Introduction

Most evidence suggests that the earlier autism spectrum disorders (ASD) are diagnosed and treated, the better the outcomes will be (Dawson et al. 2010). Unlike many other psychiatric conditions, autism can be detected before the age of two, and by definition (American Psychiatric Association 2000), must emerge before the age of 36 months. The symptoms of ASD manifest similarly in children across different cultures, but the meaning attributed to particular symptoms, help-seeking behavior, the degree that researchers and clinicians in different cultures follow the international diagnostic criteria, and available treatment options may vary greatly (Bernier et al. 2010; Daley 2002). Despite the renaissance in international autism research, there has been little attention to the effects of cultural context on the presentation, diagnosis and treatment of ASD, perhaps because of the assumption that autism is a neurobiological condition and that the social meanings of the condition for a particular population, while crucial in determining how people respond to and manage the symptoms, are relatively unimportant for diagnosis (Daley 2002).

The bulk of the research in cross-cultural psychiatry has focused on disorders other than autism, and on older children, adolescents and adults. A large amount of literature on mental disorders from a cross-cultural perspective exists and the guidelines published by the American Psychological Association and the Association for Multicultural Counseling and Development have provided culture or population-specific guidance for clinicians and service providers (Whaley and Davis 2007). For example, the guidelines suggest that Asians are more responsive than other groups to psychotherapy. Similarly, lower dosages of psychotropic drugs are recommended for Asians due to a possibly slower enzymatic metabolism (Lin and Cheung 1999).

To understand ASD in cultural context, this paper reviews the literature on early child development among Koreans, with a focus on ASD. The first epidemiological study of autism in South Korea comprised a total population study of 7–12 year olds and estimated the prevalence to be 2.64 %, the highest rate ever reported for ASD in any country (Kim et al. 2011). Approximately two-thirds of these children were enrolled in mainstream elementary schools, and were undiagnosed and untreated, raising the question of what accounts for the lack of diagnosis among children with a clinical presentation comparable to that many children with autism in other countries. The goal of the current paper is to explore the potential influences of Korean culture on ASD identification, diagnosis, assessment and treatment through a review of the English and Korean-language peer-reviewed literature. Although Korean attitudes towards health and illness, child development and education, undoubtedly vary according to a range of socio-demographic characteristics, country of residence, language skills, geographic origin within Korea, and religion, numerous patterns are discernable in the literature on Korean child development. An understanding of Koreans’ parenting attitudes, early child education style, and ways of coping with children’s developmental disabilities can help clinicians and other social service providers to fashion outreach plans and provide culturally competent services to Korean families of children with ASD.

Methods

The literature search was conducted in both English and Korean. The electronic databases used for the literature search in English included: Pubmed, EBSCO, Google Scholar Beta, ISI, PsycInfo, Health STAR, sociological abstract, PsycCritiques, and International Bibliography of the Social Sciences (IBSS). Two keyword searches were conducted: (1) Korean, child, and early development; and (2) Korea and child development. A total of 951 abstracts were reviewed in English and 15 articles that provided empirical evidence of the impact of Korean parenting attitudes and education system on children’s early development were selected for the full review. The literature search in Korean was conducted using the National Discovery for Science Leaders, a South-Korean government database. In the review of Korean literature, autism was used as a keyword. Despite the relative paucity of research on ASD outside of Europe and North America, we expected to find literature on autism published in the Korean language since autism is a common illness across countries and there has been increased awareness of autism in recent years with the rapid advancement of medicine and technology in South Korea. A total of 101 abstracts in Korean were reviewed and the 13 articles that provided a practice review of diagnosis and treatment of ASD in South Korea, empirical evidence of psychosocial interventions for children with autism, or the information on Korean parents’ ways of coping with their child’s developmental disability were selected for full review. With the exception of the 13 articles, all articles on ASD in Korean concerned neurological, genetic, and pharmacological data, and were therefore excluded from the review.

Results

Tables 1 and 2 list the English and Korean literature identified through the search. Among the studies identified in the English literature search, seven studies were conducted in the US using a Korean-American sample, two studies were conducted in both South Korea and the US, one study was conducted in South Korea and England, and five studies were conducted exclusively in South Korea. All studies written in Korean were conducted in South Korea and nine of the 13 included study samples of either children with ASD or their mothers. More than three quarters of the Korean language literature on autism was published after 2004. The sample sizes of qualitative studies ranged from three to twenty and the sample sizes of quantitative studies (including those with mixed-methods designs) greatly varied, ranging from 46 to 55,266. The age of children included in the studies ranged from one to 12 years. Below we summarize findings from these studies in three categories: (1) those specific to the assessment and treatment of ASD in Korea and children of Korean descent, (2) systems of care for children with ASD in Korea and (3) more general issues related to child development in this population.

