Correspondence: Tae Young Choi, MD, PhD, Department of Psychiatry, Catholic University of Daegu School of Medicine, 3056-6, Daemyung-4 Dong, Nam-Gu, Daegu 705-718, Korea. Email: firstname.lastname@example.org
The problems of youth social withdrawal (or hikikomori) became a hot-button social issue in Japan in the 1990s. Unfortunately, current nosology in the DSM-IV may not adequately capture the concept of socially withdrawn youth (SWY) or hikikomori. This study aimed to investigate core SWY issues, evaluate SWY's psychopathologies, and approach them therapeutically through a home visitation program.
Participants were 65 youth referred by community mental health centers and psychiatric clinics around Seoul and Kyongki-Do province. Among them, only 41 participants (31 male, 10 female, mean age 15 ± 3.6 years) fit our SWY criteria. In addition, 248 middle and high school students in Seoul were recruited as a baseline control group. Caseworkers interviewed the SWY participants and their parents in their homes, using our structured interview manual and a number of psychiatric scales. Caseworkers also approached the participants therapeutically.
Participants' Depression Inventory, Trait Anxiety Inventory, Social Anxiety Scale, and Internet Addiction Scale scores were significantly higher than those of baseline controls. Participants' mean number of psychotherapeutic sessions was 2.8, and the mean number of parental interview sessions was 3.4. After the therapeutic sessions, Global Assessment Functioning scores and social activities had improved somewhat in 68.3% of participants.
These findings suggest that SWY is a complex phenomenon, so an individual psychopathologic process is very important for treatment. The most difficult problem in SWY treatment was therapeutic access. Hence, the home visit approach with a structured manual may be a good gateway for solving this problem.
SOCIALLY WITHDRAWN YOUTH (SWY) are those who cut themselves off from social communication with the outside world and stay all day long at home, even blocking off communication with family members, and their numbers are increasing. This phenomenon is a very serious problem, especially considering that adolescence is a critical period for trying out various interpersonal relationships. When SWY reach adulthood, they may become susceptible to serious social problems, such as unemployment or, specifically, the status of ‘NEET’ (Not in Employment, Education or Training), ‘Freeter’ (a Japanese expression for people aged 15–34 who lack full-time employment or are unemployed), or ‘Twixter’ (a Western neologism somewhat analogous to the Japanese term ‘parasite single’).
During the mid-1990s in Japan, a sudden increase in the numbers of socially withdrawn people, staying in their rooms, became a social hot-button issue, and many sociologists described it as a unique phenomenon, seen only in Japanese culture. Dr Saito of Japan introduced the term ‘hikikomori ()’, meaning ‘secluded person,’ and defined such persons as those who stayed confined at home for more than 6 months without having an explicit psychological problem. In 2003, the Japanese Ministry of Health, Labor and Welfare officially defined hikikomori and estimated 1% (1.3 million) of Japan's total population were hikikomori. Since then, psychologists' perspectives on the hikikomori have shifted away from the initial view that they are a specifically Japanese social phenomenon, and, amid controversy, various academicians are working to clarify the definition and cause of the phenomenon. Although hikikomori were first described in Japan, whether the phenomenon might exist elsewhere remains unclear. Experts have debated as to whether hikikomori is a culture-bound syndrome specific to Japan or a syndrome that they can classify, using the criteria of the ICD-10 or DSM-IV.[3-5] Furthermore, some have already reported hikikomori-like phenomena in other countries, such as Oman, Spain, and Korea.[6-8]
In the early 2000s in Korea, the SWY arose as a social concern associated with increasing numbers of nuclear families, the severing of relationships with neighbors due to the apartment lifestyle, increasing numbers of only children showing extreme individualism, the decreasing need for interpersonal face-to-face contacts owing to information technology (IT) improvements, rising numbers of Internet-addicted adolescents, and increasing numbers of school-refusal students due to students failing academic competitions or to school bullying. The Korean Broadcasting System (KBS) reported the number of SWY in Korea may be 0.1 million, and a study estimated 15% of school-refusal students were SWY.
The first systematic Korean study on SWY was titled, ‘How can society support socially-maladapted, withdrawn adolescents?’ and was funded by the National Youth Commission. It was from a survey of 1461 high school students, 2.3% of whom had experienced the state of social withdrawal, with less than one person to talk to, and 0.3% of whom had experienced dropping out of school. Most of them – those who met the classification criteria for the SWY latent, or at-risk group – revealed their major difficulties in peer relationships were due to poor social skills and bullying, low school achievement, the ‘worthlessness’ of school life, and, finally, familial conflict.
