CLINICAL PERSPECTIVES Chinese International Students: An Emerging Mental Health Crisis Justin A. Chen,
MD, MPH,
Lusha Liu,
MD, PhD,
T
he number of international students at US colleges and universities has nearly doubled during the past 20 years, from 450,000 in 1993 through 1994 to a record high of more than 886,000 in 2013 through 2014, or 4% of the total US higher education population. By far the lion’s share of these students now hail from China (31% of the total, or 274,439 students)—a 6-fold proportional increase over the past 15 years. Several factors contribute to this robust expansion. Institutions of higher education increasingly value diversity and global reach, while also recognizing that international students’ ability to pay full tuition helps subsidize their US-born classmates. Meanwhile, a university degree from the United States is a potent status symbol for China’s growing middle and upper classes. In fact, so strong is the desire to gain entry into a selective university that Chinese parents have begun enrolling their children at prestigious US secondary schools in hopes of gaining a head-start on the admissions process. This arrangement may benefit schools economically, but it also generates unique challenges for students due to profound cross-cultural differences. Today’s Chinese international students grew up during a time of unprecedented social and political upheaval following the People’s Republic of China’s 1978 economic opening to the West. Often, the unique experiences and values these individuals bring to campus conflict with those of their US-born classmates and professors. This cultural mismatch is exacerbated by challenges affecting all students during the transition to college, including loss of structure, separation/individuation from parents, and increased availability of alcohol and drugs. Most Chinese international students move to the United States at an age when they are particularly vulnerable to the onset of common psychiatric disorders and their sequelae, including poor academic performance, absenteeism, and self-harm. Suicide is the third-leading cause of death in young adults 18 to 24 years old, and Asian American college students are more likely than white students to have had suicidal thoughts and to attempt suicide, although these rates specifically among Chinese international students are currently unknown. The mental health struggles of Chinese international students have become a topic of great concern among secondary school and college counselors, but accurate diagnosis and effective management are often hampered by cultural and language barriers. Unfortunately, basic systematic research is lacking regarding the prevalence of mental illness, maladaptive behaviors, and suicidal thoughts in Chinese international
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 11 NOVEMBER 2015
Xudong Zhao,
DrMed,
Albert S. Yeung,
MD, ScD
students in the US. A cross-sectional survey of 130 Chinese international undergraduate and graduate students at Yale University published by Han and colleagues found that 45% exhibited symptoms of depression (score 5 on the 9-item Patient Health Questionnaire) and 29% exhibited symptoms of anxiety (score 5 on the 7-item Generalized Anxiety Disorder instrument).1 In comparison, a recent study of university students in Harbin, China found a prevalence of depressive symptoms of just 11.7% using a threshold score of at least 14 on the Beck Depression Inventory (comparable to the cutoff used by Han et al.1),2 suggesting that Chinese international students indeed face a greater burden of psychological distress than their counterparts in China. What are the hypothesized contributors to this heightened distress? Chinese international students have been proposed to be affected by difficulties with communication, social connectedness, homesickness, acculturative difficulties, and racism. Although seemingly disparate and primarily sociocultural in origin, these factors may exert their harmful effects on mental health along a final common pathway involving chronic stress. In addition, low mental health literacy and stigmatization of mental illness and treatment mean that struggling Chinese students are often unaware of available services and/or are reluctant to seek help. Even less is known about the mental health of the growing population of younger Chinese international secondary school students. Most research to date has focused on the mental health of Chinese international students in the United States, with little attention paid to their developmental trajectories prior to migration. Yet these students’ psychological characteristics are undoubtedly shaped by unique features of the rapidly changing society in which they spent their formative years. Among the most obvious of these is the One-Child Policy, which affected nearly all urban Chinese families after 1979. A direct result of this policy is the “421 generation” (421时代), in which a “singleton” child is reared by 2 parents and 4 grandparents. As demonstrated by the colloquial designation “little emperors” (小皇帝), this policy has widely been assumed to exert harmful effects on psychological development. Some studies have asserted that singleton children are “more egocentric and uncooperative” and “unable to manage impulses for immediate gratification.”3 Although other research contradicts these findings, the enduring consequences of such a sweeping social policy warrant further careful long-term follow-up. In addition, the unprecedented rapidity with which Chinese society has transformed during the past several decades owing to a rapid influx of wealth, particularly in urban areas, cannot be
www.jaacap.org
879
CHEN et al.