Table 1 Description of studies included in the review of English literature
Full size table
Table 2 Description of studies included in the review of Korean literature
Full size table

Assessment and Treatment of Autism Spectrum Disorders

To date, only one epidemiologic study of ASD has been conducted in Korea. Kim et al. (2011) found that two-thirds of children with ASD were unrecognized and untreated, receiving no special education services. The majority of these children differed markedly, however, from those with ASD in special education environments. The sex ratio of children with ASD in the mainstream schools was more narrow (2.5 boys for every girl in mainstream schools compared with 5.1 boys to every girl in special education schools), the majority had average or above average IQs, and 12 % had superior IQs (Kim et al. 2011).

The diagnostic practice parameter for ASD used in Korea is based on the DSM-IV and the Autism Diagnostic Interview-Revised (ADI-R; Yoo et al. 2007). Treatment recommendations are, for the most part, adopted from the American Academy of Child and Adolescent Psychiatry’s practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. Previous studies have used the ADI-R, the Autistic Diagnostic Observation Schedule (ADOS) and the Childhood Autism Rating Scale (Ju et al. 2007; Lee 2008; Lim et al. 2006; Won et al. 2005; Kim et al. 2011).

In South Korea, children that American clinicians might diagnose with autism tend to be diagnosed with reactive attachment disorder (RAD), pejoratively referred to as “lack of love” (aejǒng kyǒlpip), a term that parallels the older American concept of the “refrigerator mother.” In Korea, RAD is often thought to be a condition mimicking autism, caused by a mother’s absence of attachment to her child (Shin et al. 1999; Hong 2006; cf. Grinker 2007). For example, Shin et al. (1999) assessed children who had received a diagnosis of autism. Their study observed twenty-five children between the ages of 2 and 4 (all living in “intact nuclear families”) and their mothers playing for 20 min while they were observed through a two-way mirror. Researchers report that the mothers lacked social skills, failed to join in play with their children, appeared insensitive to their children’s cues, and engaged in parallel play. They report that the children’s behavioral problems improved as their mothers’ symptoms improved, and play therapy and child-mother psychotherapy were effective in improving children’s language and socio-emotional areas. They also emphasize providing appropriate mental health services to mothers with children with ASD.

Two studies conducted in Korea provide information on the development and clinical presentation of ASD in Korean children. Cho (2003) reported that the speech of Korea children with ASD was largely repetitive and echolalic and that they were unable to consistently engage in social communication. The author found that the more repetitive the child’s speech was, the more it was morpho-syntactically impaired. Jung and Seong (2007) found that Korean children with autism and normal development had differences in both tonal patterns at the end of the prosodic phrases and the degree of rising and falling slope related to pitch contour.

One study described Korean families’ mechanisms for coping with their child’s ASD or developmental disability. Korean families’ perception of strong social support has been found to be positively associated with their resilience and coping with children with developmental disorders (Tak and Lee 1996).

Four of the studies reviewed here described psychosocial interventions for children with ASD. The interventions used in the studies include music therapy, massage therapy, behavioral therapy involving mothers, attachment promotion, and maternal training on social reciprocity for children with autism. These interventions focus on developing a healthy and supportive emotional relationship between mother and child, with the goal of increasing attachment. Music therapy has been found to have a positive effect on Korean children’s verbal skills, laughing/smiling and play behavior (Ju et al. 2007). Lee (2008) reported that massage therapy and an attachment promotion program significantly improved the social maturation of children with ASD, as measured by the Korean Vineland Social Maturity Scale. The researchers found no significant differences between pre- and post-intervention attributes when measured using the Childhood Autism Rating Scale. The attachment promotion program was found to be effective in helping Korean mothers become more child-centered, respond more positively to their children’s behavior, and show more support for their children’s needs (Im et al. 2006). Training in social reciprocity for mothers of children with autism has been reported to increase Korean mothers’ use of imitation with animation and expectant waiting, and to increase children’s initiation of interaction, vocalizations, and verbal production (Won et al. 2005).