This study was the second project for socially withdrawn adolescents supported by the Korean National Youth Commission. The first study's target population was the SWY latent or at-risk group, rather than the core SWY, so we defined SWY as any youths under the age of 25 years who stayed at home all day, due to being severely socially withdrawn, for more than 3 months, and without a specific reason. Due to difficulties with meeting participants, a well-trained caseworker visited each participant's home to interview both the participant and their parents. Caseworkers also provided person-centered counseling (PCC) at the same time. This study aimed to describe the hikikomori syndrome at the core the SWY phenomenon and to evaluate these youths' psychopathologies and behavioral problems at home. In addition, we also attempted to approach these South Korean SWY therapeutically, through a home-visit program, and evaluate the SWY treatment outcomes after five sessions of home-visit psychotherapy. Through this study, we expected to have an opportunity to establish a therapeutic network among psychiatric clinics and community mental health centers.
Participants were 65 people referred by 13 community mental health centers and several psychiatric clinics due to suspected SWY. Our SWY inclusion criteria were as follows: socially withdrawn, aged under 25 years, refusal to attend school, unemployed, and mainly staying at home all day. Furthermore, these life patterns had to have lasted longer than 3 months without being due to any particular reasons or goals. Exclusion criteria were psychosis, affective disorder, pervasive developmental disorder, and mental retardation. We excluded 24 of the 65 during the individual therapeutic approach for the following causes: home visit refusal (three cases), parents' refusal to be interviewed (one case), insufficient socially withdrawn period or severity of social withdrawal (five cases), psychiatric disease (six schizophrenia, three autism spectrum disorder, one moderate mental retardation, one bipolar disorder), and incomplete survey forms (four cases).
Of the SWY participants, 31 were male (75.6%) and 10 were female (24.4%). Their average age was 16.5 ± 3.8 years for male and 16.1 ± 2.5 years for female participants (Table 1). Of these SWY participants, 16 (39.0%) had a family history of psychiatric diseases within tertiary relatives or closer, seven (17.1%) had experienced some form of developmental delay, and 18 (43.9%) had experienced child abuse or neglect. Only 41.5% of them were sociable early in life. SWY had hostile relationships with their family members, especially with their fathers.
Table 1. Comparison of sociodemographic data between SWY and NC
SWY (n = 41) Number (%)
NC (n = 239) Number (%)
NC, normal controls; SWY, socially withdrawn youth.
Mean age (SD)
Mean hours (SD)
Experience of bullying
Socially withdrawn period
Mean months (SD)
We also recruited a normal control group of 246 middle and high school students and their parents. We excluded seven of the 246 due to incomplete answers on the applied scales. Of the 239 normal controls, 173 were male (72.4%) and 66 were female (27.6%), which showed no significant sex difference (P = 0.748; Table 1).
The study protocol was approved by the Ethics Committee of Chung-Ang University Hospital and was conducted in accord with the Declaration of Helsinki.
Home visitation program
The home visitation program team consisted of 65 mental health personnel: 34 well-trained caseworkers and 31 assistants. All caseworkers were female, and they worked at local mental health centers and general hospitals as social workers. We held two workshops for training caseworkers and assistants before beginning the visitation program. A visit team comprised a caseworker and an assistant, and they visited each home after the SWY's parents presented written informed consent. Whenever they visited an SWY's home, they interviewed the SWY and the parents separately, and each interview session took about 1 h. We created plans for five sessions of person-centered psychotherapy, while each caseworker conducted a structured interview, in accord with the manual, at each SWY's first session.
Eight child and adolescent psychiatrists prepared a manual for this home visitation program. This manual had three parts, one each for the participant, the parents, and the caseworker. The participant self-report form contained the structured interview items about peer relationships, school life, daily activities, emotion, cognition of present status, and problem-solving pattern. Using this structured interview, we enrolled each participant in the home visitation program. The self-rating scales our study employed for these first visits were the Derogatis Symptom Checklist-90-Revised (SCL 90-R), Kovac's Children's Depression Inventory (CDI), Beck's Depression Inventory (BDI), Rosenberg's Self-esteem Scale (SES), Spielberger's Trait Anxiety Inventory (STAI), LaGreca's and Stone's Social Anxiety Scale for Children-Revised (SASC-R), Watson's and Friend's Social Anxiety and Distress Scale (SADS),[18, 19] Seo's and Hwang's Avoidant Personality Disorder Scale (APDS), Lee's and Shin's Socially Withdrawn Youth Questionnaire (SWYQ), and Young's Internet Addiction Scale (IAS). For the normal control group, we just applied the self-rating scales for participants and parents, without using the structured interview.