overemphasized. Against this backdrop, it should come as no surprise that some Chinese families view money as the single answer to many of life’s problems, placing much less emphasis on other factors generally considered important for healthy development in the West. Many Chinese international students’ families have rigid expectations that their children will attain an elite education. In such cases, there is often little awareness of the existence of other educational institutions beyond a select few of the most prestigious. McNeal and Yeh4 coined the term “compensation syndrome” to refer to a phenomenon in which Chinese parents who feel deprived of their own opportunities by the Cultural Revolution place immense pressure on their children to succeed academically. Unsurprisingly, such high expectations can be tremendously burdensome and model a perfectionist cognitive pattern associated with depression in Chinese international students.5 The modern Chinese family structure has become increasingly fragmented. Often, children are raised from a young age by their grandparents while their parents relocate to distant cities in search of economic opportunities. Students traveling abroad for their education simply perpetuate this dynamic. A culturally informed understanding of each family’s motivations for sending their child to study abroad is crucial when assessing psychological distress in a student. Some parents may use international study as a strategy for addressing their own marital problems, whereas others might be attempting to provide alternative opportunities for children who are struggling within the Chinese educational system. Thus, the emergence of psychiatric symptoms in the student must be considered in terms of potential functional significance within the larger family system. In fact, the strongest contributors to mental distress may not relate to the students at all, but rather to the outsized influence of parents within Confucian social structures. The impact of parental pressure on students’ psychological development and long-term emotional health and strategies for modifying maladaptive parenting styles represent fascinating areas of inquiry with significant implications for students from Chinese and Western backgrounds alike. A bioecological systems approach could be useful for conceptually organizing the many factors that influence the mental health of these populations. Chinese international students and scholars comprise a range of individuals at different life stages, from adolescent high school students to postdoctoral researchers, and a nuanced approach will be needed to clarify the specific
needs of each group. In addition, it is important to avoid overgeneralizing from Chinese international students to American-born Chinese or other Asian Americans, and vice versa—though certainly, similarities and differences between these groups are well worth exploring. In sum, the dramatic and accelerating growth of Chinese international students in this country presents a tremendous challenge for the US educational and mental health systems. However, it also represents an opportunity to deepen our understanding of the effects of culturally variant childrearing practices on normal and abnormal adult development. Much more research is needed on the prevalence, determinants, and trajectory of psychological problems in this community, in addition to resilience-promoting factors. Stigmatizing beliefs regarding mental problems and their treatment require innovative strategies for care engagement. Further, although this article has focused on impairment-promoting factors and stressors affecting Chinese international students, researchers also should consider this community’s considerable strengths, including tremendous motivation to succeed and family supports. It is in part to address these needs that the authors of this article have recently founded the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness, an initiative that seeks to promote the mental health of international students and advance knowledge in our field through primary prevention, research, and clinical consultation. We hope that other researchers will recognize the tremendous need and potential that exist in this area for improving the lives of young people of diverse cultural backgrounds. &
REFERENCES
3. Wang Y, Fong VL. Little emperors and the 4:2:1 generation: China’s singletons. J Am Acad Child Adolesc Psychiatry. 2009;48:1137-1139. 4. McNeal JU, Yeh C-H. Development of consumer behavior patterns among Chinese children. J Consum Mark. 1997;14:45-59. 5. Wei M, Heppner PP, Mallen MJ, Ku T-Y, Liao KY-H, Wu T-F. Acculturative stress, perfectionism, years in the United States, and depression among Chinese international students. J Couns Psychol. 2007;54:385-394.
1. Han X, Han X, Luo Q, Jacobs S, Jean-Baptiste M. Report of a mental health survey among Chinese international students at Yale University. J Am Coll Health. 2013;61:1-8. 2. Chen L, Wang L, Qiu XH, et al. Depression among Chinese university students: prevalence and socio-demographic correlates. PLoS One. 2013; 8:e58379.
