Family features in primary social withdrawal among young adults

Authors


Dr Mami Suwa, Aichi Prefectural Mental Health Welfare Center, 3-2-1 Sannomaru Naka-ku, Nagoya 460-0001, Japan. Email: msuwacci@japan-net.ne.jp

Abstract

Abstract  The problem of ‘social withdrawal’ among young adults is the focus of considerable attention in Japan today. Among the various manifestations of social withdrawal, a ‘primary social withdrawal’ group has been identified that cannot be diagnosed by the established classification of mental disorders. In an earlier report it was suggested that the onset mechanism for primary social withdrawal is not merely a problem of the withdrawn person themselves, but also includes problems of family relationships. The aim of the present study was to identify the characteristics and problems in family relationships associated with primary social withdrawal. For that purpose a survey was conducted using David H. Olson's Family Adaptability and Cohesion Evaluation Scale as well as a questionnaire that the present authors devised on family interactions and the personal situation of the withdrawn person. The results pointed to the following four characteristics of primary social withdrawal families: (i) there are definite rules within the family; (ii) the families share values and an unfounded pride; (iii) there is a lack of emotional exchange in the family, and it is difficult for members to sympathize with each other's negative feelings; and (iv) although concerned about each other, there is little verbal exchange. From these family characteristics, the onset mechanism for withdrawal is triggered by insignificant matters such as minor setbacks in the developmental issues of youth. Then, given the person's personality traits and aforementioned characteristics in family relationships, the person becomes mired in social withdrawal.

INTRODUCTION

In the present article we define ‘primary social withdrawal’ as one constellation of social withdrawal phenomena that cannot be described with the current disease concepts in psychiatry. Since the 1990s, ‘social withdrawal’ among young adults has been a focus of considerable attention as a new social problem in Japan. In this social withdrawal phenomenon, young adults who have graduated from high school or university, or have dropped out altogether, do not take up employment but rather cut off contact with society and confine their lives to mainly the home. The number of such people in Japan is said to range anywhere from 500 000 up to 1 million. This ‘social withdrawal’, however, is not the name of a disease but rather a term to indicate a condition involving problem behaviors. This notion therefore may cover a spectrum of various psychiatric diseases. It may, for example, include considerable aspects of mental diseases such as schizophrenia, affective disorder, taijin-kyofu-sho, obsessive–compulsive neurosis, anxiety neurosis, eating disorders, pervasive developmental disorders, and personality disorders.1–3 In a separate report we focused on ‘primary social withdrawal’ and considered the pathology of this condition.1 In that report we suggested that the onset mechanism for primary social withdrawal is not merely a problem of the withdrawn person themselves alone, but also includes problems of family relationships.

The aim of the present study was to clarify the features and problems in family relationships in primary social withdrawal. For this purpose we adopted the Family Adaptability and Cohesion Evaluation Scale (FACES) of David H. Olson.4–7 In addition, we devised a questionnaire on family interactions and the personal situation of the withdrawn person, and used this in a survey of study participants. Family evaluation, family interactions, and personal situations were then compared between those with primary social withdrawal, or other types of social withdrawal, and a group of healthy controls, to identify the characteristics of family relationships in primary social withdrawal.

METHODS

Participants

Each year, 20 to 30 parents whose children are experiencing social withdrawal come to the Aichi Prefectural Mental Health Welfare Center for consultations. We consult with these parents individually and conduct group psychotherapy with them together with other parents. In the present study we surveyed the family situations of parents of 27 patients currently undergoing group psychotherapy from among the 46 parents who have participated in a parents’ group for 6 years from August 1996 to March 2002.

Subgroups of the main subject group

Because the diagnosis of the withdrawn persons was made based only on consultations with their parents, careful and detailed interviews were necessary to obtain sufficient information for accurate diagnosis. Intake information was first obtained by the case worker during the initial visit, after which consultations with a psychiatrist were held and a therapy plan was decided. The psychiatrist then conducted preparatory interviews for 3–6 months during the private consultations, during which time problems such as schizophrenia or affective disorder were identified according to the Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria. With families in which no such problems were identified, group psychotherapy was conducted for those who so desired.

