Services for People with Intellectual/Developmental Disabilities in China: An American Experience

Barbara Pilarcik, BSN, RN

Abstract

In September 2001, professional delegates representing the American Association of Mental Retardation were invited to visit the People’s Republic of China to view programs and services for individuals with intellectual/developmental disabilities. The goal of the exchange was to increase awareness and knowledge of China’s present approach to intellectual disabilities, and to identify prospects for future service and policy development.

China is the world’s most populous country, four times that of the United States. It is also a country that is rapidly changing in many ways including its approach to intellectual disabilities and health care. Thus, it was timely to enhance and extend the dialogue between professionals in China who are concerned with helping people with intellectual disabilities.

The delegates visited services in three large cities: Beijing, Xi’an, and Shanghai. Programs visited included the leading hospital for children in Beijing; a venture between a disability federation and a manufacturing company that provided services to employees’ disabled family members; a residential school developed and directed by a parent of a child with cerebral palsy; mental health hospitals; special education schools; and a rehabilitation center. Topics discussed included government support of families, screening and assessment programs, educational services, employment programs, medical services, the use of neighborhood councils for service provision, and the integration of traditional Chinese medicine with allopathic treatments. Several research projects were observed.

In this paper I will discuss those visits and describe what I observed. Although I am a westerner, I will try to leave interpretation to you, the reader, as much as possible. I will describe some of the history of China and will provide current information from the World Health Organization. As nurses, we recognize the importance of the culture in which individuals live and I present a brief description of the cultural context of China. While it is not my intent to invite comparison, I have presented some information on World Health Organization health indicators that describes both the United States and China. Nursing education, including the joint efforts of United States and China’s educational institutions, is reviewed. It is my hope that I have portrayed the services and our visits accurately. Finally, information in this article is largely based upon our time in China and the interactions with our hosts. I do not have any Chinese language ability and most of our visits/interactions were done through translation. While some of our Chinese hosts spoke English, none of the delegates were conversant in Chinese. Communicating through translation has made me realize how challenging communication can be, and given me a much greater appreciation for those individuals who work so much harder to understand and be understood.

Keywords:

INTRODUCTION

In September 2001, I was privileged to visit programs for persons with intellectual disabilities in the People’s Republic of China as part of the American Association of Mental Retardation Delegation to China. Under the sponsorship of the People-to-People Ambassador program, 25 delegates from the United States, Canada and Mexico visited schools and residential facilities for people with intellectual disabilities in three major cities: Beijing, Xi’an and Shanghai. The goals of the delegation were to increase awareness and knowledge of China’s and American’s present approach to mental retardation and developmental disabilities; and to explore prospects for the future.

It became abundantly clear as our trip progressed how important these goals would become as we looked forward to learning about another country and culture. The September 11 terrorist attacks on the United States occurred during our second day in Beijing and transformed the group, our country and the response of the Chinese people and government to our delegation. One of our Chinese hosts said, “We are strongly against the terrorists and what they did because we all try to help people with problems.” Our trip proceeded without incident and we were able to leave as scheduled although our flights home were very different than our arrival.

CULTURE, RELIGION, SOCIETY, AND HISTORY

China is the world’s most populous country with 1,292,378,000 people – about one fifth of the world’s population ¹. It is also a civilization with five thousand years of rich and complex history. In the last half of the 20^th century, China experienced the fall of Imperial splendor, the rise of Communism, the deprivation of the Great Leap Forward, the violence of the Cultural Revolution and the opening of the country to foreign ideas and membership in the World Trade Organization.

It is the third largest country (in size) and is increasingly seen as one of the foremost powers in the world. China invented paper, gunpowder and the compass². By the third century BC the Qin Empire had begun the Great Wall of China and laid the framework for government structures that exist to this day³.

The relationship between the West and China has been and remains a complex one. A communist country since 1949, it has only been open to the West since 1972. From the time of Marco Polo in 1271 through the Opium Wars of 1840, China and the West have engaged in a dance of uncertain rapprochement. China has been invaded but never vanquished and has retained its own individual identity.