Systems of Care for Children with ASD in Korea

Several studies described systems of care for children with ASD in Korea. Although education for children with disabilities is mandatory in Korea under the special education promotion act of 1977, the quality of education is reported to be substandard (Shin 2002). According to the South Korea Ministry of Education, Science, and Technology (2010), among 79,711 students receiving special education in the country (population 44 million), 5.6 % (approximately 4,500 students) have a diagnosis of ASD. Given an estimate of 9.7 million children ages 5–19 in Korea as of 2005 (United Nations Demographic Yearbook 2008), a figure of 4,500 school-age children with a government classification of autism would yield a diagnosed prevalence of .046 %, much lower than the Kim et al. (2011) estimate. A previous survey (Seo 1997) reported that among the children who are entitled to special education in South Korea, only 42 % are enrolled in special education programs. The children not enrolled in special education are reported to attend regular classes at regular schools or welfare facilities that pay little attention to individual capabilities and difficulties (Park 2010). Although the Korean Special Education for Individuals with disabilities and Others Law (2007) promotes inclusive education by increasing the number of special education classrooms in regular schools, the lack of special education classrooms and the shortage of trained staff remain major obstacles towards improving school-based services. Perhaps as a result, Korean families with children with ASD often have trouble obtaining the social support that they need outside of school (Lee and Jung 2005).

Impact of Korean Culture on Early Child Development of Korean Children

Previous research has investigated the impact of Koreans’ parenting style and school culture on children’s cognitive development, including executive function and theory of mind. Executive function is generally defined as “the ability to maintain an appropriate problem-solving set for attainment of a future goal” (Welsh and Pennington 1988, 201, cited in Oh and Lewis 2008). Oh and Lewis’ (2008) study of Korean preschoolers’ advanced inhibitory control and its relationship to other executive skills and mental state understanding found that Korean children younger than 3.5 years of age showed ceiling effects on some inhibition measures. The link between executive function and mental state understanding was not as strong as in a sample of British children. The authors found that executive skills, including inhibitory control, working memory, and switching were not significantly correlated and raised questions about whether the executive system is as unified in preschoolers as has been suggested and whether the structure of the executive system is consistent across cultures. Oh and Lewis suggest that Confucianism, in particular, the enforcement of proper etiquette and strict rules of social engagement between children and elders, could be a factor associated with Korean children’s high inhibitory control; Korean teachers continue to prefer to adopt whole class teaching, emphasize the teacher’s authority, extrinsic motivation, completion of worksheets, and clear separation of play time and work time.

In contrast to the hypothesis that Korean teaching customs negatively influence the development of children’s social skills, including theory of mind, Korean parents’ authoritative parenting is reported to have a positive impact. Korean parents have been found to generally exhibit more authoritative parenting styles than their Anglo-American counterparts. Vinden (2001) found that authoritative parenting is positively associated with a more developed theory of mind in Korean children, while such a parenting style is negatively associated with Anglo-American children’s development of theory of mind. The authors suggested that culturally different parenting styles achieve similar developmental goals and that evaluations of good parenting should be based on the complex of attitudes and behaviors within particular socio-cultural contexts. With regard to early word acquisition, Korean and English-speaking children appear to follow a similar developmental pattern. Au et al. (1994) found that Korean-speaking children, like English-speaking infants, learn nouns faster than verbs although Korean parents’ verbal communication with their children incorporated significantly more verbs than nouns in comparison to English-speaking parents.

Social relationships in Korean culture are based to a large degree on a hierarchy of differences that confer status, including age, gender, family, and social role such as parent, child, teacher, and student (Howe 1988; Min 1997; Park and Cho 1995). Studies have found major cultural differences between Korean and Anglo-American families regarding how children play and socialize. Farver and Lee-Shin (2000) found that Korean children spend a greater proportion of time not being engaged in any activity involving social communication and engage in more parallel play than social and pretend play compared with Anglo-American children. Compared to American children, Korean children engaged in mostly parallel play (46 %) and solitary play (29 %). The researchers also found that, in comparison to Anglo-American children, Korean children were more cooperative and showed more neutral affect. Anglo-American children were found to be more negative and aggressive in pretend play, but also exhibited more shared positive affect. Although this study observed Korean-American children, not the Korean children residing in Korea, the study findings likely reflect Korean parenting style since the children’s parents were all Korean immigrants.

Korean parents’ attitudes toward early child development also differ from those of American families. Despite rapid cultural changes in Korea in response to both endogenous historical forces and exposure to non-Korean cultures, Koreans’ child rearing practices, parent–child relationships, and children’s development and behavior continue to be strongly influenced by Confucian ideals, which highly value parental control over children’s lives and decision-making (Lee and Lee 1990; Park and Cho 1995; Choi 1997; Park 2001; Hong 2006).

