.

Religious holidays are observed by respective members of each group. Besides being celebrated by Chinese Christians, Christmas is also celebrated as a secular holiday as a sort of Valentine's Day for young couples, complete with bouquets, teddy bears, and heart-shaped candy boxes.

It is important for SLPs working within this population to be aware of the different holidays especially when it comes to scheduling, as well as topics of to be incorporated into therapy sessions.

Food

Food is of primary importance within Chinese culture. Chinese people frequently greet each other with a phrase which translates into English as, "Have you eaten yet?" Likewise, there are many food-related idiomatic expressions in Chinese. People often give nicely packaged food as gifts to one another. There are a variety of food practices in China that are based on folk culture, religion, district or festivals. For example, it is common to eat noodles on one's birthday as a symbol of longevity (one must eat the noodles whole without cutting them to shorter lengths); moon cakes during Mid-Autumn Festival; and dumplings for Spring Festival (Chinese New Year). Diets based on religion are usually vegetarian such as with Buddhism and Taoism. In addition, those who practice Islam do not eat pork. Traditional dining practices consist of the family unit coming together to eat an evening meal. Chinese people drink hot water with meals and throughout the day, as this is said to aid the digestive process. Tea is also an important drink, though slightly less prominent than simple hot water. The principles of Yin-Yang are prevalent in Chinese society. Maintaining a balance between Yin (white)-Yang (black) can play a role in diet. Each represents a cooling or warming property. An imbalance can result in illness.

Since the role of food can be greatly different among this population it is important as SLPs to investigate your client's families view of what foods can be consumed. Large regions of China do not traditionally eat rice, for example, and more commonly pair their meat and vegetable dishes with noodles instead. When working with feeding and swallowing disorders, it is important to work with the foods the client is going to be consuming at home.

Family

Traditionally the roles of each family member were based on the social order from Confucianism. The father, traditionally had complete control of the family unit. Today, the father has less rule of the family. Men still hold a dominant role within the family unit, however women are gradually gaining a more equal status. It is common for children to live with their families until marriage. In addition, it is expected that the children return for important holidays such as Chinese New Years. It was the original stereotype that among Chinese families, there are multiple generations all living under the same roof. This may still be the case for Chinese families, but should not be assumed. It is important for the SLP to learn each families structure and who is involved in the client's life. It should not be assumed that grandparents will be a caregiver within the home.

Traditional American Medicine vs. Chinese Medicine

China is one of the first countries to have a medical culture. While American medicine is focused on treating the symptoms of specific ailments, Chinese medicine is traditionally focused on a holistic approach. Influenced by Confucianism, Buddhism and Taoism, Chinese medicine has an emphasis on mind and social interactions.

Acupuncture, for example, is based on the principles of yin-yang and qi. Yin-Yang is where the body is divided into regions and qi is based around energy. Chinese herbal medicine is also based on the principles of yin-yang and dates back to 3rd century BC.

Western and Chinese medicine are slowly becoming integrated. Many Chinese medical students take courses in both Western and Chinese medical philosophy. Within China, traditional Chinese medicine is considered to be most efficacious and most doctors are firm believers, though Western medicine is widely practiced in China.

View of Receiving Medical Treatment

Since there is such an integration of Western medicine in Chinese society most Chinese do not see Western medicine and traditional Chinese medicine as being in conflict. In emergency situations, there is no hesitation in using Western medicine. However, a belief in Chinese medicine to maintain health is still strong. The biggest concern is the language barrier. It is important for SLPs working in hospital settings to do everything to bridge the communication gap between clinician and patient. Having an interpreter during evaluations and treatment can be extremely important in the medical setting. This is evident within the area of swallowing disorders where the training of swallowing precautions with the family and client can become a life-saving skill.

Education

Public education, though not universal, is now widely available across China, lending to high literacy levels nationwide. 96% of males and 88.5% of females (2007 estimate) over the age of 15 can read and write (total population), while approximately 99% of males and females between the ages of 15 and 24 are fully literate. In 1986, the government began working towards providing a compulsory 9-year education for children nationwide. Twenty years later, in 2006, the government declared their commitment to providing free education for all children ages 6 to 15, including textbooks and fees. After the 9 years, people may choose to continue on to vocational school, or senior high school, and eventually on to college, or university. In order to attend university, graduating high school students must sit for a national exam, which they spend many years preparing for, both in regular day school, as well as in in specialized evening schools. Based on the exam outcomes, there may be opportunities to obtain higher education, but tuition costs pose another barrier to some. Paying for higher education is funded out of pocket, no government support is provided. Between 1966 and 1976 (during the Cultural Revolution), China experienced a sharp decline in higher education and the system was nearly terminated, causing a problematic interruption of many peoples' educational progress. In 1985 all public funding for higher education was discontinued. As China's economy expands and personal wealth increases, higher education is gaining momentum and the attendance rates are increasing. Universities are expanding across the nation. More and more students study abroad. In fact, more students study abroad from China than any other country.