Tianxia, or all under heaven, is the representation of the cultural and moral world of the Chinese; it is the essence of being Chinese. In ancient China, it was believed that China was the earthly representation of Heaven’s plan: the center of the world, or Middle Kingdom, from which the influence of the Chinese people and culture extend⁴. The belief in China’s supremacy influences its interactions with other nations and its openness to ideas of foreign origin. The concept of the Middle Kingdom dates to the earliest years of Chinese civilization, and along with the religious and philosophical influences of Confucianism, Taoism and Buddhism, remains a fundamental aspect of Chinese culture.

Confucius, (551-479BC) was an itinerant scholar who traveled throughout China proposing a philosophy of man and society. He believed that the individual cultivation of virtues and observance of reciprocal social obligations would lead to a harmonious society if practiced by all. He taught that xiao (filial piety) is the embodiment of all other virtues and prescribes the duties owed to one’s ancestors. Filial piety extends outwards from ancestors to one’s parents, family, authority figures and society. Obedience is paramount. Confucianism is not a religion but a philosophy, the highest attainment of which is the realization of the human potential for wisdom and virtue³.

Taoism seeks harmony with nature and focuses on the individual’s inner life and the journey of the individual through life; Tao means the “way” or the “Path”. Taoism is not associated with an individual, although Lao Tzu (604-BC-?) is generally credited as its prime exponent. Taoism encourages discipline, meditation, and ascetics in the pursuit of a long life. The balancing concepts of yang (the creative, dominating male force) and yin (the receptive, recessive female force) explained natural and social phenomena⁵. Taoism is a religion and has also evolved into elements of superstition, magic and divination³.

Another major influence on Chinese life and culture is Buddhism. Buddhism began in India and was founded by Prince Siddharta Gautama (560-480 BC). Buddhism teaches the four noble truths related to suffering and the transcendence of suffering through living a virtuous life of non-attachment to worldly things or desires. Buddhism teaches that the world has no reality; it is an illusion that only seems real because people want it to be so. It is this attachment to the illusion of this plane of existence, rather than the cosmic or universal, plane, that produces suffering³.

These three teachings are augmented by ancestor worship, the link between this world and the spiritual world. It is said that ancestor worship is the fundamental basis of Chinese culture³. “The worst imaginable plight for any Chinese is, while alive, to be without known parents and relatives, and when dead, to be without living descendants”³.

During our visit, we saw many reminders of China’s complexities: our guide, “Tony” Zhao lighting red candles to honor his ancestors at The Wild Goose Pagoda; a Chinese family visiting Tianamen Square and asking for a picture with the foreign visitors; the juxtaposition of centuries old sites such as the Great Wall with the fact that most programs we visited were only 30 years old; seeing the Forbidden City filled with Chinese tourists when, as recently as 1911, no one but the Emperor or his retinue were allowed within.

WORLD HEALTH ORGANIZATION HEALTH INDICATORS

The philosophy, structure and financing of health care services is vital to the overall health of the population of a country. The health care policy of China has similarities to the United States and ways in which it is different. The rapid pace of change during the last fifty or so years is evident in the services we visited and in the information gathered by the World Health Organization (WHO). In the Proposed Programme Budget of 2000-2001 of the WHO, China is described as a country undergoing change, as it moves from a centrally planned economy to a market economy. The WHO states “in rural areas, only about 15% of the population has any form of health insurance and village level subsidies for village doctors ceased in 1994. More health services, which in the past were heavily subsidized, now work on a cost-recovery basis”⁴.

As professionals in intellectual disabilities we recognize the importance of prevention, the financial support of health care services, and of qualified and available health care practitioners. The eradication of congenital rubella, elimination of exposure to lead and other toxins, and adequate and available pre-natal and peri-natal care all help to reduce life long disabilities. China has recognized these same areas and other areas uniquely Chinese. In 1996, China proposed a national health policy that emphasized seven areas: health reform, rural health support, prevention, integration of Traditional Chinese Medicine (TCM) and Western medicine, training of medical personnel, pharmacology, and the improvement of health financing. As part of China’s emphasis on prevention, China has focused on immunizations, maternal and pre-natal health and vaccinations. As a result of this, WHO states that China “has achieved high levels of immunization coverage in most areas of the country.” WHO goes on to state, “The major constraints include lack of finance at all levels of government and inequitable distribution of resources for health, including human resources”⁴. Table 1illustrates the differences in per capita health expenditure and financing of health care.

