Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary Analysis and Practice

*Victor Wong, John Yuen, Xuebing Su and Jolene Yung*

### **Abstract**

This chapter offers a critical analysis of social isolation experienced by youth in social withdrawal, who lead a hermetic way of life characterized by self-isolation or seclusion by retreating themselves at home from the rest of the world for a protracted period of time. The alienating experience of social withdrawal is defined with reference to four parameters, namely, time, place, social relations, and social status. By using these parameters, helping professionals can distinguish those who are in the state of social withdrawal at home from those who are not and map out the directions and context that NGOs and helping professionals have to thoroughly address if social isolation is to be overcome and reengagement of secluded youth is to be achieved. By conducting thorough literature review and using relevant empirical data drawn from the first author's studies and a longitudinal cohort study of secluded youth in Hong Kong, the authors argue that it is important to start where they are and deliver both home-based and community-based interventions so as to give them an enabling environment where they can cultivate a sense of agency and a sense of expectancy for making a breakthrough against social isolation with the support of interdisciplinary research and practice.

**Keywords:** social isolation, social withdrawal, home-based intervention, community-based intervention, youth, enabling environment, expectancy

#### **1. Introduction**

Social isolation experienced by young people refers to a state in which social interactions with others are limited or even absent for a long period of time. This can take place as a result of involuntary circumstances such as school bullying, peer exclusion, hospitalization, institutionalization, or absence/incarceration of family members or alternatively by voluntary social withdrawal from interacting with others to avoid bullying, frustration, social anxiety, or stress [1, 2]. In the discipline of developmental psychology, involuntary social withdrawal is considered equivalent to social isolation or school disaffection suffered by children and adolescents particularly in educational settings, who are characterized by apparent shyness, asocialness, unsociability, aloneness, and peer avoidance [3]. Social isolation resulted from peer exclusion may not necessarily lead to a sense of loneliness particularly when

young people feel that some intimate others and adult mentors are still around to listen and help. However, when the quantity of interpersonal network is limited and the quality of social support is inadequate, socially withdrawn children and adolescents are more at risk of failing to develop appropriate social and interpersonal skills for engaging in positive interaction with peers in school or community settings. When objective social isolation is further perpetuated as a consequence of involuntary peer exclusion or voluntary social withdrawal as the last resort to react against unfavorable circumstances beyond one's control, loneliness understood as a subjective experience or as "perceived social isolation" would take place [4, 5].

Unlike those student counterparts experiencing a state of social isolation and a sense of loneliness who are usually the targets of study in developmental psychology/psychopathology, this chapter focuses on discussing social isolation experienced by young people in social withdrawal as atomistic individuals, who seclude at home and lead a hermetic way of life without making face-to-face social contacts or having social relationships and interactions with the world other than their family members for a protracted period of time [5, 6]. Young people experiencing social isolation in the form of social withdrawal are characterized by their socially avoidant behavior and their invisibility from the care of helping professionals and the scrutiny of the public [7, 8], who are labeled as "hikikomori" (i.e., young hermits) in Japan [9] and as "hidden youth" in Hong Kong [10]. Young people who seclude themselves at home are asocial in behavioral and relational terms and thus silently trapped in the state of asocialness without enjoying much emotional and instrumental support. However, in the case of young people who are having a psychiatric problem, physical illness, or disability, which has prevented them from participating in the community, they would not be considered as "pure" or "primary" social withdrawal cases. They are instead regarded as secondary social withdrawal cases as a consequence of primary psychiatric or physical problems [11]. In other words, social withdrawal is not primarily a mental health or disability problem, but an anomic behavioral response to difficulties encountered by young people [12]. However, it is entirely possible for primary social withdrawal cases to develop symptoms of depression or social anxiety if they are left alone and feel alone at home for an incredibly long period of time without receiving any professional service.

This chapter first defines social withdrawal experienced by youth with reference to four parameters so as to highlight the nature of social isolation confronted by these young people who are turned invisible, voiceless, and disengaged. Informed by the principle of "starting where the client is," we then discuss different forms of in-home and community-based social work intervention targeted to self-secluded young people who are socially isolated from others other than their family. By using the empirical data drawn from a longitudinal study of youth with social withdrawal experience at home, the next session addresses the importance of interdisciplinary research and practice which is deemed important to facilitate young people to regain a sense of agency and a sense of expectancy for overcoming social isolation and its alienating relational and health outcomes. Before drawing a conclusion, we highlight the importance of advocacy work and its relationship with interdisciplinary research and practice.

#### **2. Parameters for defining the state of social withdrawal**

The first two are the interlocking parameters of time and place; the third one is the lack of face-to-face contacts and interactions other than family members; and the final one is the deprivation of a legitimate social status [4].

**13**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

is a state where people seclude themselves at home for 6 months or more [13]. The length of time is important for temporary seclusion and solitude at home; if it is planned and preferred, it can be productive in nature, which may enhance one's knowledge of one's self and identity and the social environment, and provide relief from the pressures involved in interacting with other people in daily life and regain an orientation for leading a healthy and purposeful life ahead. Nowadays with the use of advanced computer and communication technology, working at home has become commonplace. Nobody will assume that the practice of home office is a manifestation of social withdrawal or social isolation. However, spending more than 6 months at home without working on designated tasks or having a clear purpose will likely cause anxious and lonely feelings [5]. The home or even a small room is largely the space where young people in social withdrawal spend their time and life. However, they may step out of the home boundary for a stroll alone on a silent street at midnight to avoid meeting or greeting neighbors or go out on their own to buy stuff at a corner store at a time when few people or customers are anticipated [8]. Self-seclusion at home was in the first place taken by young people as a viable solution, if not the last resort, to escape from experiencing frustrations such as school bullying, job-seeking failures, parental marital discord, and so on and do the things they prefer doing on their own. To avoid conflicts with the family and the parents in particular, it is not unusual for youth secluded at home to sleep throughout the day and stay awake at night to play online games or watch television alone [5, 7, 8]. However, the longer the period they seclude themselves at home, the more likely they will feel locked in time and space as if time was running slow [5]. Simply imagining that stepping out of their homebound cocoon into a community or public place will lead to a heightening sense of anxiety and insecurity will become an insurmountable barrier to reducing the further perpetuation of social isolation experienced in both an objective and subjective manner.

**2.2 Third parameter: lack of face-to-face contacts and interactions**

health in terms of poor diet and lack of physical exercises [16, 17].

Most of the youth respondents were happy with their secluded lives in the first few months as they could take a break without being interfered, play online games, surf the Internet, and do many other things they were fond of doing. Nevertheless, dispensing with social relationships with others for a long time has deskilled young people in the sense that it leads them to forget how to engage in normal interactions and relationships with others and, accordingly, heightens their anxiety to venture into the community [5, 8]. As shown in research studies in Japan, *hikikomori* dare not go out the home on their own for fear of having eye contacts with distant others or to respond to normal social greetings with neighbors or friends [14]. To avoid conflicts with the family and the parents in particular, it is not unusual for youth secluded at home to sleep throughout the day and stay awake at night to play online games or watch television alone [5, 7, 8]. Mallett argued that home is a "socio-spatial system," where social relations are shaped and reproduced [15]. In the case of extended social withdrawal, the confined space of home causes the inter-generational relationship to spiral further downward. In case of worsened relationship with parents and family members, young people suffering from extended social withdrawal at home may just retreat to their own tiny room with a modest level of interaction with their family. Worse comes to worse, they may even decline eating with the family and take a few biscuits or a cup of instant noodle in their own tiny safe cocoon on a daily basis [6], which is, however, harmful to their

According to the Japanese government, social withdrawal or *hikikomori* in Japanese

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

**2.1 First two parameters: time and place**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

#### **2.1 First two parameters: time and place**

*Social Isolation - An Interdisciplinary View*

young people feel that some intimate others and adult mentors are still around to listen and help. However, when the quantity of interpersonal network is limited and the quality of social support is inadequate, socially withdrawn children and adolescents are more at risk of failing to develop appropriate social and interpersonal skills for engaging in positive interaction with peers in school or community settings. When objective social isolation is further perpetuated as a consequence of involuntary peer exclusion or voluntary social withdrawal as the last resort to react against unfavorable circumstances beyond one's control, loneliness understood as a subjective experience or as "perceived social isolation" would take place [4, 5]. Unlike those student counterparts experiencing a state of social isolation and a sense of loneliness who are usually the targets of study in developmental psychology/psychopathology, this chapter focuses on discussing social isolation experienced by young people in social withdrawal as atomistic individuals, who seclude at home and lead a hermetic way of life without making face-to-face social contacts or having social relationships and interactions with the world other than their family members for a protracted period of time [5, 6]. Young people experiencing social isolation in the form of social withdrawal are characterized by their socially avoidant behavior and their invisibility from the care of helping professionals and the scrutiny of the public [7, 8], who are labeled as "hikikomori" (i.e., young hermits) in Japan [9] and as "hidden youth" in Hong Kong [10]. Young people who seclude themselves at home are asocial in behavioral and relational terms and thus silently trapped in the state of asocialness without enjoying much emotional and instrumental support. However, in the case of young people who are having a psychiatric problem, physical illness, or disability, which has prevented them from participating in the community, they would not be considered as "pure" or "primary" social withdrawal cases. They are instead regarded as secondary social withdrawal cases as a consequence of primary psychiatric or physical problems [11]. In other words, social withdrawal is not primarily a mental health or disability problem, but an anomic behavioral response to difficulties encountered by young people [12]. However, it is entirely possible for primary social withdrawal cases to develop symptoms of depression or social anxiety if they are left alone and feel alone at home for an incredibly long period of time without receiving any profes-

This chapter first defines social withdrawal experienced by youth with reference

The first two are the interlocking parameters of time and place; the third one is the lack of face-to-face contacts and interactions other than family members; and the

to four parameters so as to highlight the nature of social isolation confronted by these young people who are turned invisible, voiceless, and disengaged. Informed by the principle of "starting where the client is," we then discuss different forms of in-home and community-based social work intervention targeted to self-secluded young people who are socially isolated from others other than their family. By using the empirical data drawn from a longitudinal study of youth with social withdrawal experience at home, the next session addresses the importance of interdisciplinary research and practice which is deemed important to facilitate young people to regain a sense of agency and a sense of expectancy for overcoming social isolation and its alienating relational and health outcomes. Before drawing a conclusion, we highlight the importance of advocacy work and its relationship with interdisciplin-

**2. Parameters for defining the state of social withdrawal**

final one is the deprivation of a legitimate social status [4].

