“Language Therapy Teacher?”
The man across the table considered this as he slurped his bowl of noodles. “So you help people when they can’t speak well?”
“Yeah. Well… that’s part of it.”
It was a hot summer’s day and sweat beaded my brow as I told this chatty stranger about what I was studying back in the US. He listened patiently and even helped me fill in words I didn’t know. Looking back, maybe it was amusing for him to watch me talk about helping repair communication in my obviously broken Mandarin.
“You know, my niece started talking late and still mixes a lot of words up. A friend of mine also had a stroke a few years ago and had trouble communicating. I haven’t heard from him in a while. People here don’t talk about this kind of stuff even though they could use help. Come back and help us someday, ok?” he smiled.
As I left Suzhou that summer in 2017, I contemplated the implications of our conversation. If public knowledge and access of speech-language services is still less than ideal in the U.S, a country that is generally educated and accommodating to disabilities & disorders, what was the state of speech-language pathology like in China? Three years later as I wrap up my graduate studies, I reflect on all I’ve learned about barriers to services and considerations when working with culturally & linguistically diverse clients since that summer.
In this blog, I’ll be sharing my findings about the state of speech-language pathology in China as well as my own personal experiences.
Speech-language Pathology as a Profession
One of most prominent barriers people in China face when it comes to getting services is the limited number of specialists available. An estimated 10,000 speech-language pathologists (SLPs) are currently working in China (Hao et al., 2015) which is only about 6% of America’s estimated 153,700 SLPs (US Bureau of Labor Statistics, 2020). Imagine a fraction of our professionals scrambling to serve a country with more than four times the population!
Speech-language pathology is still a relatively new field in mainland China. The first speech therapy department was started in the 1980s as rehabilitation medicine was introduced (Ip et al., 2012). While rehabilitation medicine in general has been advancing rapidly since then, the development of speech-language therapy has been dragging behind.
The slow progress is in part due to the lack of national systems in place to become a trained professional in this field. If someone were to be interested in the field, they could become easily deterred from pursuing it once they discover that the education and certification to be an SLP are still surprisingly inadequate. According to Lin et al (2016), there were “only 4 medical schools in Mainland China that have 4-year undergraduate-level programs, and less than 10 medical schools that have 3-year graduate- or doctoral-level training programs for speech-language therapists.” This is a stark contrast to the US which as of 2020 has 289 master’s degree programs in the field (ASHA, 2020). Additionally, courses and skills are not standardized across programs in China which hinders students from obtaining a comprehensive education for diagnosing and treating a wide range of communication disorders (Lin et al., 2016).
Since these programs are so few and far in between the route that many seem to take to become an SLP has been to train as a physical therapist and then participate in continuing education programs in speech-language therapy for a few months. This is acceptable as there is little to no guidance for certification. There are no national standards to be met. Doctors, nurses, and others can even self-identify as SLPs citing their experience working with clients who have communication or swallowing disorders as sufficient (Lin et al., 2016). The Chinese International Speech, Language and Hearing Association (CISHA) was only founded in 2014 (Hao et al,, 2015). And while its establishment is certainly a big step in the right direction, there is a lot of catching up to do in terms of creating and implementing standards for SLPs.
Why has it taken so long to get the ball rolling for SLP services anyway? The answer lies in slow-to-change cultural attitudes surrounding well-being.
Cultural perceptions and knowledge of speech-language disorders
In China, good health is the most prized possession. Everyone witnessing an ailment that attack’s one physical health agrees that it is a serious matter to be addressed immediately. But what about other maladies that aren’t so easily explained or understood? True to what the man in Suzhou had told me, speech-language disorders, mental illnesses, and other conditions are commonly swept under the rug.
When my mom called me in the beginning of April, we talked about the unfolding of our new normal during COVID-19. As we were about to hang up, my mom yelled “Wait! I forgot to tell you. Do you know what’s special about this month?”
“Ah yes but no. I was talking about 星星的孩子 (xing xing de hai zi) month. I’m surprised you don’t know.” she said smugly.
It turns out that April is Autism Awareness Month.
星星的孩子 (xing xing de hai zi) translates to “children of the stars”. That was the first time I had heard this term used for children with autism spectrum disorder (ASD). I was more familiar with the other terms “ 孤独症” (gu du zheng) which translates into “alone syndrome,” and 自闭症 (zi bi zheng) or literally “self‐enclosed syndrome.”
My mom was proud not only because she knew the occasion but also because she actually knows more about the disorder than many of her friends. Even though autism is recognized in China, it is still not widely understood. Cultural attitudes as well as lack of access to education when it comes to ASD and many other disorders in China continue to pose barriers to services for individuals.
All cultures hold their own beliefs and perceptions as to what is typical and what is different in terms of physical appearance, behavior, values, and illness. Stigma exists in all cultures and is generally attached to those who are different or even considered by the public to be deficient. To understand China’s cultural attitudes towards speech-language disorders, we must discuss the concept of “face” which in English is incompletely translated to honor. “Face” is directly tied to relationships and interactions with others and one’s image within a social group. Lin Yutang (1935) wrote, “it is not a face that can be washed or shaved, but a face that can be ‘granted’ and ‘lost’ and ‘fought for’ and ‘presented as a gift’. Here we arrive at the most curious point of Chinese social psychology. Abstract and intangible, it is yet the most delicate standard by which Chinese social intercourse is regulated”.