Table 1: Healthcare Finances

	China	United States
Total Population (1000)	1,292,378	285,925
GDP Per Capita (Int'l $)	3852	34637
Total Health Expenditure Per Capita (Int'l $)	205	4499
Total Health Expenditure as % of GDP	5.3	13
Social Security Expenditure (as % of general government exp on health)	50.7	33.7
Population Growth	0.96%	0.92%
Adult Literacy Rate	83%	97% [1]

Prevention is highlighted in the Proposed Programme Budget with two specific goals: lead poisoning and immunizations. They are “Food Safety [4.3.2]” which lists “improved public awareness and interventions for childhood lead poisoning” and “Vaccine-Preventable diseases [5.2.1]” which aims to provide “strengthening of measles control and improving the quality of EPI services including certification of poliomyelitis eradication”⁴. We saw clear evidence of the work on these goals at the Capitol Institute of Pediatrics in Beijing where much of our discussion focused on maternal and pre-natal health care and lead poisoning prevention.

Our experience in China presented us with a mobius loop in time. It seemed we simultaneously experienced one of the oldest developed cultures in the world weaving itself into the new world order of modern technology and economic globalization.

Nursing Education

China opened its first nursing school in 1884, and in 1909 the Nurses’ Association of China was formed⁵. During the Cultural Revolution, nursing schools were closed: for a period of 4-5 years there was no training of nurses, and a nursing shortage resulted⁵. Reorganization of nursing education was gradual. The first college level nursing school opened at Tianjin Medical College in 1983⁶. In 1992 the first Nursing Master’s Degree program opened at the Beijing Nursing School at Beijing Medical University⁷. Currently, several North American Universities have collaborative programs to develop nursing education in China. The University of Ottawa has worked with the nursing department at Tianjin Medical University since 1989. The University of Michigan, funded by the W.K. Kellogg Foundation, has initiated a Community-Based Learning Program between the School of Nursing and the Beijing Medical University⁷. Yale University’s School of Nursing and Hunan Medical University Nursing Department are working collaboratively to provide a “Train-the-Trainer” program on HIV-AIDS prevention and care, a curriculum in community nursing, and a home care nursing system in Changsha⁸.

During our visit, we encountered nurses at the hospitals and mental health centers, but did not have time to engage in further understanding of the nurse’s role. A brief encounter on the stairway resulted in the photograph of a delegate and two nurses.

Intellectual disabilities nursing, as practiced in this country, does not appear to have a counterpart in China.

CHALLENGES

China faces many challenges as it works to expand and develop its health care services. World Health Organization charts comparing the United States and China illustrate disparities in funding, system infrastructure, and leading health indicators. Although United States versus Chinese life expectancy and healthy life expectancy rates are similar there are dramatic differences in child mortality rates⁹, see table 2. As seen in table 3, China child mortality rates for males approach four times as high and for females approaching six times as high. The United States spends $4499 per capita on health care services, and the Chinese, $205. As a percent of the gross domestic product, the United States spends 13% and China 5.3%. Representing a more challenging phenomenon is the WHO indicator regarding insurance coverage: the United States has 62.5% coverage of the population, while 0.4% of China’s population benefits from insurance-type payments. Out of pocket expenditures on health as a percentage of total expenditure on health for China is 60.40% and for the United States it is 15.30%.

Table 2: Life Expectancy Comparison

	China	United States
Life Expectancy at Birth, male	69.8	74.3
Life Expectancy at Birth, female	72.7	79.5
Healthy Life Expectancy at birth (years), male	62	66.4
Healthy Life Expectancy at birth (years), female	64.3	68.8

Table 3: Mortality Rates

	China	United States
Child Mortality (per 1000), male	34	9
Child Mortality (per 1000), female	40	7
Adult Mortality (per 1000), male	157	144
Adult Mortality (per 1000), female	106	83
Infant Mortality Rate (per 1000), live births	37.9 [1]	7.5 [1]
Maternal Mortality Rate (per 100,000), live	56.2	8 [2]

WHO, in a Western Pacific Rim Organization⁹ profile on financing health services, describes major challenges for China as it shifts from a collective or socialized system to a market oriented one. According to the report, inadequate control and regulation of the market has led to decreased access to care and reduced preventive services. WHO describes a gap in China’s health system between the urban areas and the rural provinces.