**12**

sional service.

ary research and practice.

According to the Japanese government, social withdrawal or *hikikomori* in Japanese is a state where people seclude themselves at home for 6 months or more [13]. The length of time is important for temporary seclusion and solitude at home; if it is planned and preferred, it can be productive in nature, which may enhance one's knowledge of one's self and identity and the social environment, and provide relief from the pressures involved in interacting with other people in daily life and regain an orientation for leading a healthy and purposeful life ahead. Nowadays with the use of advanced computer and communication technology, working at home has become commonplace. Nobody will assume that the practice of home office is a manifestation of social withdrawal or social isolation. However, spending more than 6 months at home without working on designated tasks or having a clear purpose will likely cause anxious and lonely feelings [5]. The home or even a small room is largely the space where young people in social withdrawal spend their time and life. However, they may step out of the home boundary for a stroll alone on a silent street at midnight to avoid meeting or greeting neighbors or go out on their own to buy stuff at a corner store at a time when few people or customers are anticipated [8]. Self-seclusion at home was in the first place taken by young people as a viable solution, if not the last resort, to escape from experiencing frustrations such as school bullying, job-seeking failures, parental marital discord, and so on and do the things they prefer doing on their own. To avoid conflicts with the family and the parents in particular, it is not unusual for youth secluded at home to sleep throughout the day and stay awake at night to play online games or watch television alone [5, 7, 8]. However, the longer the period they seclude themselves at home, the more likely they will feel locked in time and space as if time was running slow [5]. Simply imagining that stepping out of their homebound cocoon into a community or public place will lead to a heightening sense of anxiety and insecurity will become an insurmountable barrier to reducing the further perpetuation of social isolation experienced in both an objective and subjective manner.

#### **2.2 Third parameter: lack of face-to-face contacts and interactions**

Most of the youth respondents were happy with their secluded lives in the first few months as they could take a break without being interfered, play online games, surf the Internet, and do many other things they were fond of doing. Nevertheless, dispensing with social relationships with others for a long time has deskilled young people in the sense that it leads them to forget how to engage in normal interactions and relationships with others and, accordingly, heightens their anxiety to venture into the community [5, 8]. As shown in research studies in Japan, *hikikomori* dare not go out the home on their own for fear of having eye contacts with distant others or to respond to normal social greetings with neighbors or friends [14]. To avoid conflicts with the family and the parents in particular, it is not unusual for youth secluded at home to sleep throughout the day and stay awake at night to play online games or watch television alone [5, 7, 8]. Mallett argued that home is a "socio-spatial system," where social relations are shaped and reproduced [15]. In the case of extended social withdrawal, the confined space of home causes the inter-generational relationship to spiral further downward. In case of worsened relationship with parents and family members, young people suffering from extended social withdrawal at home may just retreat to their own tiny room with a modest level of interaction with their family. Worse comes to worse, they may even decline eating with the family and take a few biscuits or a cup of instant noodle in their own tiny safe cocoon on a daily basis [6], which is, however, harmful to their health in terms of poor diet and lack of physical exercises [16, 17].

An extended absence of a variety of face-to-face contacts and interactions at home and beyond the home boundary is likely to lead to the deskilling of young people in relation to intimate others such as parents, siblings, and friends and outsiders such as neighbors and strangers. The longer the period of social withdrawal, the higher the likelihood young people will find it difficult to read facial expressions, respond to causal greetings, and engage in causal chats, which in turn results in a downward spiral or vicious cycle of social isolation. Being confined at home without interacting with people face to face does not preclude the possibility of young people's interaction with previous close friends and "virtual others" on the Internet platform. They may have online chatting with peers and ex-classmates on an occasional basis particularly in the beginning phase of self-isolation. But they would likely stop doing so when their ex-peers' pacing and environment of life have become so different from theirs. Self-secluded individuals at home may chat with online players even though without knowing them personally. Virtual online interaction may be interpreted as a manifestation of their desire to make contact with the outside world. This kind of "virtual chatting," however, is not conducive to developing trustful relationship particularly in view of the lack of offline interaction and companionship [5].

#### **2.3 Fourth parameter: deprivation of a legitimate social status**

Unlike their student counterparts suffering from social isolation in school settings, young people in social withdrawal at home do not lead a life with a social status as a student, worker, or trainee. They are instead labeled as NEET youth who are socially excluded from the institution of education, employment, or training. After staying for a long while without resuming study at school, going out to find a job in the labor market, or learning something useful in nearby community center, conflicts with their parents and siblings will take place. The conflict taking place on the same generation and across generations in the family context is usually focused on achieving a legitimate youth status as a student, worker, or trainee just like their normal youth counterparts. However, the concern of the family is different from that of the focal person who is too anxious and frightened to map out their transition to a socially legitimate social status. The following verbatim quotes from the first author's field data are representative of clients' reactions against practitioners or outsiders' intrusions into their safe "cocoon" [6]:

*As for the school worker, since he works in the school, he must speak for the school. So I did not want to talk to him. And the other one […] I did not know where he came from […] he did not look like a social worker. He looked like a construction worker […] I was very scared and ran into my room. At last, he talked to my mom instead of talking to me, saying something that I did not want to hear at all. I just hope that he will never come to disturb me again. (Sam, a client with social withdrawal experience)*

*I did not know where they had come from. I just thought they must be the allies of my parents. I can still remember that woman just asked me to stop surfing the internet and listen to her bullshit […] Another woman just told me "[I] would make my mom unhappy and disappointed if [I] kept on staying at home" […] She did not attempt to listen to me or understand my worries. (Peter, a client with social withdrawal experience)*

What is obvious is that making a transition from the state of NEET to that of engagement in education, employment, or training will be a long rugged journey

**15**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

characterized by ups and downs. Unlike their NEET counterparts with antisocial behavior, self-secluded and socially isolated home hermits are characterized by their asocial, non-prosocial, and socially avoidant behavior. NEET is just an umbrella term which covers a wide spectrum of youth behaviors, ranging from antisocial to asocial. Many of these NEET youth just look like normal youth with sociable and prosocial behavior with the only exception of whether making a suc-

However, without enjoying a socially legitimate social status as a student, worker, or trainee, it does not mean that these self-secluded and finally socially isolated youth at home are not engaged in activities at all. Many of them were surfing information related to heritage and ecology preservation, leading an eco-friendly life at home, helping out household chores to reduce the care burden of their mother, and developing interest on their own by ongoing googling and/or practice at home, e.g., photo-taking, pet care, handicraft, production of eco-friendly stuff for domestic use, etc. [5–8]. The next session discusses in what way these homebased activities undertaken by secluded youth are taken as interaction points for

**3. Intervention for engagement and facilitating youth transition to the** 

The perpetuation of social isolation is not only personal but also structural. If social isolation of youth with chronic social withdrawal experience is to be overcome, social inclusion with concerted efforts made on personal, interpersonal, and structural levels have to be made. Viewed from a social exclusion perspective, the purpose of antisocial exclusion policy and measures paving for the way for social inclusion is to address two interrelated dimensions: exclusion from work and exclusion from social relations [18]. To take a step further, Walker and Walker further argue that social exclusion should be understood "as a dynamic process of being shut out, fully or partially, from any of the social, economic, political or cultural systems which determine the social integration of a person in society" [19]. That is, the structural causes of various forms of social exclusion or disengagement experienced by disadvantaged youth have to be thoroughly addressed even though each of their unique strengths, interests, experiences, and dreams, which are embedded

**3.1 Home-based rapport building and interventions: start where the client is**

Following aforementioned discussion, professional interventions designed for facilitating youth transition to the world of study, work, or training for those who have been trapped in alienating circumstances of self-seclusion and social isolation in a tiny home space for so long should not be taken as the goal of intervention in the beginning phase. Instead, what matters most in the initial stage of intervention is to build up rapport or initial trust with involuntary, vulnerable, secluded clients who are resistant to visitors and strangers. In the case of outreaching young hermits, the social work motto "to start where the client is" can be read in a literal sense of taking home as a secure place for initial interaction and intervention. Home-based intervention is more than home visitations, and it involves activities with a modest level of conversations or dialogue [20]. Before doing any home visiting, it is considered strategic to listen to the concern of the family and the client's mother in particular who was usually the one to seek for help from social workers. At the meantime, helping professionals such as social workers, counselors, or youth

rapport building and intervention in a space the latter feel secure.

into their transition stories, has to be taken into account.