Discussion

This paper reviewed studies that have examined the impact of Korean culture on ASD and early child development. Of 15 studies reviewed in English, two were studies of ASD; of the 13 articles reviewed in Korean, nine were studies of ASD and two concerned guidelines for ASD diagnosis and treatment.

Assessment and Diagnosis

Our review suggests that autism is an uncommon diagnosis in South Korea, despite the relatively high prevalence estimate. Children in Korea who have a diagnosis of autism are assessed and diagnosed at an early age, often before the second birth date (Grinker 2007), but this is in large part due to the fact that diagnoses are made primarily for children with significant impairments (Kim et al. 2011).

Despite the fact that an attachment disorder diagnosis places blame on the mother, many mothers seem to prefer the diagnosis to autism. First, unlike autism, RAD or lack of love can be ameliorated by giving love and thus is not a permanent condition. Koreans widely consider autism to be untreatable (Grinker 2007). Second, RAD, unlike autism, is not a genetic condition. Thus, as Grinker notes, while RAD may stigmatize the mother, autism would stigmatize the whole family—past, present, and future and negatively influence the marriage prospects of an autistic person’s relatives. Third, and perhaps most importantly, the diagnosis makes sense in the context of Korea’s dramatic social changes over the past 50 years, as the country emerged from the total devastation of the Korean War to become one of the largest economies in the world. Child health experts make a causal link between contemporary nuclear families, daycare and autism, arguing that modern parents no longer know how to raise children properly, and that children left with nannies or in daycare cannot form appropriate or lasting attachments with their mothers (Hong 2006). This failure of attachment leads to RAD, which is then confused with autism (Shin et al. 1999).

In response to these phenomena, Shin et al. (1999) argued that Korean women suppress emotion more than do women in other countries, and handle stress by withdrawing from social situations; when they do express emotion they do so through somatic symptoms, especially Hwa-byung. Hwa-byung is a Korean disorder that cannot be described easily in English. It is a kind of depression with bodily complaints such as fatigue and soreness associated with old age, and the persistent feeling of a mass lodged in the stomach. Hwa-byung is thought to be caused by inhibiting anger. In addition, mothers’ withdrawal, the authors argue, is exacerbated by Korean women’s progress, as professional careers take them away from their children, the national preoccupation with educational advancement, and the widespread use of videos and computers in the household. The researchers say, “We inferred that these mothers also used videotapes as a way of avoiding direct interactions with their children” (1999: 73). To ameliorate these problems, the authors suggest that mothers of children with autism should receive appropriate mental health care.

It is important to note that the only therapies for children with ASD described in the Korean literature were music therapy, massage therapy, play therapy, psychotherapy, and attachment promotion. Behavioral and developmental interventions found to be effective in other countries do not seem to have attracted much research or clinical interest in Korea.

Systems of Care for Children with ASD in Korea

Our review suggests that obtaining appropriate resources after diagnosis can be very challenging in Korea. The studies reviewed in this paper report the lack of a formal support system for children with disabilities that could result in Korean parents becoming frustrated and children not receiving appropriate access to treatment and other services (Cho et al. 2000). Parents of children with special needs thus frequently think about the costs and benefits of traveling or immigrating to Europe or North America, where it is believed their children have a greater chance of receiving an appropriate education (Grinker 2007: 249). While more impaired children may be obtaining some services, most children, especially those with above average intelligence, are not. One reason for the lack of services may be the relative youth of child psychiatry in Korea. The first division of child psychiatry within a medical center was established in 1981 at what was then Korea’s largest and most prestigious university hospital, Seoul National University Hospital. This remains one of only two medical schools in Korea that offer a fellowship in child psychiatry (Seoul National University 2008). At the time of this writing, Seoul National University Hospital is the only academic medical hospital in Korea that employs a clinician certified to administer the diagnostic instruments for ASD that are the gold standard throughout the world: the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview. The Behavior Assessment System for Children II (BASC-II) questionnaire has only recently been translated into Korea and is currently undergoing field trials in Korea (Song et al. 2011). Although there are only a few centers in Korea that provide assessment, treatment or services for children with ASD, there is a large volume of information available online through Korean websites. These sites are news blogs and Internet cafes that provide guidance for parents on coping skills, and facilitate the sharing of experiences among families. An extensive web search conducted by the authors found few sites offering information on the delivery of institutionally-based services. Nonetheless, as evidence of the increasing awareness of ASD in Korea, the websites of several academic and professional organizations in Korea such as the Korean Society of Special Education, the Korean Association for Persons with Autism, the Korean Psychological Association, the Korean Academy of Child and Adolescent Psychiatry, and the Korean Society for Early Childhood Special Education list ASD as a focus.