Accepted August 17, 2015. Drs. Chen and Yeung are with the Massachusetts General Hospital Depression Clinical and Research Program, Harvard Medical School, Boston. Dr. Yeung also is with South Cove Community Health Center, Boston. Dr. Liu is a community and private practice psychiatrist in Quincy, Massachusetts. Dr. Zhao is with Shanghai East Hospital and Tongji University, Shanghai, China. Disclosure: Drs. Chen, Liu, and Yeung are cofounders of the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness, a research and clinical service at Massachusetts General Hospital focused on international student mental health. Dr. Zhao is affiliated faculty with the center. Correspondence to Justin Chen, MD, MPH, Massachusetts General Hospital, Psychiatry, MGH DCRP, 1 Bowdoin Square, 6th Floor, Boston, MA 02114; e-mail: [email protected] 0890-8567/$36.00/ª2015 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2015.06.022
JOURNAL 880
www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 11 NOVEMBER 2015
MD, MPH,
Lusha Liu,
MD, PhD,
T
he number of international students at US colleges and universities has nearly doubled during the past 20 years, from 450,000 in 1993 through 1994 to a record high of more than 886,000 in 2013 through 2014, or 4% of the total US higher education population. By far the lion’s share of these students now hail from China (31% of the total, or 274,439 students)—a 6-fold proportional increase over the past 15 years. Several factors contribute to this robust expansion. Institutions of higher education increasingly value diversity and global reach, while also recognizing that international students’ ability to pay full tuition helps subsidize their US-born classmates. Meanwhile, a university degree from the United States is a potent status symbol for China’s growing middle and upper classes. In fact, so strong is the desire to gain entry into a selective university that Chinese parents have begun enrolling their children at prestigious US secondary schools in hopes of gaining a head-start on the admissions process. This arrangement may benefit schools economically, but it also generates unique challenges for students due to profound cross-cultural differences. Today’s Chinese international students grew up during a time of unprecedented social and political upheaval following the People’s Republic of China’s 1978 economic opening to the West. Often, the unique experiences and values these individuals bring to campus conflict with those of their US-born classmates and professors. This cultural mismatch is exacerbated by challenges affecting all students during the transition to college, including loss of structure, separation/individuation from parents, and increased availability of alcohol and drugs. Most Chinese international students move to the United States at an age when they are particularly vulnerable to the onset of common psychiatric disorders and their sequelae, including poor academic performance, absenteeism, and self-harm. Suicide is the third-leading cause of death in young adults 18 to 24 years old, and Asian American college students are more likely than white students to have had suicidal thoughts and to attempt suicide, although these rates specifically among Chinese international students are currently unknown. The mental health struggles of Chinese international students have become a topic of great concern among secondary school and college counselors, but accurate diagnosis and effective management are often hampered by cultural and language barriers. Unfortunately, basic systematic research is lacking regarding the prevalence of mental illness, maladaptive behaviors, and suicidal thoughts in Chinese international
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 11 NOVEMBER 2015
Xudong Zhao,
DrMed,
Albert S. Yeung,
MD, ScD
students in the US. A cross-sectional survey of 130 Chinese international undergraduate and graduate students at Yale University published by Han and colleagues found that 45% exhibited symptoms of depression (score 5 on the 9-item Patient Health Questionnaire) and 29% exhibited symptoms of anxiety (score 5 on the 7-item Generalized Anxiety Disorder instrument).1 In comparison, a recent study of university students in Harbin, China found a prevalence of depressive symptoms of just 11.7% using a threshold score of at least 14 on the Beck Depression Inventory (comparable to the cutoff used by Han et al.1),2 suggesting that Chinese international students indeed face a greater burden of psychological distress than their counterparts in China. What are the hypothesized contributors to this heightened distress? Chinese international students have been proposed to be affected by difficulties with communication, social connectedness, homesickness, acculturative difficulties, and racism. Although seemingly disparate and primarily sociocultural in origin, these factors may exert their harmful effects on mental health along a final common pathway involving chronic stress. In addition, low mental health literacy and stigmatization of mental illness and treatment mean that struggling Chinese students are often unaware of available services and/or are reluctant to seek help. Even less is known about the mental health of the growing population of younger Chinese international secondary school students. Most research to date has focused on the mental health of Chinese international students in the United States, with little attention paid to their developmental trajectories prior to migration. Yet these students’ psychological characteristics are undoubtedly shaped by unique features of the rapidly changing society in which they spent their formative years. Among the most obvious of these is the One-Child Policy, which affected nearly all urban Chinese families after 1979. A direct result of this policy is the “421 generation” (421时代), in which a “singleton” child is reared by 2 parents and 4 grandparents. As demonstrated by the colloquial designation “little emperors” (小皇帝), this policy has widely been assumed to exert harmful effects on psychological development. Some studies have asserted that singleton children are “more egocentric and uncooperative” and “unable to manage impulses for immediate gratification.”3 Although other research contradicts these findings, the enduring consequences of such a sweeping social policy warrant further careful long-term follow-up. In addition, the unprecedented rapidity with which Chinese society has transformed during the past several decades owing to a rapid influx of wealth, particularly in urban areas, cannot be
www.jaacap.org
879
CHEN et al.