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

cessful transition to work or study.

**community**

#### *Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

characterized by ups and downs. Unlike their NEET counterparts with antisocial behavior, self-secluded and socially isolated home hermits are characterized by their asocial, non-prosocial, and socially avoidant behavior. NEET is just an umbrella term which covers a wide spectrum of youth behaviors, ranging from antisocial to asocial. Many of these NEET youth just look like normal youth with sociable and prosocial behavior with the only exception of whether making a successful transition to work or study.

However, without enjoying a socially legitimate social status as a student, worker, or trainee, it does not mean that these self-secluded and finally socially isolated youth at home are not engaged in activities at all. Many of them were surfing information related to heritage and ecology preservation, leading an eco-friendly life at home, helping out household chores to reduce the care burden of their mother, and developing interest on their own by ongoing googling and/or practice at home, e.g., photo-taking, pet care, handicraft, production of eco-friendly stuff for domestic use, etc. [5–8]. The next session discusses in what way these homebased activities undertaken by secluded youth are taken as interaction points for rapport building and intervention in a space the latter feel secure.

#### **3. Intervention for engagement and facilitating youth transition to the community**

The perpetuation of social isolation is not only personal but also structural. If social isolation of youth with chronic social withdrawal experience is to be overcome, social inclusion with concerted efforts made on personal, interpersonal, and structural levels have to be made. Viewed from a social exclusion perspective, the purpose of antisocial exclusion policy and measures paving for the way for social inclusion is to address two interrelated dimensions: exclusion from work and exclusion from social relations [18]. To take a step further, Walker and Walker further argue that social exclusion should be understood "as a dynamic process of being shut out, fully or partially, from any of the social, economic, political or cultural systems which determine the social integration of a person in society" [19]. That is, the structural causes of various forms of social exclusion or disengagement experienced by disadvantaged youth have to be thoroughly addressed even though each of their unique strengths, interests, experiences, and dreams, which are embedded into their transition stories, has to be taken into account.

#### **3.1 Home-based rapport building and interventions: start where the client is**

Following aforementioned discussion, professional interventions designed for facilitating youth transition to the world of study, work, or training for those who have been trapped in alienating circumstances of self-seclusion and social isolation in a tiny home space for so long should not be taken as the goal of intervention in the beginning phase. Instead, what matters most in the initial stage of intervention is to build up rapport or initial trust with involuntary, vulnerable, secluded clients who are resistant to visitors and strangers. In the case of outreaching young hermits, the social work motto "to start where the client is" can be read in a literal sense of taking home as a secure place for initial interaction and intervention. Home-based intervention is more than home visitations, and it involves activities with a modest level of conversations or dialogue [20]. Before doing any home visiting, it is considered strategic to listen to the concern of the family and the client's mother in particular who was usually the one to seek for help from social workers. At the meantime, helping professionals such as social workers, counselors, or youth

*Social Isolation - An Interdisciplinary View*

tion and companionship [5].

**2.3 Fourth parameter: deprivation of a legitimate social status**

or outsiders' intrusions into their safe "cocoon" [6]:

*withdrawal experience)*

*social withdrawal experience)*

Unlike their student counterparts suffering from social isolation in school settings, young people in social withdrawal at home do not lead a life with a social status as a student, worker, or trainee. They are instead labeled as NEET youth who are socially excluded from the institution of education, employment, or training. After staying for a long while without resuming study at school, going out to find a job in the labor market, or learning something useful in nearby community center, conflicts with their parents and siblings will take place. The conflict taking place on the same generation and across generations in the family context is usually focused on achieving a legitimate youth status as a student, worker, or trainee just like their normal youth counterparts. However, the concern of the family is different from that of the focal person who is too anxious and frightened to map out their transition to a socially legitimate social status. The following verbatim quotes from the first author's field data are representative of clients' reactions against practitioners

*As for the school worker, since he works in the school, he must speak for the school. So I did not want to talk to him. And the other one […] I did not know where he came from […] he did not look like a social worker. He looked like a construction worker […] I was very scared and ran into my room. At last, he talked to my mom instead of talking to me, saying something that I did not want to hear at all. I just hope that he will never come to disturb me again. (Sam, a client with social* 

*I did not know where they had come from. I just thought they must be the allies of my parents. I can still remember that woman just asked me to stop surfing the internet and listen to her bullshit […] Another woman just told me "[I] would make my mom unhappy and disappointed if [I] kept on staying at home" […] She did not attempt to listen to me or understand my worries. (Peter, a client with* 

What is obvious is that making a transition from the state of NEET to that of engagement in education, employment, or training will be a long rugged journey

An extended absence of a variety of face-to-face contacts and interactions at home and beyond the home boundary is likely to lead to the deskilling of young people in relation to intimate others such as parents, siblings, and friends and outsiders such as neighbors and strangers. The longer the period of social withdrawal, the higher the likelihood young people will find it difficult to read facial expressions, respond to causal greetings, and engage in causal chats, which in turn results in a downward spiral or vicious cycle of social isolation. Being confined at home without interacting with people face to face does not preclude the possibility of young people's interaction with previous close friends and "virtual others" on the Internet platform. They may have online chatting with peers and ex-classmates on an occasional basis particularly in the beginning phase of self-isolation. But they would likely stop doing so when their ex-peers' pacing and environment of life have become so different from theirs. Self-secluded individuals at home may chat with online players even though without knowing them personally. Virtual online interaction may be interpreted as a manifestation of their desire to make contact with the outside world. This kind of "virtual chatting," however, is not conducive to developing trustful relationship particularly in view of the lack of offline interac-

**14**

workers have to seek relevant information about the client, e.g., personal particulars, length of self-seclusion at home, daily routines or activities, personal interest, relationship with family members, etc.

According to the practice wisdom of experienced social workers, it took on average nine contacts for building up an initial working relationship with each youth client, including but not restricted to home visiting, celebrating client's birthday or doing festival celebration at home, presenting a small gift with the name of the client on it, telephone chatting, leaving behind a handwritten note for Internet or mobile phone contact, texting by using text messaging apps, etc. [5–8]. In the first few home visitations, social workers usually go in pair, as the primary social worker was to initiate interaction with or minimal conversations with the client on something he or she felt interested about, and the other worker was to talk with other family members outside the home environment particularly when they were moralizing the issue or blaming their child. The underlying principle is to start where the client is, which is understood in two interlocking senses: the first of which is to talk about something different from the family's primary concern or about the previous traumatic experience of the client; and the second is to be sensitive to the home environment in terms of both statics and dynamics of which the former refers to family photos, pictures, toys, books, magazines, gifts, souvenirs, etc., whereas the latter refers to family conversations and interactions, activities, or interests that the client was engaged in such as cooking, making desserts, taking care of a pet or two, cleaning goldfish tanks, taking photos of the street, playing online game, etc. Acknowledging the skills and knowledge involved in undertaking all these interest activities or daily routines can open up a space for engaging secluded youth in social interaction and minimal conversations that they have not experienced for so long.

In a home setting, the artifacts available for providing clues to possible talking points include family ornaments, souvenirs, furniture, and so on. In case of difficulties to engage in direct conversation with clients because of their resistance to visitors, it was through talking about artifacts or pictures in the living room that the parents, usually the mothers, were able to elicit happy memories with their beloved children in relation to their unique strengths and abilities. As most of the cases of the first authors' studies were of working class background, their living space was tiny, and the partitioned walls in the clients' homes were not a barrier to their overhearing conversations taking place in the living room. The explicit absence of clients, hidden away from any interaction with social workers as strangers, did not rule out their implicit presence in hearing what is said positive about them. This could help youth clients recall the previous harmonious relationship with their family. These conversations provide a contrast with more recent and current stories filled with frustration, conflict, and anger. This indirect intervention approach can at least help build up an initial working relationship with clients' family and may arouse clients' curiosity about the friendly attitude of helping professionals.

Starting where the clients are does not mean ending up where they are. After gaining initial trust with the worker, the client could be invited to initiate some ideas that they would like to pursue at home, for example, learn to develop one's interest at home in the presence of the worker perhaps with the company and instruction from a youth mentor or try out some new interest that they could not afford to do or dare to dream of doing so, e.g., learn to play magic, keyboard, drum, or guitar, use recycled materials for handicraft making, or even do home-based volunteering or simple paid job by designing a poster for promoting an agency's program targeted to others in need [5]. In this sense, secluded youth at home could develop a sense of agency and a sense of contribution which are all good for rebuilding their self-esteem.

**17**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

Another innovative means to build initial rapport at clients' homes is to work with animal-assisted therapists or practitioners to use a therapy dog for doing home visitations and interactions. In accordance to the verbatim drawn from a study of the first author, a social worker working with youth in social withdrawal made a

*The dog is called "Fat Fat," which is a tiny dog. Fat Fat is very nice and friendly… Tiny dogs are more acceptable for home visitations, as security guards usually turned a blind eye to this. It's harder if we use therapy dogs of a bigger size...Fat Fat was shortsighted, and he was used to smell and greet others at close distance. Whenever he smelt the presence of young people at proximity, the latter would feel* 

Affective relations with pet or therapeutic animals go beyond the conventional understanding of human relations [21]. The interaction process with the therapy dog Fat Fat opened up the space for dialogues between clients and social workers. The clients were less defensive to relate to social workers as visitors, since the focus of conversation was around the therapy dog rather than taking clients as the focus of concern. The use of therapeutic dogs is not only effective for icebreaking and building trust and rapport with social workers but also affective by giving youth clients a sense of warmth and a sense of touch that they had not experienced with

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

*less on guard…. (Adrian, a social worker).*

their family members and any others outside the home for so long.