There is a Chinese expression used to indicate the resilience of the Chinese:

chi-kee, to “eat bitter”¹⁰. China is accustomed to making difficult choices. When visiting programs where physical facilities or resources were primitive by Western standards, it was critical to remember the words of our national guide, Tony Zhao who told us, kindly but firmly, to be very careful to “not compare our country to yours.” Comparison would blind our senses to the rich complexity of the Chinese culture.

OUR VISIT

During our visit to China we visited psychiatric hospitals, residential schools, a rehabilitative center, pediatric hospitals and a joint venture of a Disabled Person’s Federation and an electrical manufacturer.

Capital Institute of Pediatrics in Beijing

Our meeting with the leaders of the Capital Institute of Pediatrics, in the capital city of Beijing, brought WHO statistics to life. The Institute, the leading pediatric hospital in Beijing, was founded in 1958 and has over 900 staff members. It has a 300-bed hospital, outpatient clinics, biomedical product development and sales, professional education, and research. It is a WHO facility. The hospital has more than 4000 inpatients and about 550,000 outpatient visits annually. There is modern equipment available such as CT scanner, Doppler and auto biochemical analyzer.

A comprehensive medical facility, the Capital Institute of Pediatrics is particularly concerned with the diseases of diarrhea, pneumonia and influenza. The Institute monitors trends and patterns in these diseases and attempts to develop vaccines in advance of outbreaks. In discussions with our hosts, Dr. Dai Yaohua, Director of Institute, and Vickie Lin, Director of the Center for Learning Abilities, our delegation explored a variety of topics relevant to intellectual and developmental disability. There is concern regarding lead exposure and of phenylketonuria in their patient population, and our hosts were interested to know of screening and treatment methods for these preventable causes of childhood disability. They reported a significant shift in pre-natal care with the majority of births now taking place in hospitals, thereby reducing their infant mortality rate, as well as morbidity associated with complicated births. We were interested to learn that prenatal substance abuse, while a leading cause of preventable intellectual disability in the United States, is not common in the People’s Republic¹¹. China’s “one-child policy” means that prospective parents are very careful regarding both maternal and paternal health, and penalties for drug possession are quite strict.

The Institute also engages in screening for developmental disability. There is a weekly clinic for assessment of mental retardation. We discussed autism, which they referred to as “withdrawn into self”. In recent years, assessment and screening methods have been expanded from assessment of IQ alone to observation of multiple areas of development. Clinicians at the Institute expressed interest in how we work with the language problems and the social isolation of individuals with autism.

The Institute was representative of modern China: side by side with some of the latest technology were scenes from 30 years ago in the United States. We left the Capital Institute of Pediatrics with a deeper appreciation of the challenges facing this ancient, yet rapidly evolving society.

Mental Health Centers

While in China we visited two mental health hospitals. Although the delegation was in China to visit services for intellectual disabilities, we were surprised to be taken to mental health centers. We didn’t observe services for individuals with intellectual disabilities at either of these facilities.

Mental Health Institute of Beijing

A WHO designated hospital; the Mental Health Institute provides 200 inpatient beds. There are outpatient services, including an eye movement recorder test for schizophrenia and ADHD, sensory integrative therapy, and EEG biofeedback treatment. The Institute also supports community-based home care, and a professional training program that includes post-doctoral studies and research. The Institute uses both Western medicine and TCM.

One difference highlighted was the treatment of obsessive-compulsive disorder (OCD). They stated that they used Morita Therapy to treat OCD. It is a four-week regimen of rest followed by progressive integration into a normal life. At the conclusion of the four weeks, the individual is ready to resume his normal life and has no further OCD symptoms¹².