Learning Disabilities in the Schools

In China, children who are gifted advance in grade level. Those with disabilities are allowed to attend school as long as they are making progress. If progress is not made, the child will not advance to the next stage of education. There are no special classrooms within the school for those with disabilities, handicaps, or psychological disorders. Traditionally, the responsibility to educate the child rests on the parents, not the school. In 1984 the China Welfare Fund was established. As a result, greater attention was given to blind and hearing-impaired children, but only 2% of eligible children were admitted to the special schools. The Welfare Fund allowed China to receive funding for special education from abroad. Unfortunately it was not well funded and special education remains a low priority, although small changes are occurring. Precise numbers vary, but there are approximately 550 schools for the deaf in mainland China, and somewhere between 683 and 1,540 schools for special education, some of which have additional classrooms for the deaf. Additionally, there are a reported 1,000 vocational training institutes for people with disabilities, almost 3,000 standard vocational training and education institutes that admit people with disabilities, and over 1,700 training organizations for the hearing-impaired--all of which are publicly funded. In 2004, 4,112 students with disabilities attended ordinary schools of higher education. According to 2006 statistics from the China Disabled Persons' Federation, there are just over 20,000,000 people who are deaf living in China.

Languages Spoken in China

There are approximately 300 spoken languages and multiple written languages in China. The following is a list of some of the most prominent spoken languages and dialects:

• Standard Chinese or Mandarin (Putonghua, based on the Beijing dialect),

• Yue (Cantonese )

• Wu (Shanghainese)

• Minbei (Fuzhou)

• Minnan (Hokkien-Taiwanese)

• Xiang

• Gan

• Hakka Dialects

Pragmatics/Social Communication

• Greetings - Shaking hands is becoming a more universal greeting with China's increasing internationality, however in China it is commonly paired with a head nod or the a slight bow of the head.

• Personal space - Personal space is much smaller in China than is customary in American society.

• Beckoning - To beckon for someone the palm of your hand needs to be down and your fingers make a scratching motion. It is important to avoid using the typical Western gesture of having the palm up and curling the index finger. In China this is a gesture used to beckon an animal and is considered to be rude.

• Other - In Chinese culture, people tend to avoid using the word “no”. In Mandarin, 'no' or a negation is usually said in phrase form. Therefore, in therapy sessions it would be considered polite to use a more indirect way of saying “no”. In addition, in formal settings (such as a therapy session), many Chinese individuals would consider it most respectful to refrain from speaking up until directly addressed or asked their opinion. When interacting with Chinese families, it is important that the clinician allow the family space and time to respond, as well as be clear that their input is valued and desired.

Interacting With People from the Chinese Culture

When interacting with Chinese people, as with any client, it is important to be respectful, self-aware, and cognizant of potentially disparate viewpoints regarding definitions of disability, the cause of the disability, and best practices for assessment and treatment. The following are some suggestions which are universally applicable:

The Meeting

Respect the hierarchy of the family. Address adults with their proper title. Don't assume familiarity. Speak slowly and clearly, regardless of the family's linguistic background. Make sure to reserve time in the meeting for questions, and ask the family for feedback--not everyone will voluntarily comment unprompted. Focus on strengths and include bilingualism among them.

The Assessment

It is possible to experience hesitation from the family to receive therapy. To facilitate this cultural exchange, it is most helpful to have a competent interpreter. It is also important to clearly state your intentions as the SLP and what you are going to be doing beforehand (i.e. before taking surveys, asking personal questions, or administering tests). This process may seem very intrusive to some and it is important to keep the process as transparent as possible.

The Diagnosis

When diagnosing a disorder, be aware that certain diagnostic labels may be particularly upsetting to the parents or family. Use descriptive terms when describing disorders and delays which open the conversation to your proposed treatment plan.

Among Chinese families, disorders are sometimes considered an embarrassment for the family which they would prefer to downplay or deny. Discretion and tact on the part of the SLP and diagnostic team are therefore paramount.

The Treatment Plan

• Don't take it personally if a family refuses service. There are multiple reasons that this may occur including fear, mistrust, and a lack of buy-in.

• It is very helpful to provide information about the whole assessment/diagnosis/treatment process in the family's native language. Additionally, including a representative from the community may be helpful to serve as a cultural liaison. Be aware, however, that involving a non-family member may create some stress for the family, as they may wish to keep very private the presence of a disorder.

• When devising a treatment plan, the SLP should be in charge of the plan. At this point, the family has deferred to the professional and is looking to the professional for guidance. Create the treatment plan so that it has structure but is open for changes or input. This allows the family to contribute to the plan if the family feels comfortable.

• It is commonly acceptable for the SLP to provide suggestions for parent intervention outside of clinical therapy.

• It is often difficult for those in the Chinese culture to ask questions directly. It is important as the SLP to ask specific questions to determine if therapy is going smoothly (i.e. "What happens when you ask Jon to put on his jacket?") versus general questions (i.e. "Do you think Jon understands what you say when you ask him to do something?").

Helpful Functional Spoken Phrases for the SLP

Expanded and updated by Molly Franz, March 2013