**3.2 Community-based interventions: interest-based and client-centered** 

As to youth with extended self-seclusion experience, anywhere beyond the home environment is a groan zone where they find it risky and uncomfortable. The longer these isolated young people stay at home without making any face-to-face contacts and interactions with others in the community, the more difficult they will find it to make a move outside their comfort zone. One of the effective ways to give these young people an incentive to destabilize their sense of "homeboundedness" is for their entrusted social worker to accompany them to do an unfinished task or two they aspired to settle. The needs and tasks may be as simple as fixing a computer, enjoying a trip to the countryside, having a haircut, buying something in nearby commercial arcade, seeing some heritage buildings, taking photos of beautiful flowers, etc. Acknowledging clients' intention to do or settle something beyond their home environment, though seemingly minute to the rest of the world, can serve as a starting point for making a breakthrough against home confinement, spatially and mentally. Social workers can make use of this opportunity to facilitate homebound youth to plan ahead, make decision, and do mental rehearsal for the tasks they would like to pursue with the company and support from social workers. The experience of venturing into the community can provide secluded youth a solid base for driving out their fear and anxiety for meeting strangers outside their home environment and reflecting on the experience for drawing learnings that could be

NGOs with a drop-in corner or activity rooms can provide homebound youth an ideal setting to learn new things of interest to them, as the service environment has given tangible resources and mentoring support that are conducive to rebuilding the trust of homebound youth to outsiders. That is, the focus is placed on interest-based learning for satisfying their learning needs and resuming normal social interactions with others rather than on seeking formal educational or vocational qualifications which were too demanding to them. Another advantage of giving young people

related remark as follows:

**interventions**

applied for the next outing.

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

Another innovative means to build initial rapport at clients' homes is to work with animal-assisted therapists or practitioners to use a therapy dog for doing home visitations and interactions. In accordance to the verbatim drawn from a study of the first author, a social worker working with youth in social withdrawal made a related remark as follows:

*The dog is called "Fat Fat," which is a tiny dog. Fat Fat is very nice and friendly… Tiny dogs are more acceptable for home visitations, as security guards usually turned a blind eye to this. It's harder if we use therapy dogs of a bigger size...Fat Fat was shortsighted, and he was used to smell and greet others at close distance. Whenever he smelt the presence of young people at proximity, the latter would feel less on guard…. (Adrian, a social worker).*

Affective relations with pet or therapeutic animals go beyond the conventional understanding of human relations [21]. The interaction process with the therapy dog Fat Fat opened up the space for dialogues between clients and social workers. The clients were less defensive to relate to social workers as visitors, since the focus of conversation was around the therapy dog rather than taking clients as the focus of concern. The use of therapeutic dogs is not only effective for icebreaking and building trust and rapport with social workers but also affective by giving youth clients a sense of warmth and a sense of touch that they had not experienced with their family members and any others outside the home for so long.

#### **3.2 Community-based interventions: interest-based and client-centered interventions**

As to youth with extended self-seclusion experience, anywhere beyond the home environment is a groan zone where they find it risky and uncomfortable. The longer these isolated young people stay at home without making any face-to-face contacts and interactions with others in the community, the more difficult they will find it to make a move outside their comfort zone. One of the effective ways to give these young people an incentive to destabilize their sense of "homeboundedness" is for their entrusted social worker to accompany them to do an unfinished task or two they aspired to settle. The needs and tasks may be as simple as fixing a computer, enjoying a trip to the countryside, having a haircut, buying something in nearby commercial arcade, seeing some heritage buildings, taking photos of beautiful flowers, etc. Acknowledging clients' intention to do or settle something beyond their home environment, though seemingly minute to the rest of the world, can serve as a starting point for making a breakthrough against home confinement, spatially and mentally. Social workers can make use of this opportunity to facilitate homebound youth to plan ahead, make decision, and do mental rehearsal for the tasks they would like to pursue with the company and support from social workers. The experience of venturing into the community can provide secluded youth a solid base for driving out their fear and anxiety for meeting strangers outside their home environment and reflecting on the experience for drawing learnings that could be applied for the next outing.

NGOs with a drop-in corner or activity rooms can provide homebound youth an ideal setting to learn new things of interest to them, as the service environment has given tangible resources and mentoring support that are conducive to rebuilding the trust of homebound youth to outsiders. That is, the focus is placed on interest-based learning for satisfying their learning needs and resuming normal social interactions with others rather than on seeking formal educational or vocational qualifications which were too demanding to them. Another advantage of giving young people

*Social Isolation - An Interdisciplinary View*

relationship with family members, etc.

experienced for so long.

workers have to seek relevant information about the client, e.g., personal particulars, length of self-seclusion at home, daily routines or activities, personal interest,

According to the practice wisdom of experienced social workers, it took on average nine contacts for building up an initial working relationship with each youth client, including but not restricted to home visiting, celebrating client's birthday or doing festival celebration at home, presenting a small gift with the name of the client on it, telephone chatting, leaving behind a handwritten note for Internet or mobile phone contact, texting by using text messaging apps, etc. [5–8]. In the first few home visitations, social workers usually go in pair, as the primary social worker was to initiate interaction with or minimal conversations with the client on something he or she felt interested about, and the other worker was to talk with other family members outside the home environment particularly when they were moralizing the issue or blaming their child. The underlying principle is to start where the client is, which is understood in two interlocking senses: the first of which is to talk about something different from the family's primary concern or about the previous traumatic experience of the client; and the second is to be sensitive to the home environment in terms of both statics and dynamics of which the former refers to family photos, pictures, toys, books, magazines, gifts, souvenirs, etc., whereas the latter refers to family conversations and interactions, activities, or interests that the client was engaged in such as cooking, making desserts, taking care of a pet or two, cleaning goldfish tanks, taking photos of the street, playing online game, etc. Acknowledging the skills and knowledge involved in undertaking all these interest activities or daily routines can open up a space for engaging secluded youth in social interaction and minimal conversations that they have not

In a home setting, the artifacts available for providing clues to possible talking points include family ornaments, souvenirs, furniture, and so on. In case of difficulties to engage in direct conversation with clients because of their resistance to visitors, it was through talking about artifacts or pictures in the living room that the parents, usually the mothers, were able to elicit happy memories with their beloved children in relation to their unique strengths and abilities. As most of the cases of the first authors' studies were of working class background, their living space was tiny, and the partitioned walls in the clients' homes were not a barrier to their overhearing conversations taking place in the living room. The explicit absence of clients, hidden away from any interaction with social workers as strangers, did not rule out their implicit presence in hearing what is said positive about them. This could help youth clients recall the previous harmonious relationship with their family. These conversations provide a contrast with more recent and current stories filled with frustration, conflict, and anger. This indirect intervention approach can at least help build up an initial working relationship with clients' family and may arouse clients' curiosity about the friendly attitude of helping professionals.

Starting where the clients are does not mean ending up where they are. After gaining initial trust with the worker, the client could be invited to initiate some ideas that they would like to pursue at home, for example, learn to develop one's interest at home in the presence of the worker perhaps with the company and instruction from a youth mentor or try out some new interest that they could not afford to do or dare to dream of doing so, e.g., learn to play magic, keyboard, drum, or guitar, use recycled materials for handicraft making, or even do home-based volunteering or simple paid job by designing a poster for promoting an agency's program targeted to others in need [5]. In this sense, secluded youth at home could develop a sense of agency and a sense of contribution which are all good for rebuild-

**16**

ing their self-esteem.

with social withdrawal experience a variety of choices of one-off events or shortterm courses with just a few sessions is to give them a chance to make decision on their own, try out new things without making any commitment, and make new friends who may have the same interests or the same background of having selfseclusion and social isolation experience. In an environment that is relatively free of name-calling, teasing, and testing out behaviors, and in an environment where people are more sympathetic and supportive to each other, young people with shyness or social phobia are more able to develop sociable and prosocial behaviors for exploring and experimenting informal relationships in the real world. This reminds social workers the importance of working with youth clients in a professional yet informal manner which can provide them a secure place for appreciating and building informal and faithful peer relations that will last much longer than formal worker-client relationship [5].

In another career intervention program supervised by the first author, young people with seclusion experience were invited to visit shelter dogs which had abused or abandoned experience before and engaged in human-canine activities designed to promote a positive relationship between humans and animals. Narrative review is used to help youth participants explore the values, attitudes, skills, and knowledge involved in caring for sheltered dogs and find meaning in life. Young people reported that a reciprocal relationship was experienced in the process of caring for the dogs, which offered trust, acceptance, unconditional love, and nonjudgmental contact. The youth participants offered love, care, companionship, and a secure interacting environment for the dogs, which encouraged them to believe in their ability to care for living beings. A positive self-identity with a greater sense of achievement and self-worth was built up. The interaction was also beneficial to the dogs as they became trusting, confident, and accepting of human care. Such a positive response from the dogs further reinforced a sense of contribution among the youth participants. Many of them were inspired to explore animal care work and to promote animal welfare. The program also supported young people to become mentors, to share their transformations with new members of the program and with parents, teachers, and other community stakeholders. And through the provision of workplace learning and mentoring opportunities, they were facilitated to explore about the possibility of continuing doing volunteering in animal care and animal rights and developing a vocational career related to animal care or pet care industries. In a career and life adventure planning project funded by the Hong Kong Jockey Club Charities Trust which is the number one donor in Hong Kong, the experience to date shows that when young people such as those with chronic social withdrawal experience are provided an enabling environment with resources, opportunities, and networks, they can archive, reflect, and develop their own set of transferable values, attitudes, skills, and knowledge across different domains of paid and unpaid work experiences [22] and define their own meaningful career roadmap; they can and will make positive contributions toward a better and more inclusive world [23].