The 27 cases in the present study were divided into subgroups according to the diagnosis based on information obtained in preparatory interviews and group psychotherapy. Using the criteria of the DSM-IV, the following disease categories were examined for each case: paranoid disorder, depressive disorder, obsessive–compulsive disorder, pervasive developmental disorders, and personality disorders (including paranoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, and histrionic personality disorder); cases were then divided into subgroups. We made a provisional diagnosis of primary social withdrawal in cases that could not be diagnosed in this way from the DSM-IV criteria. It is possible that provisional diagnoses of primary social withdrawal included, in addition to primary social withdrawal, phenomena difficult to ascertain solely from information from parents, such as social phobia (taijin-kyofu-sho), apathy syndrome, and personality disorders (schizoid personality disorder, narcissistic personality disorder, withdrawal personality  disorder  etc.).1–3,8–10 This  method  of  diagnosis is limited in that it cannot precisely identify primary social withdrawal, but it is a non-invasive method that can be used for such a withdrawn group that has an extremely low rate of examinations in person. The unavailability of these persons for examination left us with no choice but to establish a diagnosis of the person in question based on information from his or her family. Using this method, the 27 cases were classified into four subgroups: 10 cases of primary social withdrawal, six cases of personality disorders such as narcissistic personality disorder, six cases of developmental disorders such as Asperger's disorder, and five cases of neurotic syndrome such as obsessive–compulsive disorder.

The three subgroups of personality disorders, developmental disorders, and neurotic syndrome together were called the ‘other social withdrawal group’, and this group was compared with the primary social withdrawal group.

Control group

A control group was established with the cooperation of 20 unaffected parents who lived together with their children aged over 20. They were selected so that the mean age and proportion of each of the sexes matched those of the parents in the study group.

Procedures

At the final group meeting in March 2002, the parents were asked to complete a questionnaire covering a family evaluation, and another on their family interactions and the withdrawn person. At this time we gave a full oral explanation of the purpose of the study, indicated that the data would not be used for any purpose other than the present study, their privacy would be protected, their cooperation voluntary, and that a report of the study results would be sent to participants. The questionnaires were completed by only those persons who consented. Twenty-five people responded to the family evaluation questionnaire and 27 responded to the family interactions and withdrawn person-related questionnaires.

Questionnaires

The family evaluation questionnaire used was the standardized FACES at Kwansein Gakuin (FACESKG)-IV,11–13 developed by Tachiki et al. from Olson's FACES with due consideration to the cultural and social background of Japan (Appendix I) This tool looks at family relationships on the two axes of adaptability and cohesion. The results are assessed based on a score that is the sum of the number obtained by multiplying the points for each question by an appropriate coefficient suited to the content. ‘Adaptability’ is the ability of the family to adapt to various stressors, and the specific variables that are of interest in terms of this dimension are: family power structure (assertiveness and control), negotiation styles, role relationships and relationships rules, and feedback (positive and negative). ‘Cohesion’ indicates the family's emotional bonds, and specific variables that can assess the degree of family cohesion include emotional bonding, independence, boundaries, coalitions, time, space, friends, decision-making, and interests and recreation.4 Adaptability and cohesion were each given a score of between −8 points and +8 points, and the intermediate group with scores from −2 to +2 was judged to have a high level of health in these areas. Thus, both extremes in which rules were either too strict or too lenient, and bonds too close or too loose, were judged to have a low level of health in terms of family relationships.

The items devised for the family interactions and withdrawn person-related questionnaire are shown in Appendix II.

RESULTS

Summary of primary social withdrawal cases

The 10 cases of primary social withdrawal are summarized in Table 1.