Because “face” is rooted in social interaction, disorders that affect communication will be especially detrimental. Those with ASD or stuttering, for example, will be seen as atypical communicators who disrupt social harmony and thus lose face. Additionally, because of China’s collectivistic culture, an individual’s face is inseparable from their families’, meaning that the family will also feel great shame. This cultural attitude and the stigma surrounding speech-language disorders often prevents people from acknowledging these issues and seeking appropriate therapy.
Feeding into the stigma is the lack of educational resources available on disorders such as ASD. The amount of published research on autism in China is extremely scarce compared to the amount in the West. Additionally, the flow of findings from Western literature is relatively slow and dependent on the interests of Chinese academics who read English fluently (Wang et al., 2019). Therefore, little scientific information regarding autism makes it to the public. Many autism intervention organizations are founded by parents who learn techniques by trial and error with their own children (McCabe, 2013). Parents may look to schools to guide them, however most SLPs in China work in hospitals with relatively few working in schools. The next people to turn to then are teachers. In wealthier provinces and cities, teachers are more knowledgeable about working with children with autism and other disorders. In the majority of regions of China, however, accommodations are missing as teachers do not receive proper training and knowledge. Even worse, it is not uncommon for children with autism to be excluded from government-run schools, whether general or special education (McCabe, 2013). Intervention for children with autism occurs generally outside of the school system usually in private organizations or medical institutions. This is extremely costly to families and introduces yet another barrier to services.
As I’ve been researching the state of speech-language services in China, I can’t help but think about my own experiences here in the US and specifically in Maryland. This spring semester I had the opportunity to work with children in pre-k to 2nd grade in a public elementary school as part of my graduate externship. Alongside my supervisor, I provided therapy to children with ASD, intellectual disabilities, and a range of other disorders. One of my favorite experiences was being able to take part in an Augmentative & Alternative Communication (AAC) evaluation for a child with ASD who we’ll call Peter. Peter was nonverbal and engaged in self-stimulating behaviors like hand-flapping and rocking his body often. We found in previous therapy sessions that he could identify common objects and animals by pointing to pictures in a communication book, however the book was cumbersome and ineffective at communicating his actual needs. During the AAC evaluation, with guidance from the SLPs he picked up how to use a speech-generating device quickly and by the end was even requesting goldfish crackers independently.
When I think about kids in China like Peter, it feels so unfair. Not to say that everything is perfect in the US, but here at least, there are resources. SLPs in school systems are common. Awareness of speech-language disorders is more prevalent and there exists greater accessibility to knowledge. I want to imagine a future where China has an adequate supply of SLPs, where children are supported rather than excluded, and where everyone has access to tools that will enable them to communicate joyfully.
As my graduate career comes to an end, I can’t believe how much I’ve learned in the past two years about speech-language disorders, cultural & linguistic considerations, and ultimately how to interact with other human beings. In the fall, I’ll be heading to Shanghai, China to start my Clinical Fellowship Year as an SLP. It almost seems too good to be true– to have this opportunity to both experience first-hand what the field is like over there and to take part in the future that I imagine. I’m proud to be joining the team at China ELG because they are leaders in a movement to raise awareness and provide educational resources to the public regarding SLP services. As I begin my next adventure, I’m excited to share all my new knowledge with another poor soul in a noodle shop.
ASHA. (2020). Retrieved from https://www.asha.org/
Hao, G., Mccrea, E., Mcneilly, L., & Wang, R. (2015). CISHA: The History and Development of the Chinese International Speech, Language and Hearing Association. Perspectives on Global Issues in Communication Sciences and Related Disorders, 5(1), 12–20. doi: 10.1044/gics5.1.12
Ip, M. L., Louis, K. O. S., Myers, F. L., & Xue, S. A. (2012). Stuttering attitudes in Hong Kong and adjacent Mainland China. International Journal of Speech-Language Pathology, 14(6), 543–556. doi: 10.3109/17549507.2012.712158
Lin, Q., Lu, J., Chen, Z., Yan, J., Wang, H., Ouyang, H., … Oyoung, B. (2016). A Survey of Speech-Language-Hearing Therapists Career Situation and Challenges in Mainland China. Folia Phoniatrica Et Logopaedica, 68(1), 10–15. doi: 10.1159/000442284
Speech-Language Pathologists : Occupational Outlook Handbook. (2020, April 10). Retrieved from https://www.bls.gov/ooh/healthcare/speech-language-pathologists.htm
Wang, B., Cao, F. T., & Boyland, J. T. ( 2019) Addressing autism spectrum disorders in China. In Y. Liu (Ed.), Child and Adolescent Development in China. New Directions for Child and Adolescent Development, 163, 137– 162.
Yutang, Lin (1935). My Country and My People (Hardcover) New York: Reynal & Hitchcock. pp. 199–200.
About the Author
Tracy Wong is a graduate student in the department of Hearing and Speech Sciences at the University of Maryland. She is a member of the Cultural-Linguistic Diversity Emphasis Program (CLD-EP) and the Bilingual Certification Program. Her clinical interests include school-age language development and literacy.
Expenses related to this research were funded by the MCM Fund for Student Research Excellence. This award is designed to support independent student research projects, and is made possible by an anonymous donation to the Department and by other donations by faculty, alumni, and friends. Please consider donating to the fund through the following link: https://giving.umd.edu/giving/Fund.php?name=mcm-fund-for-student-research-excellence-in-hearing-and-speech-sciences