#### **3.3 Interdisciplinary collaboration across healthcare and social care disciplines for research and youth engagement**

In a brand-new interdisciplinary study conducted by a team of academics and researchers of the background of nursing and social work professions in Hong Kong, a total of 104 youth clients with social withdrawal experience were invited to participate in a research study as respondents by means of completing a set of questionnaires and going through some anthropometric and physical measurements. Measurements were taken by a well-trained nursing student, which include body

**19**

health outcomes.

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

weight, height, length and width of ears, blood pressure, pulse rate, respiratory rate, and waist and hip circumference which were recorded and used for calculating the body mass index and waist-hip ratio. This interdisciplinary study across nursing and social work professions is the first ever study studying the physical health

This group of youth respondents living with a *hikikomori* lifestyle was found to have a high incidence of prehypertension and hypertension, which were correlated with the weight gains during the course of their secluded life at home. The length of *hikikomori* duration was associated with a shift of body weight from underweight to overweight and obesity and also with elevated blood pressure. This may be resulted from their unhealthy diets and distorted sleep patterns over the course of extended social withdrawal. Over 1 year, the respondents showed improvement in health measures including reduced blood pressure levels and waist-hip ratios. Most surprisingly, the prevalence of hypertension was significantly reduced from 15.4 to 9.0% over 1 year, which was below the 12.6% adult prevalence of diagnosed hypertension [24] and the 12.8% age-specific prevalence for young people aged 15–34 [25]. The prevalence of prehypertension also slightly dropped from 31.7 to 29.1% [17]. In 12 months' time, they also witnessed an upward trend of practicing

This positive change in terms of health actions taken by the respondents could be related to two episodes of experiences. First, the respondents were informed by the nursing researcher the measures in an archived format immediately after the physical assessment, which could trigger their health awareness and their eagerness to take actions to make improvements for the next round of follow-up assessments 6 and 12 months after. Second, although social workers are not health professionals by themselves, they can use the archived record as a talking point and remind their clients to lead a healthy lifestyle by doing more exercises and developing healthier diet habits. That is, taking actions for making improvement with health and physical measures to impress oneself and others over time is considered conducive to creating a sense of expectancy among the respondents. The practice of using archived records for talking and reminder purpose consistent with the health belief model which emphasizes beholders' awareness of threat perception (risk) and positive initiatives (opportunity) is the key to trigger appropriate actions for realizing positive health outcomes [26, 27]. This implies that promoting interdisciplinary collaboration across healthcare and social care disciplines is not only good for breeding new ideas for conducting research studies but also for producing health measures in the form of visible archive for engaging secluded youth to develop a sense of expectancy and a sense of agency for making improvements with their lifestyle and

As viewed from the nursing perspective, the focus is placed on providing care using a holistic approach and with interdisciplinary collaboration to ensure the best possible outcome for the client. Nursing care models and the "nursing process" help guide and organize how care is provided to clients. As demonstrated in the aforementioned interdisciplinary study of youth living a *hikikomori* lifestyle, the youth group showed interest to make improvement of their own health, which coincides with the principles of the McGill model of nursing where the client's health is improved by means of actively engaging them in the learning process of their care [28]. The aforementioned study identified many health risks of the youth group such as prehypertension, hypertension, obesity, an unhealthy diet, and disrupted sleep patterns [17]. If these were the health focuses for the client, the nursing intervention would be to provide health education or promotion knowledge to clients in order to help them make an informed choice regarding their care or activity performed on a daily basis. Any application of an holistic approach to care

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

moderate-intensity exercises among the respondents.

aspects of *hikikomori* [17].

#### *Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

weight, height, length and width of ears, blood pressure, pulse rate, respiratory rate, and waist and hip circumference which were recorded and used for calculating the body mass index and waist-hip ratio. This interdisciplinary study across nursing and social work professions is the first ever study studying the physical health aspects of *hikikomori* [17].

This group of youth respondents living with a *hikikomori* lifestyle was found to have a high incidence of prehypertension and hypertension, which were correlated with the weight gains during the course of their secluded life at home. The length of *hikikomori* duration was associated with a shift of body weight from underweight to overweight and obesity and also with elevated blood pressure. This may be resulted from their unhealthy diets and distorted sleep patterns over the course of extended social withdrawal. Over 1 year, the respondents showed improvement in health measures including reduced blood pressure levels and waist-hip ratios. Most surprisingly, the prevalence of hypertension was significantly reduced from 15.4 to 9.0% over 1 year, which was below the 12.6% adult prevalence of diagnosed hypertension [24] and the 12.8% age-specific prevalence for young people aged 15–34 [25]. The prevalence of prehypertension also slightly dropped from 31.7 to 29.1% [17]. In 12 months' time, they also witnessed an upward trend of practicing moderate-intensity exercises among the respondents.

This positive change in terms of health actions taken by the respondents could be related to two episodes of experiences. First, the respondents were informed by the nursing researcher the measures in an archived format immediately after the physical assessment, which could trigger their health awareness and their eagerness to take actions to make improvements for the next round of follow-up assessments 6 and 12 months after. Second, although social workers are not health professionals by themselves, they can use the archived record as a talking point and remind their clients to lead a healthy lifestyle by doing more exercises and developing healthier diet habits. That is, taking actions for making improvement with health and physical measures to impress oneself and others over time is considered conducive to creating a sense of expectancy among the respondents. The practice of using archived records for talking and reminder purpose consistent with the health belief model which emphasizes beholders' awareness of threat perception (risk) and positive initiatives (opportunity) is the key to trigger appropriate actions for realizing positive health outcomes [26, 27]. This implies that promoting interdisciplinary collaboration across healthcare and social care disciplines is not only good for breeding new ideas for conducting research studies but also for producing health measures in the form of visible archive for engaging secluded youth to develop a sense of expectancy and a sense of agency for making improvements with their lifestyle and health outcomes.

As viewed from the nursing perspective, the focus is placed on providing care using a holistic approach and with interdisciplinary collaboration to ensure the best possible outcome for the client. Nursing care models and the "nursing process" help guide and organize how care is provided to clients. As demonstrated in the aforementioned interdisciplinary study of youth living a *hikikomori* lifestyle, the youth group showed interest to make improvement of their own health, which coincides with the principles of the McGill model of nursing where the client's health is improved by means of actively engaging them in the learning process of their care [28]. The aforementioned study identified many health risks of the youth group such as prehypertension, hypertension, obesity, an unhealthy diet, and disrupted sleep patterns [17]. If these were the health focuses for the client, the nursing intervention would be to provide health education or promotion knowledge to clients in order to help them make an informed choice regarding their care or activity performed on a daily basis. Any application of an holistic approach to care

*Social Isolation - An Interdisciplinary View*

worker-client relationship [5].

with social withdrawal experience a variety of choices of one-off events or shortterm courses with just a few sessions is to give them a chance to make decision on their own, try out new things without making any commitment, and make new friends who may have the same interests or the same background of having selfseclusion and social isolation experience. In an environment that is relatively free of name-calling, teasing, and testing out behaviors, and in an environment where people are more sympathetic and supportive to each other, young people with shyness or social phobia are more able to develop sociable and prosocial behaviors for exploring and experimenting informal relationships in the real world. This reminds social workers the importance of working with youth clients in a professional yet informal manner which can provide them a secure place for appreciating and building informal and faithful peer relations that will last much longer than formal

In another career intervention program supervised by the first author, young people with seclusion experience were invited to visit shelter dogs which had abused or abandoned experience before and engaged in human-canine activities designed to promote a positive relationship between humans and animals. Narrative review is used to help youth participants explore the values, attitudes, skills, and knowledge involved in caring for sheltered dogs and find meaning in life. Young people reported that a reciprocal relationship was experienced in the process of caring for the dogs, which offered trust, acceptance, unconditional love, and nonjudgmental contact. The youth participants offered love, care, companionship, and a secure interacting environment for the dogs, which encouraged them to believe in their ability to care for living beings. A positive self-identity with a greater sense of achievement and self-worth was built up. The interaction was also beneficial to the dogs as they became trusting, confident, and accepting of human care. Such a positive response from the dogs further reinforced a sense of contribution among the youth participants. Many of them were inspired to explore animal care work and to promote animal welfare. The program also supported young people to become mentors, to share their transformations with new members of the program and with parents, teachers, and other community stakeholders. And through the provision of workplace learning and mentoring opportunities, they were facilitated to explore about the possibility of continuing doing volunteering in animal care and animal rights and developing a vocational career related to animal care or pet care industries. In a career and life adventure planning project funded by the Hong Kong Jockey Club Charities Trust which is the number one donor in Hong Kong, the experience to date shows that when young people such as those with chronic social withdrawal experience are provided an enabling environment with resources, opportunities, and networks, they can archive, reflect, and develop their own set of transferable values, attitudes, skills, and knowledge across different domains of paid and unpaid work experiences [22] and define their own meaningful career roadmap; they can and will make positive contributions toward a better and more

**3.3 Interdisciplinary collaboration across healthcare and social care disciplines** 

In a brand-new interdisciplinary study conducted by a team of academics and researchers of the background of nursing and social work professions in Hong Kong, a total of 104 youth clients with social withdrawal experience were invited to participate in a research study as respondents by means of completing a set of questionnaires and going through some anthropometric and physical measurements. Measurements were taken by a well-trained nursing student, which include body

**18**

inclusive world [23].