Table 1.  Summry of primary social withdrawal cases
CaseAgeSexCase history
123MaleHe started wanting to skip school at the age of 17 (second year of high school). He could not decide what
to do after graduating from high school, and spent most of the time in his own room. Gradually he came
to avoid and not speak to other family members. He currently goes out in the neighborhood by himself
or goes shopping.
224MaleAt the age of 16 (first year of high school), he began saying he wanted to quit school and get a job, and then
dropped out. At first he looked for a job, but then came to stay closed in his room. After a time he did
not speak to his parents at all. He goes out in the car at night, where it seems he meets friends.
325MaleHe quit school at age 16 (first year of high school) and stayed at home, sleeping during the day and staying
awake through the night. He converses normally in the home, and helps with the housework. He later
took a part-time job at the age of 24, and acquired a driver's license.
425MaleHe could not obtain the needed school credits at the age of 20 (second year of university) and dropped out.
He went to a technical school but did not continue. He helps with the housework and converses
normally, and goes out on weekends; he sometimes meets friends.
530MaleAt the age of 20 he had studied privately for 2 years to get into university, but was not accepted. His
mother took him to a private institution, where he resided for 2 years, occasionally doing part-time
work. Finally, he could not continue and returned home. He is currently going to computer school.
631MaleAt the age of 24 he wanted to quit school (second year of graduate school) and spent his days sleeping and
nights awake.He returned home from his boarding house. He converses normally within the home, and
goes shopping in the neighborhood in the evening. At the age of 30 he found a part-time job, which he
is continuing.
732MaleAt the age of 24 he had just graduated from university and found a job, but after the entrance ceremony
never reported for work. After 2 years mainly at home, he began participating in interview and group
therapy. He freely goes out, and sees friends.
834MaleAt the age of 20 he had studied for 2 years to get into university but afterward mostly spent his time at
home. He interacts normally at home, and helps others. He goes out evenings and weekends.
938MaleHe graduated from university and worked for 9 years, then took a 2 year leave to study in the USA. He
returned home at the age of 34 and quit his job. He tried to find new employment but could not, and
spends his time at home. He occasionally helps out in the house.
1038MaleHe graduated from university and worked for 10 years but quit after being transferred from a technical to
a sales position. Afterward he studied at home to obtain qualifications. He goes out on weekends and
evenings only, and meets friends. He rarely speaks to his family.

Comparison of family attributes

The attributes of parents and children in the four subgroups of subjects and the control group are shown in Table 2. A t-test was conducted between the primary social withdrawal group and the control group with regard to the mean age of the subject, and the order of birth (i.e. first-born, second-born etc.) and sex of the subjects were tested with the χ2 test. No significant difference was seen between the groups in either of these factors. A one-way analysis of variance was conducted among the four subgroups for parent's mean age and mean age at the time of withdrawal, child's mean age and mean age at the time of withdrawal, and the mean number of years of social withdrawal. A χ2 test was conducted for history of refusal to attend school and employment history. No significant differences were found among the four subgroups in any of these factors.

Table 2.  Family attributes
 nParent’s
sex
Parent’s
mean age
Child’s
sex
Child’s
mean age
Years of
social
withdrawal
Order of birthSchool
refusal
Employment
history
MFNowToWMFNowToW1st2nd3rdYesNoYesNo
  1. ToW, time of withdrawal; M, male; F, female.

Control group2021858.217330.414 51
Social withdrawal
groups
2722557.049.423428.721.17.614121621819
 Primary social  withdrawal101 958.450.910030.022.57.5 6 313 72 8
 Personality  disorders 60 655.849.2 5125.218.56.7 1 502 41 5
 Developmental  disorders 61 556.247.5 6030.021.38.8 5 101 52 4
 Neurotic syndrome 50 556.449.0 2329.021.67.4 2 300 53 2

Comparison of family evaluation

The results of the FACESKG-IV family evaluation questionnaire are shown in Table 3.

Table 3.  FACESKG-IV comparison of five groups
 ControlPSWPDDDNSTukey's HSD
  • FACESKG-IV, Family Adaptability and Cohesion Evaluation Scale at Kwansein Gakuin 4th version; HSD, honestly significant difference; C, control; PSW, primary social withdrawals; PD, personality disorders; DD, developmental disorders; NS, neurotic syndrome.

  • *

    P < 0.1;

  • **

    P < 0.05.

n208665 
Adaptability (mean ± SD)−0.375 ± 1.58  −2.5 ± 2.760.167 ± 1.033 −1.2 ± 2.25−0.8 ± 0.91C > PSW*
PD > PSW*
Cohesion (mean ± SD)   1.1 ± 3.41−3.188 ± 2.20.833 ± 1.720.833 ± 3.71 1.9 ± 2.82C > PSW**
NS > PSW**

Among the control group, primary social withdrawal group, personality disorders group, developmental disorders group, and neurotic syndrome group, only the primary social withdrawal group had parents with an average score of more than +2 or less than −2. These scores are considered to show a low level of health in terms of family relationships. Both adaptability and cohesion were judged to be low in the primary social withdrawal group.