Impact of Korean Culture on Early Child Development of Korean Children

The studies suggest that particular areas of children’s development can be affected by cultural factors. Korean schools, from preschools through high school emphasize structure and routine within the classroom, learning by rote memory, with few transitions or alterations in daily schedules. Indeed, the authors of the Korean study of ASD prevalence suggest that the structure suits some of the needs of children with ASD who are high functioning, thus facilitating their participation in mainstream schools (Kim et al. 2011). This teaching method may promote Korean children’s development of executive function, although it may not necessarily emphasize the development of knowledge or insight into other’s internal states (theory of mind), a notable deficit in many children with ASD.

Although Korean children show similar patterns of language and communication development, the use of honorifics is unique in Korean language. In interviews with Grinker, clinicians reported a consistent deficit among children and adults with ASD in the use of honorifics, the suffixes appended to verbs to denote the social and/or hierarchical relationship between speakers (Grinker 2007). As a result, in Korea, and in the many other societies that employ grammatical forms to convey respect or mark one’s place in a hierarchy, abnormalities in language and communication suggestive of an ASD can be identified in a clinical assessment or a screening instrument that includes a question about the appropriate or inappropriate use of honorifics (Grinker et al. 2011).

Based on the differences identified in this review, assessment and treatment of ASD without an understanding of Korean culture and Korean families’ coping strategies with ASD may hinder the implementation of effective intervention for Korean families. Culture, and parental belief systems in particular, can be constitutive of the ways parents identify, understand and manage aberrations in development. For example, Mandell et al. (2002) hypothesize that one reason African-American children with ASD may be diagnosed later than white children is that during assessments African-Americans parents may describe some autistic behaviors in children as disruptive while white parents describe the same behaviors as idiosyncrasies or social oddities, thus leading to more diagnoses of conduct disorder in African-American children. Studies have reported that among certain ethnic groups, such as Hispanics or American Indians, families are less likely to use the services of professionals such as case managers, psychologists, and developmental pediatricians (Thomas et al. 2007). The poor outreach and the lack of cultural competency of providers, overall mistrust of the system as a function of institutionalized discrimination, and greater reliance on extended family members and friends than professionals have been identified as reasons for underutilized professional services (Thomas et al. 2007).

Koreans frequently attribute children’s disabilities to poor tae kyo (prenatal practices), that might negatively affect the health and intelligence of babies, or mistakes in early parenting (Cho et al. 2000). The concept of tae kyo refers to the total relationship a mother forms with her unborn child and can thus include all prenatal experiences affecting the fetus, such as the mother’s mood, loud verbal conflicts, excessive noise, or poor diet. While the relationship between mother and child does not cause ASD, therapists should pay greater attention to the fact that Korean parents believe in that causal relationship, and consider how to explain and structure interventions for the child that will not reinforce that belief. As it now stands, most family-based studies conducted in Korea focus almost exclusively on the relationship between mother and the child with ASD.

Attention should also be paid to the educational system since teachers can often identify functional impairments that are manifested, or are more salient, in settings outside the child’s routine home setting. Because the law for integrated education (Tonghap Gyokuk Bôp), ratified by the Korean congress in 1994, mandated inclusion for all children without severe physical or intellectual disabilities, children on the autism spectrum who are verbal, educable, and with above average intelligence, are generally educated within mainstream schools, most of which do not provide special education services.

Although this literature review is incomplete and may have been influenced by the particular search terms used and the necessary reliance on one Korean-language database, it is clear that early child development and interventions, at both conceptual and practical levels, must be understood within cultural context. Cultural context refers here not only to patterns of Korean culture in Korea but also in the many societies in which Koreans now live, whether in Canada, the US, England, or Australia. This review highlighted existing studies on ASD in Korean, but few focus on culture. And while numerous English-language publications on Korea focus on the cultural aspects of the Korean family, marriage, and kinship, very few focus on ASD or developmental disorders. A first step towards new research would involve the study of cultural, structural, and financial barriers to care. A second step would involve the production of culturally informed materials written in Korean that can be distributed to healthcare professionals and service providers with a robust Korean clientele, as well as to patients and families.