**for research and youth engagement**

in future study should also address the health concerns of the clients' family, understand their family dynamics, identify any environmental factors that may affect or help the clients, locate health resources and initiate referrals as appropriate, ensure clients' exercise of autonomy, facilitate communication between the interdisciplinary healthcare team and the clients, while ensuring professionalism, ethical practice and confidentiality.

In cooperation with other healthcare professionals, nursing interventions offer access to empirical health data as well as clients' specimens for a better understanding of the pathophysiology. Biomedical scientists look into the potential biomarkers for making accurate diagnosis and to explain the pathological pathways, in order to allow for effective medical treatments. Recently, based on the assumption of avoidant personality disorder as the most common comorbidity of *hikikomori*, a medical team has evaluated 101 blood specimens obtained from 46 males and 55 females. Results of this study suggested two gender-different biomarkers potential for explaining the biological basis of *hikikomori*, namely, uric acid (UA) in men and high-density lipoprotein cholesterol (HDL-C) in women, which were expressed in lower serum levels than with healthy controls [29]. This has opened up a new page in this field of research with increasing trend of the *hikikomori* prevalence worldwide.

#### **4. Advocacy work**

Socially withdrawn youth suffering from social isolation have not been able to receive regular targeted funding support from the Social Welfare Department (SWD) which is responsible for allocating and administering the bulk of government-funded social welfare services in Hong Kong, whether in statutory, governmental, or NGO settings. On many different occasions, SWD bureaucrats just replied that integrated youth service teams are capable of outreaching secluded youth in the community. These integrated teams are established to provide a wide range of services including children and youth center services, school social work services, and outreaching youth work under one management to meet the multifarious needs of children and youth aged 6–24. However, as these homebound cases are very much demanding of time and effort, and the integrated teams are under pressure to deliver sufficient service output to satisfy the Funding and Service Agreement requirements of the SWD, this invisible group of atomistic individuals would be subject to the risk of receiving inadequate attention and services from integrated teams. Wong argued that government inaction on this specific "hidden problem" which does not upset the community like their street counterparts with antisocial behavior has resulted in ironing out the diversity and differences of NEET youth [6], thus reproducing the inverse care law: availability of services tends to vary inversely with the need of the population served [30]. Advocating for a concerted social policy and more financial and manpower resources to set up separate teams all over Hong Kong to outreach young people in social withdrawal can prevent extended social isolation and consequential poor physical and mental health outcomes from taking place. With the consolidation of practice wisdom and evidence-based practice developed on interdisciplinary collaboration platforms with input from a diversity of health and social care professionals such as social workers, teachers, nurses, doctors, animal-assisted therapists, physiotherapists, physical exercise experts, etc., and with resources, opportunities, and networks by means of engaging multiple stakeholders including employers, parents, and mentors, youth with chronic social withdrawal and social isolation experience can be facilitated to make a transition into the community as a student, trainee, or worker

**21**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

in the conventional sense or as a lifelong learner eager to be engaged in paid and unpaid work experiences and other life-wide experiences in order to map out their

All this does not rule out the possibility that with the support of solid research work and studies, social workers and youth work practitioners can share their practice wisdom and evidence-based practices with their professional counterparts working in school, center-wise, and other community-based settings. And it is entirely possible for different professional parties to work in a collaborative manner to involve multiple stakeholders including employers to provide seamless provision of services ranging from a variety of home-based interventions to a plurality of initiatives and measures including interest development, workplace learning, and

Social isolation experienced by young people in the form of extended or chronic social withdrawal at home for a protracted period of time is characterized by its invisibility and inaccessibility to adequate social provisions. For each single and unique case of youth with social withdrawal experience, helping professionals have to address the temporal, spatial, relational, and status-wise parameters in a comprehensive manner in order to map out the context and direction of professional

However, self-seclusion with resulted stagnation in transition to a legitimate social status does not imply any clientele inactivity at home. Starting where the clients are is to stay tuned with their current interest, routines, and activities they do at home, which can provide the basis for interaction, rapport building, and modest level of conversations. This can help scaffold their further interest- and activitybased learning at home and pave the way for pursuing beyond home learning and

Individual young people have to learn to interact with others, kick off learning momentum, develop a healthy diet, do exercises, step out their alienating comfort zone, reengage with the community, try out workplace learning, map out their career roadmap, and make contributions to others and the community, but it will not be effective if they are confronted with blaming-the-victim discourses and circumstances unfavorable for realizing their abilities, strengths, and aspirations. Examples of such circumstances include the inadequacy of structural and institutional support; the lack of institutional, organizational, and professional flexibility; the lack of social networks and social capital; the lack of cross-sectoral and interdisciplinary collaboration; and the lack of the provision of an enabling environment where young people can enjoy access to resources, opportunities, and networks for reflecting and developing transferable values, attitudes, skills, and knowledge

Giving young people an enabling environment by means of engaging the participation and involvement of multiple stakeholders for the sake of enhancing youth's agency, esteem and expectancy can nourish their hopes and raise their aspirations. Again, it is important to seek research funding support to conduct empirical interdisciplinary research studies that could address both the personal and the structural aspects of social withdrawal and social isolation and deliver an analysis of problems and interventions. The causes of social isolation of young people in the form of extended social withdrawal at home are both personal and structural, and thus the conceptualization and delivery of viable measures and interventions have to address both personal and structural dimensions [5, 31]. Interdisciplinary collaboration in

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

career pathway with life's deep meanings.

**5. Concluding remarks**

intervention.

other on-the-job and corporate mentoring programs.

fulfilling unfinished tasks in the community.

across different life domains.

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

in the conventional sense or as a lifelong learner eager to be engaged in paid and unpaid work experiences and other life-wide experiences in order to map out their career pathway with life's deep meanings.

All this does not rule out the possibility that with the support of solid research work and studies, social workers and youth work practitioners can share their practice wisdom and evidence-based practices with their professional counterparts working in school, center-wise, and other community-based settings. And it is entirely possible for different professional parties to work in a collaborative manner to involve multiple stakeholders including employers to provide seamless provision of services ranging from a variety of home-based interventions to a plurality of initiatives and measures including interest development, workplace learning, and other on-the-job and corporate mentoring programs.

#### **5. Concluding remarks**

*Social Isolation - An Interdisciplinary View*

and confidentiality.

worldwide.

**4. Advocacy work**

in future study should also address the health concerns of the clients' family, understand their family dynamics, identify any environmental factors that may affect or help the clients, locate health resources and initiate referrals as appropriate, ensure clients' exercise of autonomy, facilitate communication between the interdisciplinary healthcare team and the clients, while ensuring professionalism, ethical practice

In cooperation with other healthcare professionals, nursing interventions offer access to empirical health data as well as clients' specimens for a better understanding of the pathophysiology. Biomedical scientists look into the potential biomarkers for making accurate diagnosis and to explain the pathological pathways, in order to allow for effective medical treatments. Recently, based on the assumption of avoidant personality disorder as the most common comorbidity of *hikikomori*, a medical team has evaluated 101 blood specimens obtained from 46 males and 55 females. Results of this study suggested two gender-different biomarkers potential for explaining the biological basis of *hikikomori*, namely, uric acid (UA) in men and high-density lipoprotein cholesterol (HDL-C) in women, which were expressed in lower serum levels than with healthy controls [29]. This has opened up a new page in this field of research with increasing trend of the *hikikomori* prevalence

Socially withdrawn youth suffering from social isolation have not been able to receive regular targeted funding support from the Social Welfare Department

(SWD) which is responsible for allocating and administering the bulk of government-funded social welfare services in Hong Kong, whether in statutory, governmental, or NGO settings. On many different occasions, SWD bureaucrats just replied that integrated youth service teams are capable of outreaching secluded youth in the community. These integrated teams are established to provide a wide range of services including children and youth center services, school social work services, and outreaching youth work under one management to meet the multifarious needs of children and youth aged 6–24. However, as these homebound cases are very much demanding of time and effort, and the integrated teams are under pressure to deliver sufficient service output to satisfy the Funding and Service Agreement requirements of the SWD, this invisible group of atomistic individuals would be subject to the risk of receiving inadequate attention and services from integrated teams. Wong argued that government inaction on this specific "hidden problem" which does not upset the community like their street counterparts with antisocial behavior has resulted in ironing out the diversity and differences of NEET youth [6], thus reproducing the inverse care law: availability of services tends to vary inversely with the need of the population served [30]. Advocating for a concerted social policy and more financial and manpower resources to set up separate teams all over Hong Kong to outreach young people in social withdrawal can prevent extended social isolation and consequential poor physical and mental health outcomes from taking place. With the consolidation of practice wisdom and evidence-based practice developed on interdisciplinary collaboration platforms with input from a diversity of health and social care professionals such as social workers, teachers, nurses, doctors, animal-assisted therapists, physiotherapists, physical exercise experts, etc., and with resources, opportunities, and networks by means of engaging multiple stakeholders including employers, parents, and mentors, youth with chronic social withdrawal and social isolation experience can be facilitated to make a transition into the community as a student, trainee, or worker

**20**

Social isolation experienced by young people in the form of extended or chronic social withdrawal at home for a protracted period of time is characterized by its invisibility and inaccessibility to adequate social provisions. For each single and unique case of youth with social withdrawal experience, helping professionals have to address the temporal, spatial, relational, and status-wise parameters in a comprehensive manner in order to map out the context and direction of professional intervention.