A t-test was conducted between the control group and the social withdrawal groups overall but no significant difference was found in adaptability and cohesion.

Next, a one-way analysis of variance was conducted among all five groups; namely, the four social withdrawal subgroups and the control group. The results are  shown  in  Table 3.  A  trend  in  differences  was  seen in adaptability (F4,43 = 2.49, P < 0.10). Tukey's honestly significant difference (HSD) test was conducted between each pair of groups and a trend in differences was seen between the primary social withdrawal group and control group, and between the primary social withdrawal group and personality disorders group. A significant difference (F4,44 = 3.41, P < 0.05) was seen in cohesion. With Tukey's HSD test, significant differences were seen between the primary social withdrawal group and control group, and between the primary social withdrawal group and neurotic syndrome group.

A one-way analysis of variance was conducted between the primary social withdrawal group, other social withdrawal group, and control group. There was a significant difference in adaptability (F2,43 = 4.18, P < 0.05). Tukey's HSD test between each of the groups revealed significant differences between the primary social withdrawal group and the control group, and between the primary social withdrawal group and the other social withdrawal group. There was also a significant difference in cohesion (F2,44 = 6.87, P < 0.01). Tukey's HSD test showed significant differences between the primary social withdrawal group and the control group, and between the primary social withdrawal  group  and  the  other  social  withdrawal  group. In all cases the primary social withdrawal group had lower results.

Tests were conducted between adaptability and cohesion for the factors thought to affect the family evaluation scale: parent's sex and age, child's sex and age, child's and parent's age at the time of initial withdrawal, number of years of social withdrawal to date, history of refusal to attend school, and employment history. Next, t-tests were conducted by sex and for the presence or absence of history of refusal to attend school, and employment history. There was a biased distribution of ages and number of years of social withdrawal, so the subjects were divided into two groups by median value for examination by t-test. The respective median values were 57 years for parent's age, 29 years for withdrawn child's age, 49 years for parent's age at time of withdrawal, 21 years for child's age at time of withdrawal, and 7 years for number of years from withdrawal to date. There were no significant differences between adaptability and cohesion for any of the items, and thus none of these factors were considered to affect the family evaluation scale.

Comparison of family interactions and withdrawn person

To examine the interactions between the family and the withdrawn person, the χ2 test was conducted between four groups for the difference in response rate. Among the 18 items, differences were seen in the three items following. A χ2 test was conducted between each pair of groups for these three items. For the item ‘can enjoy going out with one's father’, there were significantly fewer people able to do this in the primary social withdrawal group than in the developmental disorders group (χ2 = 5.00, P < 0.05). In the item ‘can be together with father for meals etc.’, the primary social withdrawal group tended to be less able to be together with their fathers than the personality disorders or developmental disorders groups (both χ2 = 3.75, P < 0.10). In the item ‘can enjoy going out with one's mother’, fewer people in the primary social withdrawal group tended to be able to enjoy this than in the personality disorders or developmental disorders groups (both χ2 = 2.86, P < 0.10).

χ2 tests were also conducted between the two groups of primary social withdrawal and other social withdrawal. Differences were found in three items, with tendencies for differences in the items ‘can talk about anything with one's father’ (χ2 = 3.23, P < 0.10), ‘can be together with father for meals etc.’ (χ2 = 4.00, P < 0.10), and ‘can be together with mother for meals, etc.’ (χ2 = 2.90, P < 0.10). Compared to the other social withdrawal group, fewer persons in the primary social withdrawal group tended to be able to talk about anything with their fathers or to be together with their parents for meals etc.

The difference in response rate for the six items was examined by χ2 test in the four groups for the current situation of the withdrawn person. A significant difference was seen in the item ‘can go out’. The primary social withdrawal group had a significantly higher frequency of going out than the neurotic syndrome group (χ2 = 10.91, P < 0.01). It was seen from the item ‘interacts with friends’ that the primary social withdrawal group tended to have more interaction with friends than the developmental disorders group (χ2 = 2.86, P < 0.10).