overemphasized. Against this backdrop, it should come as no surprise that some Chinese families view money as the single answer to many of life’s problems, placing much less emphasis on other factors generally considered important for healthy development in the West. Many Chinese international students’ families have rigid expectations that their children will attain an elite education. In such cases, there is often little awareness of the existence of other educational institutions beyond a select few of the most prestigious. McNeal and Yeh4 coined the term “compensation syndrome” to refer to a phenomenon in which Chinese parents who feel deprived of their own opportunities by the Cultural Revolution place immense pressure on their children to succeed academically. Unsurprisingly, such high expectations can be tremendously burdensome and model a perfectionist cognitive pattern associated with depression in Chinese international students.5 The modern Chinese family structure has become increasingly fragmented. Often, children are raised from a young age by their grandparents while their parents relocate to distant cities in search of economic opportunities. Students traveling abroad for their education simply perpetuate this dynamic. A culturally informed understanding of each family’s motivations for sending their child to study abroad is crucial when assessing psychological distress in a student. Some parents may use international study as a strategy for addressing their own marital problems, whereas others might be attempting to provide alternative opportunities for children who are struggling within the Chinese educational system. Thus, the emergence of psychiatric symptoms in the student must be considered in terms of potential functional significance within the larger family system. In fact, the strongest contributors to mental distress may not relate to the students at all, but rather to the outsized influence of parents within Confucian social structures. The impact of parental pressure on students’ psychological development and long-term emotional health and strategies for modifying maladaptive parenting styles represent fascinating areas of inquiry with significant implications for students from Chinese and Western backgrounds alike. A bioecological systems approach could be useful for conceptually organizing the many factors that influence the mental health of these populations. Chinese international students and scholars comprise a range of individuals at different life stages, from adolescent high school students to postdoctoral researchers, and a nuanced approach will be needed to clarify the specific
needs of each group. In addition, it is important to avoid overgeneralizing from Chinese international students to American-born Chinese or other Asian Americans, and vice versa—though certainly, similarities and differences between these groups are well worth exploring. In sum, the dramatic and accelerating growth of Chinese international students in this country presents a tremendous challenge for the US educational and mental health systems. However, it also represents an opportunity to deepen our understanding of the effects of culturally variant childrearing practices on normal and abnormal adult development. Much more research is needed on the prevalence, determinants, and trajectory of psychological problems in this community, in addition to resilience-promoting factors. Stigmatizing beliefs regarding mental problems and their treatment require innovative strategies for care engagement. Further, although this article has focused on impairment-promoting factors and stressors affecting Chinese international students, researchers also should consider this community’s considerable strengths, including tremendous motivation to succeed and family supports. It is in part to address these needs that the authors of this article have recently founded the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness, an initiative that seeks to promote the mental health of international students and advance knowledge in our field through primary prevention, research, and clinical consultation. We hope that other researchers will recognize the tremendous need and potential that exist in this area for improving the lives of young people of diverse cultural backgrounds. &
REFERENCES
3. Wang Y, Fong VL. Little emperors and the 4:2:1 generation: China’s singletons. J Am Acad Child Adolesc Psychiatry. 2009;48:1137-1139. 4. McNeal JU, Yeh C-H. Development of consumer behavior patterns among Chinese children. J Consum Mark. 1997;14:45-59. 5. Wei M, Heppner PP, Mallen MJ, Ku T-Y, Liao KY-H, Wu T-F. Acculturative stress, perfectionism, years in the United States, and depression among Chinese international students. J Couns Psychol. 2007;54:385-394.
1. Han X, Han X, Luo Q, Jacobs S, Jean-Baptiste M. Report of a mental health survey among Chinese international students at Yale University. J Am Coll Health. 2013;61:1-8. 2. Chen L, Wang L, Qiu XH, et al. Depression among Chinese university students: prevalence and socio-demographic correlates. PLoS One. 2013; 8:e58379.
Accepted August 17, 2015. Drs. Chen and Yeung are with the Massachusetts General Hospital Depression Clinical and Research Program, Harvard Medical School, Boston. Dr. Yeung also is with South Cove Community Health Center, Boston. Dr. Liu is a community and private practice psychiatrist in Quincy, Massachusetts. Dr. Zhao is with Shanghai East Hospital and Tongji University, Shanghai, China. Disclosure: Drs. Chen, Liu, and Yeung are cofounders of the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness, a research and clinical service at Massachusetts General Hospital focused on international student mental health. Dr. Zhao is affiliated faculty with the center. Correspondence to Justin Chen, MD, MPH, Massachusetts General Hospital, Psychiatry, MGH DCRP, 1 Bowdoin Square, 6th Floor, Boston, MA 02114; e-mail: [email protected] 0890-8567/$36.00/ª2015 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2015.06.022
JOURNAL 880
www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 11 NOVEMBER 2015