Xi’an Mental Health Center

The services in Beijing represent a more “western” facility. Much different was our visit to the Xi’an Mental Health Center. Xi’an, the largest city in Shaanxi Province, lies in the interior of China. Home to the famous terra cotta warriors, and ancient capital of the Qin Emperors, Xi’an was the eastern terminus of the ancient Silk Road. It was the least “western” of all of our visits. The Xi’an Mental Health Center practices both TCM and Western medicine, and is organized according to more traditional Chinese social categories.

The Xi’an Mental Health Center, founded in 1957, has 550 beds. The hospital has 11 sections including 5 male sections, 3 female, 1 “first-class patient” section, drug dependence section and a recovery section. Foreigners are housed separately, on the top floor of the hospital.

Traditional Chinese Medicine is used as an adjunct to Western psychotropic drug treatment, as well as a primary therapy. I tried one of the TCM treatments, “Music Audio Frequency Acupuncture Therapy”. I listened to music while receiving a mild electric shock from electrodes placed on each ear. Depending on the severity of the illness, the intensity of the current varies. Acupuncture may be added to increase the effectiveness of the treatment. The current was quite mild and I could not discern any effect. He-Ne Laser Therapy or Blood Irradiation Therapy is used to cleanse the blood, and treats mania, depression and strokes. An IV catheter is placed, and about 200 ml of blood is removed. The blood is then irradiated, oxygenated, heparinized, and re-infused into the individual undergoing treatment. In addition to these TCM treatments the facility has music recreation therapy, recreation therapy, and Western pharmacological drugs such as atypical antipsychotics.

We toured the “first-class” section and one governmental supported section. The only apparent difference was in the type of clothing. In the first-class section, people had on street clothes while in the governmental unit everyone wore a pajama type outfit.

In both of the mental health centers, we observed that the patients were calm, yet did not appear sedated. We also observed a high staff to patient ratio and much involvement in structured activities. It was at the Xi’an Mental Health Center that we were very touched by the words of our host, Dr. Shi Jianguo, who spoke of his condolences for the recent tragedy in the United States. He stated that the prayers of the staff of the Center, as well as his countrymen were with our delegates and all the citizens of the United States.

We had the opportunity to discuss the etiology and treatment of mental retardation with out hosts. They stated that they believe that mental retardation comes from a poor prenatal blood supply, and therefore TCM herbs are used to stimulate the blood and improve circulation.

The countryside of Xi’an was beautiful with fields of apples, pomegranates, corn, peaches and many other crops. People were outside everywhere: cooking, playing games, eating food, even sewing at a foot-operated machine! Bicycles and cell phones will be an enduring image for me of urban China.

Joint Venture: Disabled Person’s Federation and Industry

In Xi’an, we visited a collaborative between industry and services for persons with disabilities. The Disabled Person’s Federation of Shaanxi Province and the Xi-an Electric Manufacturing Corporation have joined together to provide jobs, education and other services for employees’ family members who are disabled. The company manufactures electrical equipment and employs 30,000 people including 600 people with disabilities. Begun in 1986, its goals are ‘equality, participation and (to) share (in) social achievement”¹³. They have a very active competitive sports program for persons with disabilities and compete throughout the Pacific area.

The Disabled Person’s Federation of Shaanxi Province emphasizes integration, employment, and protection of human rights. They estimate that 5.08% of the provincial population is disabled; of this 80% reside in the countryside and 20% in the cities and towns. They estimate that there are 300,000 individuals with mental retardation in the province. A Federation publication notes that “the provincial government has designated one of its vice-governors to be in charge of the affairs of disabled persons… All the prefectures, cities and counties of the whole province have set up their own committees which are playing a positive role in the affairs of disabled persons”¹³

We visited the manufacturing plant and toured several classrooms, adult vocational training programs, and work areas. We found the students to be engaged in their class work and proud to show us their accomplishments. The classrooms held about 15-20 students, with several teachers per classroom. The students all appeared to have some degree of mental retardation, although none appeared to have profound or severe mental retardation. We saw a laboratory for quality control of electrical parts, in which all the workers were deaf. In another area, workers with disabilities were sewing uniforms. It was very interesting to see the services that a manufacturing company was providing for its employees. This joint venture is an example of effective collaboration between a commercial enterprise, a governmental agency and a private, disability federation.