However, self-seclusion with resulted stagnation in transition to a legitimate social status does not imply any clientele inactivity at home. Starting where the clients are is to stay tuned with their current interest, routines, and activities they do at home, which can provide the basis for interaction, rapport building, and modest level of conversations. This can help scaffold their further interest- and activitybased learning at home and pave the way for pursuing beyond home learning and fulfilling unfinished tasks in the community.

Individual young people have to learn to interact with others, kick off learning momentum, develop a healthy diet, do exercises, step out their alienating comfort zone, reengage with the community, try out workplace learning, map out their career roadmap, and make contributions to others and the community, but it will not be effective if they are confronted with blaming-the-victim discourses and circumstances unfavorable for realizing their abilities, strengths, and aspirations. Examples of such circumstances include the inadequacy of structural and institutional support; the lack of institutional, organizational, and professional flexibility; the lack of social networks and social capital; the lack of cross-sectoral and interdisciplinary collaboration; and the lack of the provision of an enabling environment where young people can enjoy access to resources, opportunities, and networks for reflecting and developing transferable values, attitudes, skills, and knowledge across different life domains.

Giving young people an enabling environment by means of engaging the participation and involvement of multiple stakeholders for the sake of enhancing youth's agency, esteem and expectancy can nourish their hopes and raise their aspirations. Again, it is important to seek research funding support to conduct empirical interdisciplinary research studies that could address both the personal and the structural aspects of social withdrawal and social isolation and deliver an analysis of problems and interventions. The causes of social isolation of young people in the form of extended social withdrawal at home are both personal and structural, and thus the conceptualization and delivery of viable measures and interventions have to address both personal and structural dimensions [5, 31]. Interdisciplinary collaboration in

terms of practice and research is expected to play a growing important role to do advocacy along this line in the journey ahead.

#### **Acknowledgements**

The empirical findings were drawn from a number of research projects supported by the following funding bodies: the Health and Medical Research Fund (Project No. 13144071) from the Food and Health Bureau of Hong Kong, the General Research Fund (Project No. GRF/244707) from the Research Grants Council of Hong Kong, the Faculty Research Grant (Project No. FRG/05- 06/I-01-30-05-101) from Hong Kong Baptist University, and the Trust-Initiated Project Fund (Project No. HKBU/HKJCCT-33-14-211) from the Hong Kong Jockey Club Charities Trust.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Victor Wong1 \*, John Yuen<sup>2</sup> , Xuebing Su1 and Jolene Yung2

1 Department of Social Work, Hong Kong Baptist University, Hong Kong

2 School of Nursing, The Hong Kong Polytechnic University, Hong Kong

\*Address all correspondence to: vicwong@hkbu.edu.hk

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**23**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

Journal of Sociology and Social Policy. 2012;**32**:415-430. DOI: 10.1108/01443331211249057

[8] Wong V. Social work with youth in social withdrawal: In-home and beyond-home intervention modalities. China Journal of Social Work. 2014;**7**:161-174. DOI: 10.1080/17525098.2014.921211

[9] Hattori Y. Social withdrawal in Japanese youth: A case study of thirtyfive hikikomori clients. Journal of Trauma Practice. 2005;**4**:181-201. DOI:

[10] Chan HY, Lo TW. Hidden youth services: What Hong Kong can learn from Japan. Children and Youth Services Review. 2014;**42**:118-126. DOI: 10.1016/j.

10.1300/J189v04n03\_01

childyouth.2014.03.021

[11] Suwa M, Suzuki K, Hara K, Watanabe H, Takahashi T. Family features in primary social withdrawal among young adults. Psychiatry and Clinical

[13] Kaneko S. Japan's 'socially

Neurosciences. 2003;**57**:586-594. DOI: 10.1046/j.1440-1819.2003.01172.x

[12] Furlong A. The Japanese hikikomori phenomenon: Acute social withdrawal among young people. The Sociological Review. 2008;**56**:309-325. DOI: 10.1111%2Fj.1467-954X.2008.00790.x

withdrawn youths' and time constrains in Japanese society: Management and conceptualization of time in a support group for 'hikikomori'. Time & Society. 2006;**15**:233-249. DOI: 10.1177/0961463X06067034

[14] Ogino T. Managing categorization and social withdrawal in Japan: Rehabilitation process in a private support group for hikikomorians. International Journal of Japanese Sociology. 2004;**13**:120-133. DOI: 10.1111/j.1475-6781.2004.00057.x

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

[1] Matthews TJB. The pervasive impact of social isolation and loneliness in young people: An epidemiological, longitudinal and genetically-sensitive study [thesis]. London, UK: King's College London; 2017. Available from: https://core.ac.uk/download/

[2] Morese R, Defedele M, Nervo J. I teach you to quarrel-empathy and mediation: Tools for preventing bullying. In: Socialization: A

[3] Coplan RJ, Rubin KH. Social withdrawal and shyness in childhood: History, theories, definitions and assessments. In: Rubin KH, Coplan RJ, editors. The Development of Shyness and Social Withdrawal. New York: The Guilford Press; 2010. pp. 3-22. DOI:

10.1177/0165025409103874

[4] Cacioppo S, Grippo AJ, London S, Goossens L, Cacioppo JT. Loneliness: Clinical import and interventions. Perspectives on Psychological Science. 2015;**10**:238-249. DOI: 10.1177/1745691615570616

[5] Wong V. Youth locked in time and space? Defining features of social withdrawal and practice implications. Journal of Social Work Practice. 2009;**23**:337-352. DOI: 10.1080/02650530903102692

[6] Wong V, Ying W. Social

S0219246206000064

withdrawal of young people in Hong Kong: A social exclusion perspective. The Hong Kong Journal of Social Work. 2006;**40**:61-91. DOI: 10.1142/

[7] Wong V. Social withdrawal as invisible youth disengagement: Government inaction and NGO responses in Hong Kong. International

Multidimensional Perspective. London: IntechOpen; 2018. DOI: 10.5772/

**References**

pdf/96763292.pdf

intechopen.76882

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

#### **References**

*Social Isolation - An Interdisciplinary View*

**Acknowledgements**

Club Charities Trust.

**Conflict of interest**

**Author details**

\*, John Yuen<sup>2</sup>

provided the original work is properly cited.

, Xuebing Su1

\*Address all correspondence to: vicwong@hkbu.edu.hk

1 Department of Social Work, Hong Kong Baptist University, Hong Kong

2 School of Nursing, The Hong Kong Polytechnic University, Hong Kong

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Jolene Yung2

Victor Wong1

advocacy along this line in the journey ahead.

The authors declare no conflict of interest.

terms of practice and research is expected to play a growing important role to do

The empirical findings were drawn from a number of research projects supported by the following funding bodies: the Health and Medical Research Fund (Project No. 13144071) from the Food and Health Bureau of Hong Kong, the General Research Fund (Project No. GRF/244707) from the Research Grants Council of Hong Kong, the Faculty Research Grant (Project No. FRG/05-

06/I-01-30-05-101) from Hong Kong Baptist University, and the Trust-Initiated Project Fund (Project No. HKBU/HKJCCT-33-14-211) from the Hong Kong Jockey

**22**

[1] Matthews TJB. The pervasive impact of social isolation and loneliness in young people: An epidemiological, longitudinal and genetically-sensitive study [thesis]. London, UK: King's College London; 2017. Available from: https://core.ac.uk/download/ pdf/96763292.pdf

[2] Morese R, Defedele M, Nervo J. I teach you to quarrel-empathy and mediation: Tools for preventing bullying. In: Socialization: A Multidimensional Perspective. London: IntechOpen; 2018. DOI: 10.5772/ intechopen.76882

[3] Coplan RJ, Rubin KH. Social withdrawal and shyness in childhood: History, theories, definitions and assessments. In: Rubin KH, Coplan RJ, editors. The Development of Shyness and Social Withdrawal. New York: The Guilford Press; 2010. pp. 3-22. DOI: 10.1177/0165025409103874

[4] Cacioppo S, Grippo AJ, London S, Goossens L, Cacioppo JT. Loneliness: Clinical import and interventions. Perspectives on Psychological Science. 2015;**10**:238-249. DOI: 10.1177/1745691615570616

[5] Wong V. Youth locked in time and space? Defining features of social withdrawal and practice implications. Journal of Social Work Practice. 2009;**23**:337-352. DOI: 10.1080/02650530903102692

[6] Wong V, Ying W. Social withdrawal of young people in Hong Kong: A social exclusion perspective. The Hong Kong Journal of Social Work. 2006;**40**:61-91. DOI: 10.1142/ S0219246206000064

[7] Wong V. Social withdrawal as invisible youth disengagement: Government inaction and NGO responses in Hong Kong. International Journal of Sociology and Social Policy. 2012;**32**:415-430. DOI: 10.1108/01443331211249057

[8] Wong V. Social work with youth in social withdrawal: In-home and beyond-home intervention modalities. China Journal of Social Work. 2014;**7**:161-174. DOI: 10.1080/17525098.2014.921211