Next, χ2 tests were conducted between the primary social withdrawal group and the other social withdrawal group. A significant difference was seen only in the item ‘can go out’. The primary social withdrawal group went out significantly more often than the other social withdrawal group (χ2 = 4.54, P < 0.05).

DISCUSSION

Family image from the FACESKG family evaluation scale

Adaptability

The primary social withdrawal group tended to have lower adaptability than the control group, personality disorders group, and other social withdrawal group. What kind of family do we picture from this low adaptability? From the questionnaire, low adaptability means that there are firm rules within the family, with each person's role decided. Even when faced with difficulties the roles are not changed to cope with the situation in order to resolve the problems, but everyone tries to maintain the original methods of coping and relationships. There is also a tendency for everyone to adopt the opinion of the one person (generally a parent) who decides what the family should do.

If we look at some individual cases of primary social withdrawal, we recognize that many parents said things like, ‘I always expected him to have an ordinary life and never wanted him especially to have to fulfill my own expectations’, and ‘I left it up to him/her’. However, in case 9 the father could not abandon his hope that his only son, who was experiencing primary social withdrawal, would become the family heir. In cases 5 and 8 the parents also continued to have traditional expectations, saying ‘This should have been a time when my son had a wife and I was living together with my grandchildren’. They seem to be caught up in the basic assumptions of the previous generation in Japan. In case 7, the withdrawn person said, ‘I didn’t know what I wanted to do, but I made this choice because I thought studying at this university would make my parents happy.’ In case 3 the son himself wrote in a letter, ‘I feel sorry I couldn’t live up to my mother and father's expectations.’ Such expressions make it clear how hard and fast family rules and the older entrenched values of parents can weigh down on a withdrawn person.

Cohesion

The primary social withdrawal group had less cohesion than the control group, personality disorders group, developmental disorders group, neurotic syndrome group, and other withdrawal group. From items in the questionnaire it is presumed that there is little emotional contact, for example, children consulting their parents in difficult times, telling them their problems, or sharing one another's ups and downs. Such families are concerned about each other but in their relationships they keep watch over each other without any direct verbal expression.

Among the primary social withdrawal families in the present study, the father in case 3 was extremely worried about his withdrawn child, but was apprehensive that if his son saw him worried he would think his father viewed him as a problem. The father in case 2 did not speak at all to his withdrawn child, but showed consideration for his son in such ways as gassing up his car when the tank was empty. In case 7, the withdrawn child was careful so that his parents would not notice that he was having a tough time. In the parents group, the topic ‘I don’t understand what my child is feeling’ came up at almost every meeting. Even when they were very anxious about their children, saying ‘I don’t understand because he/she won’t talk to me’, or ‘If I ask about the future, he/she just becomes silent’, they did not have the skills to get their children to talk about themselves or to intuit what their children were thinking. The relationships between the parents and children always had little interaction, either verbal or non-verbal,  and  the  parents  were  particularly  poor  at asking their children about the very problem of social withdrawal.

Family picture evoked by responses to the questionnaire on family interactions and withdrawn person's situation

From the results of the questionnaire on interactions with family, the primary social withdrawal group tended to show little involvement in the family. The primary social withdrawal group also went out less with their parents than the other groups. In contrast, they went out by themselves more than people in the other groups. In fact, in all 10 cases of primary social withdrawal, withdrawn persons often left the house, not only for short shopping excursions in the neighborhood but also for various other activities. For example, case 7 took trips with friends, and cases 3 and 6 eventually took on temporary part-time jobs. Thus, while they themselves had a certain level of social behavior, six of these 10 cases could not manage to go out with his or her family. Conversely, in other groups there were cases able to go out with their family, implying that the family facilitated the behavior and social adaptation of a withdrawn person. Hence, the problem seemed more to be the relationship with the family than the social adaptation of the person themselves.

Characteristics of primary social withdrawal families

This section summarizes the characteristics of primary social withdrawal families.

There are definite rules within the family

The father (or mother) establishes rules that other members of the family follow with little feeling of discontent. The withdrawn person becomes unconsciously fettered by these rules in the family culture. These rules are transmitted tacitly rather than voiced explicitly, which makes opposing them all the more difficult. These families are not overly invasive, and family members are not always told what to do but they are bound to a much greater extent by rigid, strict rules than is apparent at first glance.