Child Health Care Center of the Shanghai Children’s Hospital

Representative of the complexity of China’s rich history and recent change is the Child Health Care Center of the Shanghai Children’s Hospital. This facility, in the most Western and populous of China’s cities, was established in 1994. It combines TCM with Western treatments, and importantly, is doing research on these treatments and publishing the results.

The goal of the Center is to provide technical guidance and monitoring of the physical and psychological development of children in Shanghai. It collaborates with the Shanghai Association for Handicapped People, and has a special emphasis on children with cerebral palsy. The Child Health Care Center has served over 500 children with cerebral palsy in the past seven years. Children receive very intensive services that include 6 days of treatment 6 hours a day, for 3 to 9 months. Similar to trends in the United States, developmental services are begun at younger and younger ages. In 1995 the average age for initiation of services was 4-6 years; by 2000, it had become 18 months. The children receive physical therapy, occupational therapy, speech therapy, and language training. We observed the use of various TCM treatments, among them electrical acupuncture therapy, "external counter-pulsation" therapy, use of Chinese herbs for blood flow, and a combination of acupressure and massage.

One of the more interesting treatments we observed was Chinese massage for swallowing disorders. Using a combination of massage and acupressure, the therapist worked with the child for 45 minutes. Our host, Dr. Jiang De-Yu, stated that this treatment method significantly improves the long-term ability of the child to swallow.

Another therapy we observed was "external counter-pulsation". In this treatment a deep pressure stimulus was pneumatically applied to acupressure points on the body. A research abstract (bibliography) concludes that this treatment increases the velocity of the blood flow in the cerebral arteries and might "improve the cerebral blood flow volume…and is helpful for recovery of cerebral function." A second abstract examines the correlation between external counter pulsation and improvement in activities of daily living. The conclusion was that there "may be some relationship between the clinical status and the hemo-dynamics of the basal cerebral arteries".

To our Western eyes, the treatment seemed unusual. Children, ranging in age from perhaps a few months to 5 or so years of age, lay supine with wires attached at various points on the upper chest and the scalp. Pneumatic pressure was applied rhythmically such that the affected body part “jumped” moderately in response. However, while the bodies of the children jumped in response, they were either sleeping or resting quietly, some with pleasant smiles. It appeared similar to deep massage; perhaps the relaxation response was the same. External counter pulsation is used in the United States for the treatment of coronary artery disease¹⁴.

Special Education Facilities

Another area of particular interest to us was the education of children with intellectual disabilities. Our hosts had arranged for us to visit two schools for children with mental retardation, one in Beijing and one in Shanghai. Our hosts told us that most students with mental retardation are expected to attend ordinary schools with specialized classes; however, we did not visit any ordinary schools. Compulsory education in China starts at age six and continues for nine years. There are very strict admission standards to high school and college. In the higher levels, students are expected to study for twelve hours a day, including the school day. English education is compulsory starting at age nine although many start earlier.

An Hua School

The An Hua School in Beijing was the first public school for children with severe mental retardation, and was founded in 1986. It is a boarding school, with 169 students ages 4 to 20. The site we visited has students with moderate mental retardation; students with severe mental retardation are served in “experimental groups” at two other locations.

The main goal of the school is to ensure that students will be independent and not a burden to the family or community. The Headmaster, Sun Jin Ju, described the school’s four-fold emphasis: patience, a heart of love, caring for needs, and responsibility. The school is divided into three age groups: pre-school, nine years of compulsory grades (the same as regular public education) and vocational. Assessments, IQ and psychological testing are done prior to admission; the Headmaster stated that no child is rejected. He also stated their research shows that children under age 14 respond well to psychiatric medications, while for those over age 14, the emphasis shifts to behavioral approaches.