[9] Hattori Y. Social withdrawal in Japanese youth: A case study of thirtyfive hikikomori clients. Journal of Trauma Practice. 2005;**4**:181-201. DOI: 10.1300/J189v04n03\_01

[10] Chan HY, Lo TW. Hidden youth services: What Hong Kong can learn from Japan. Children and Youth Services Review. 2014;**42**:118-126. DOI: 10.1016/j. childyouth.2014.03.021

[11] Suwa M, Suzuki K, Hara K, Watanabe H, Takahashi T. Family features in primary social withdrawal among young adults. Psychiatry and Clinical Neurosciences. 2003;**57**:586-594. DOI: 10.1046/j.1440-1819.2003.01172.x

[12] Furlong A. The Japanese hikikomori phenomenon: Acute social withdrawal among young people. The Sociological Review. 2008;**56**:309-325. DOI: 10.1111%2Fj.1467-954X.2008.00790.x

[13] Kaneko S. Japan's 'socially withdrawn youths' and time constrains in Japanese society: Management and conceptualization of time in a support group for 'hikikomori'. Time & Society. 2006;**15**:233-249. DOI: 10.1177/0961463X06067034

[14] Ogino T. Managing categorization and social withdrawal in Japan: Rehabilitation process in a private support group for hikikomorians. International Journal of Japanese Sociology. 2004;**13**:120-133. DOI: 10.1111/j.1475-6781.2004.00057.x

[15] Mallett S. Understanding home: A critical review of the literature. The Sociological Review. 2004;**52**:62-89. DOI: 10.1111/j.1467-954X.2004.00442.x

[16] Yuen JWM, Yan YKY, Wong VCW, Tam WWS, So KW, Chien WT. A physical health profile of youths living with a "hikikomori" lifestyle. International Journal of Environmental Research and Public Health. 2018;**15**:315. DOI: 10.3390/ijerph15020315

[17] Yuen JWM, Wong VCW, Tam WWS, So KW, Chien WT. A one-year prospective follow-up study on the health profile of hikikomori living in Hong Kong. International Journal of Environmental Research and Public Heatlh. 2019;**16**:546. DOI: 10.3390/ ijerph16040546

[18] Roberts K. Youth unemployment and social exclusion. In: Pole C, Pilcher J, Williams J, editors. Young People in Transition: Becoming Citizens? New York: Palgrave MacMillan; 2005. pp. 116-135. DOI: 10.1057/9780230597778

[19] Walker A, Walker C, editors. Britain Divided: The Growth of Social Exclusion in the 1980s and 1990s. London: Child Poverty Action Group; 1997

[20] Waisbrod N, Buchbinder E, Possick C. In-home intervention with families in distress: Changing places to promote change. Social Work. 2012;**57**:121-131. DOI: 10.1093/sw/sws020

[21] McFarlane C. Relational sociology: Theoretical inhumanism, and the problem of the nonhuman. In: Powell C, Dépelteau F, editors. Conceptualizing Relational Sociology: Ontological and Theoretical Issues. New York: Palgrave Macmillan; 2013. pp. 45-66. DOI: 10.1057/9781137342652

[22] Wong V, Yip TCY. Promoting change: The "expanded notion of

work" as a proactive response to the social justice issues in career development practice. In: Hooley T, Sultana R, Thomsen R, editors. Career Guidance for Emancipation: Reclaiming Justice for the Multitude. London: Routledge; 2019. pp. 64-80. DOI: 10.1111/1467-9566.12548

[23] The Hong Kong Jockey Club Charities Trust. CLAP for Youth @ JC: A Career & Life Adventure Planning Programme [Internet]. 2018. Available from: https://www.clapforyouth.org.hk/ wp-content/uploads/2018/09/JC-CLAP-Case-Study.pdf

[24] Chan HY, Lo TW. Quality of life of the hidden youth in Hong Kong. Applied Research in Quality of Life. 2014;**9**:951-969. DOI: 10.1007/ s11482-013-9279-x

[25] Teychenne M, Ball K, Salmon J. Sedentary behavior and depression among adults: A review. International Journal of Behavioral Medicine. 2010;**17**:246-254. DOI: 10.1007/ s12529-010-9075-z

[26] Carpenter CJ. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Communication. 2010;**25**:661-669. DOI: 10.1080/10410236.2010.521906

[27] Abraham C, Sheeran P. The health belief model. In: Conner M, Norma P, editors. Predicting Health Behaviour: Research and Practice with Social Cognition Models. 2nd ed. New York: Open University Press; 2005. pp. 28-80. DOI: 10.0335/21776.3

[28] Gottlieb L, Rowat K. The McGill model of nursing: A practice derived model. Advances in Nursing Science. 1987;**9**:51-61. DOI: 10.1097/00012272-198707000-00008

[29] Kohei H et al. Blood biomarkers of hikikomori, a severe social withdrawal syndrome. Scientific

**25**

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary…*

*DOI: http://dx.doi.org/10.5772/intechopen.86503*

Reports. 2018;**8**:2884. DOI: 10.1038/

[30] Hart JT. The inverse care law. The Lancet. 1971;**297**:405-412. DOI:

[31] Morese R, Palermo S, Nervo J. Socialization: A Multidimensional Perspective. London: IntechOpen; 2018.

s4159-018-21260-w

S014067367192410X

DOI: 10.5772/65537

*Social Isolation Experienced by Youth in Social Withdrawal: Toward an Interdisciplinary… DOI: http://dx.doi.org/10.5772/intechopen.86503*

Reports. 2018;**8**:2884. DOI: 10.1038/ s4159-018-21260-w

*Social Isolation - An Interdisciplinary View*

[15] Mallett S. Understanding home: A critical review of the literature. The Sociological Review. 2004;**52**:62-89. DOI: 10.1111/j.1467-954X.2004.00442.x work" as a proactive response to the social justice issues in career development practice. In: Hooley T, Sultana R, Thomsen R, editors. Career Guidance for Emancipation: Reclaiming Justice for the Multitude. London: Routledge; 2019. pp. 64-80. DOI:

10.1111/1467-9566.12548

Case-Study.pdf

s11482-013-9279-x

s12529-010-9075-z

DOI: 10.0335/21776.3

[28] Gottlieb L, Rowat K. The McGill model of nursing: A practice

derived model. Advances in

Nursing Science. 1987;**9**:51-61. DOI: 10.1097/00012272-198707000-00008

[29] Kohei H et al. Blood biomarkers of hikikomori, a severe social withdrawal syndrome. Scientific

[23] The Hong Kong Jockey Club Charities Trust. CLAP for Youth @ JC: A Career & Life Adventure Planning Programme [Internet]. 2018. Available from: https://www.clapforyouth.org.hk/ wp-content/uploads/2018/09/JC-CLAP-

[24] Chan HY, Lo TW. Quality of life of the hidden youth in Hong Kong. Applied Research in Quality of Life. 2014;**9**:951-969. DOI: 10.1007/

[25] Teychenne M, Ball K, Salmon J. Sedentary behavior and depression among adults: A review. International Journal of Behavioral Medicine. 2010;**17**:246-254. DOI: 10.1007/

[26] Carpenter CJ. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Communication. 2010;**25**:661-669. DOI:

[27] Abraham C, Sheeran P. The health belief model. In: Conner M, Norma P, editors. Predicting Health Behaviour: Research and Practice with Social Cognition Models. 2nd ed. New York: Open University Press; 2005. pp. 28-80.

10.1080/10410236.2010.521906

[16] Yuen JWM, Yan YKY, Wong VCW, Tam WWS, So KW, Chien WT. A physical health profile of youths living with a "hikikomori" lifestyle. International Journal of Environmental Research and Public Health. 2018;**15**:315.

DOI: 10.3390/ijerph15020315

ijerph16040546

10.1057/9780230597778

DOI: 10.1093/sw/sws020

10.1057/9781137342652

[22] Wong V, Yip TCY. Promoting change: The "expanded notion of

[19] Walker A, Walker C, editors. Britain Divided: The Growth of Social Exclusion in the 1980s and 1990s. London: Child Poverty Action Group;

[20] Waisbrod N, Buchbinder E, Possick C. In-home intervention with families in distress: Changing places to promote change. Social Work. 2012;**57**:121-131.

[21] McFarlane C. Relational sociology: Theoretical inhumanism, and the problem of the nonhuman. In: Powell C, Dépelteau F, editors. Conceptualizing Relational Sociology: Ontological and Theoretical Issues. New York: Palgrave Macmillan; 2013. pp. 45-66. DOI:

[17] Yuen JWM, Wong VCW, Tam WWS, So KW, Chien WT. A one-year prospective follow-up study on the health profile of hikikomori living in Hong Kong. International Journal of Environmental Research and Public Heatlh. 2019;**16**:546. DOI: 10.3390/

[18] Roberts K. Youth unemployment and social exclusion. In: Pole C, Pilcher J, Williams J, editors. Young People in Transition: Becoming Citizens? New York: Palgrave MacMillan; 2005. pp. 116-135. DOI:

**24**

1997

[30] Hart JT. The inverse care law. The Lancet. 1971;**297**:405-412. DOI: S014067367192410X

[31] Morese R, Palermo S, Nervo J. Socialization: A Multidimensional Perspective. London: IntechOpen; 2018. DOI: 10.5772/65537

**27**

Section 2

Social Isolation