The families share values and an unfounded pride

In the family the values of the parents are transmitted unchanged to become those of the withdrawn person. In this way, the withdrawn person takes on the values of the parents just as they are, as a result of which the values lack diversity and flexibility. In addition, these values are transmitted together with the strong pride of the parents. However, this pride is not something built up by the withdrawn person themselves, and thus not backed by confidence.

There is a lack of emotional exchange within the family, and it is difficult for members to sympathize with each other's negative feelings

Family members try not to see or understand one another's true feelings or weaknesses. Parents feel insecure about their relationships with their children, thinking that if they look at their children's weaknesses, their existing relationship will break down. Therefore, they assume that by trying not to approach the other's true feelings, they will not cause the other person harm.

Although concerned about one another, there is little verbal exchange

Even if the child seems troubled about something, the parents will not inquire about it. They are overly cautious, and do not try to speak to the person. Moreover, the child does not speak to anyone about his or her troubles. Both the parents and children are poor at positive behaviors such as talking to each other face to face or determining each other's feelings.

Conclusion: parent consultations

Most problems of social withdrawal among youth are brought in by parents seeking consultation. The first role of such parent consultations is to alleviate the psychological burden on the parents themselves.2,14 The initial task is to support them and relieve their feelings of despair and self-condemnation. Common support is available in response to social withdrawal stemming from various mental disorders. However, the next step that must be taken to help resolve the problem is to deal with the problems specific to each individual following a differential diagnosis.

The present article has considered primary social withdrawal in terms of family relationships. Finally, we would like to briefly touch on how the present results should be reflected in support schemes in parent consultations. Although there may be no deep pathology in the family confronted with the problem of primary social withdrawal, our findings indicate that the characteristics of the family relationships serve to promote and maintain the problem. The key to overcoming the problem is changing these family relationships. First, the parents have to become more aware of their child's present state and try to face up to it; it is neither a great failure nor cause for excessive pessimism. At the same time, parents must give up their expectations that their own values will be firmly held by their children and instead take their children just as they are. By helping to change family relationships so that they will not be set in concrete, leaving no room for their children to move, we can expect to make the parents and child face up to the task of overcoming the social withdrawal problem.

Thus, from among the different types of social withdrawal, it is necessary to distinguish and separate instances of primary social withdrawal, which are not covered by the current system for the diagnosis of mental disorders. Issues for the future will then be to devise, establish, and refine measures for dealing with this problem by accumulating successful cases.

Appendices

APPENDIX I

Table 4. 
FACESKG-IV
  1. FACESKG-IV, Family Adaptability and Cohesion Evaluation Scale at Kwansein Gakuin 4th version.

  2. Cited and modified authors from the table of Tatsuki.11

How matters are decided
(1)If a problem occurs, the family discusses it together, and everyone agrees with what is decided
(2)Roles in the family are fixed, but we give in to each other to help out
(3)When a big problem arises, there is someone who always decides on their own
(4)In our home we readily exchange our respective roles
(5)Everyone tries to abide by the family rules
(6)Our family rarely carries things through even when everyone has promised
(7)If a problem occurs the family discusses it together, but the final decisions are always made according to the wishes of a certain person
(8)Even if our family decides something, no one tries to abide by the decision
Family ties
(1)Family members mostly spend time as they please, but sometimes the family spends time together
(2)When my child is feeling depressed I also worry, but I rarely ask much about his/her problems
(3)My child talks over his/her worries with the family
(4)There is a lot of physical contact in our family
(5)In our family we have absolutely no relationship except for something that has to be done
(6)We speak the bare minimum in our family and that's about all
(7)On days off we sometimes spend time as a family, and sometimes go out with friends
(8)If someone is late coming home, everyone waits up until they get back

APPENDIX II

Table 5. 
Question items on family interactions and situation of withdrawn person
Interactions with family
Can talk about anything with parents
Can chat casually with parents
Can come to a mutual understanding of intentions with parents
Can enjoy going out with parents
Can be together with parents for meals etc.
Can spend time with parents in living room etc.
Has no difficulty being face to face with others
Blames parents
Is violent toward parents
Situation of withdrawn person
Has a role in the family
Has consideration for family
Spends most of the time at home
Can go out
Interacts with friends
Interacts socially at work or school

Ancillary