Over 95% of the students live at the school, and most go home every weekend. We toured the dormitories, where students live approximately 10-12 to a room. The conditions were neat, clean, but stark by Western standards. In the classrooms for younger children, desks were arranged in rows. Class size was approximately 12-16 students with usually 2 to a desk. The vocational program concentrates on agriculture, military affairs, science and business. There is a strong emphasis on social skills and learning about various occupations in order to choose the most appropriate. The staff to student ratio is 1:2 or 1:1.5 depending on severity of involvement. Teachers have, at minimum, a 3 year Associates’ degree with most having a Bachelor’s degree. The monthly earning of a teacher is equivalent to approximately $200 USD.

The students all appeared eager to learn and interested to see us. They were all attentive, yet eager to interact with our delegation. Although the facilities were modest, even stark, by Western standards, the atmosphere was warm, caring and very calm. They readily admitted that they have a big gap in educational devices and technology, and plan to have some computers in most classrooms in the next year. They are proud of their success in placing many of their students in jobs and were eager to both show their school to the AAMR delegation and to learn from us.

Shanghai Bo Ai Children’s Rehabilitation Center

Our final program visit was to the Shanghai Bo Ai Children’s Rehabilitation Center. It was a wonderful, inspirational way to end our trip.

Fifty years ago, the Director’s story would have been a familiar one in the United States. Gao Ya Li was faced with few alternatives for her son who was born with cerebral palsy. She could have him stay home and have no services or have him attend the provincial rehabilitation center for a few hours of daily therapy. Instead she was determined to provide more intensive services for her son and for other children with cerebral palsy. She researched throughout China and other countries to find the best treatments and, in 1996, opened the Shanghai Bo Ai Center for Children with Cerebral Palsy.

Today the Center serves 66 children between the ages of 7 months to 14 years. The school is both a boarding and day school and is funded through donations and tuition. Tuition is approximately $1000 USD annually. Staff of the school consists of doctors, nurses, teachers, and therapists.

The aim of the school is to increase physical mobility, to improve the capabilities and lives of children with cerebral palsy, and to provide a standard of education equal to that provided in regular schools.

The Center is located in a two-story building in a pleasant neighborhood. The services offered are occupational therapy, physical therapy including an exercise room, computers, education and movement training, speech therapy and music therapy.

Children live in dormitories, approximately 10 to a room. The dormitories were plain by Western standards, and crowded; but they were neat, clean, and equal to or better than housing for many Chinese. As in the other schools, there was a high staff to student ratio and there were many happy smiling faces. In contrast to the other facilities we visited, this Center had more equipment and utilized many Western techniques. The School utilizes the philosophy of Conductive Education. The Conductive Education System was developed in Hungary by physician and educator Andras Peto shortly after WWII. His methods were based on the idea that, despite damage, the nervous system possesses the capacity to form new neural connections under a specific program of activities, following a holistic approach¹⁵. The Conductive Education Center of Orlando states "It is a lifestyle. Conductive Education covers all aspects of human development – physical, cognitive, communication, language, social and emotional… It is based on motivation". The unique aspects of Conductive Education are the specially trained staff, group participation, task services, rhythmic intention, and furniture¹⁶

We observed this approach through the use of music in the classroom and through the use of the special furniture. In one classroom, children moved around a series of ladders, learning to grasp and release to music. We observed the adaptation of Conductive Education to TCM. Again, smiling children were receiving treatments of electrical acupuncture and massage.

The Center maintains an active program for parents. Parents are invited to learn the methods and use them with the child. We saw several parents actively involved in the therapy rooms. They have established a “correspondence program” whereby parents can exchange information on cerebral palsy with each other. Gao Ya Li, Director, hopes that someday there will be more centers like hers throughout China so that all children with cerebral palsy will have the opportunity to realize their full potential. In an email to our group, she stated, “We really want to learn from you if we have chance. China developed slowly in these (areas), especially in disabled children’s early education and rehabilitation. As it’s not separated from its tradition, economy and culture, it is decided by various factors. But along with China’s opening (the) spirit of civilization developed further. People and government will pay attention (to) this field more and more. Its future must be better than now, but need(s) time, I think”.

It was so hard to say goodbye to these entrancing children and their dedicated, determined director, but a wonderful way to end our professional tour. (For Gao Ya Li’s own story, see the accompanying article "A Life’s Crusade".)