The parents' reporting forms comprised Moos' and Moos' Family Environmental Scales (FES), the Parents' Brief Diagnostic Interview Schedules for Children (DISC-IV), and the Hidden Youth Questionnaire (HYQ). The caseworkers' reporting forms contained the records for the families' and participants' histories and the outcome evaluations, using Global Assessment Functioning (GAF) and Clinical Global Impression (CGI) scores, from the first and last visits.
We compared the demographic and self-rating scales' scores between the SWY and normal controls using t-tests and χ2-test. Moreover, we compared three categorical groups (by IAS scores) using χ2-tests. To compare preferred game types between SWY and normal controls, we used multiple response analysis. In addition, we compared the GAF scores before and after the SWY underwent home visitation interventions using the paired t-test. Statistical significances were defined as an alpha level of 0.05 at two-tailed significance. spss 14 (spss, Chicago, IL, USA) was used for all analyses.
The SWY group had significantly fewer friends now than they had in the past and wanted a greater number of friends than the control group did (P = 0.013). In particular, 81.3% of SWY wanted more than two friends; however, 50% had no friends, and 75% had no contact with anyone during the preceding week.
The favorite SWY leisure activity was using a computer. SWY participants made longer daily use of a computer than the control group did (5.3 [SD = 3.5] h/day vs 2.2 [SD = 2.2] h/day; P < 0.001). The SWY mainly used computers for playing computer games, and their preferred game type was the first-person shooter (FPS) (32.5%) followed by role-playing games (RPG) (30.0%), real-time simulations (RTS) (20.0%), video games (12.5%), and casual games (5.0%).
The average first time the SWY reportedly wished to withdraw socially from others was during early middle school. Nineteen SWY (54.3%) had experienced neglect, rejection, or bullying, six SWY (17.1%) thought that bullying had directly caused their social withdrawal, and seven SWY (20.0%) thought that they would be in a different situation if someone had helped them at an earlier time.
Table 2 shows each of the SWY rating scale scores. We compared these scores to those of the control group. The SWY had significantly higher scores in depression, anxiety, and Internet addiction than controls did. Moreover, they had lower scores on the SES. Although it is not standardized for Korea yet, the SWY mean IAS was higher than that of controls (P = 0.008). Figure 1 shows 56.3% of SWY to be at high risk for Internet addiction and 9.4% to be addicted.
Table 2. Comparison of self-rating scales between SWY and NC
To screen for mental disorders among SWY, we surveyed their parents, using part of the simplified version of the DISC-IV. The common major or comorbid mental diseases were oppositional defiant disorder, social anxiety disorder, depression, PTSD, and Internet addiction (Fig. 2). These were brief screening results, so a further diagnostic workup appears necessary.
On the FES, the SWY participants showed statistically significant differences from normal controls on the cohesion, active-recreational orientation, organization, and control sub-scales (Table 3). Regarding the HYQ, filled out by the parents, the SWY group again showed significantly higher scores than did the control group (59.9 [SD = 17.3] vs 21.8 [SD = 9.1]; P < 0.001).
Table 3. Comparison of parent-rating scales between SWY and NC
SWY (N = 40) Mean (SD)
NC (N = 239) Mean (SD)
*Statistically significant difference between SWY and NC (P < 0.05).
FES, Moos' and Moos' Family Environment Scale; HYQ, Hidden Youth Questionnaire; NC, normal controls; SWY, socially withdrawn youth.
Before this study, 17 participants (41.5%) had undergone no therapeutic trial visits with counseling institutes or psychiatrists, 13 (31.7%) had only visited psychiatrists, nine (22.0%) had visited both, and two (4.9%) had visited only counseling institutes. The routes the SWY took to ultimate participation in this study were as follows: 41.5%, referred by a psychiatrist after a clinic visit; 14.6%, referred by a social worker; 12.2%, unreferred, via advertisements; 9.8%, referred by family members or acquaintances; and 9.8%, referred by schoolteachers.
Caseworkers held face-to-face interviews with each SWY an average of 2.8 (SD = 1.8) times and with the parents an average of 3.4 (SD = 1.75) times. Many interviews were difficult due to an SWY's refusal and/or uncooperative attitude; this study lost four participants who would not participate in any interviews. Many cases moved to treatment centers after these home visits, such as attending community mental health centers (eight cases), visiting psychiatric clinics (eight cases), participating in hikikomori camp (one case), and online counseling (one case).
Satisfaction with the home visitation program was higher in the parent group than in the SWY group. The multi-selected behavior changes after these home visitations were as follows: increased outdoor activities, 14 participants; more family conversation, 13; increased interpersonal contacts, 11; improved family relationships, 11; spending more time outside, nine; increased participation in group activities, six; returning to school, four; acquiring part-time jobs, two; and going to a private academy, one participant. Regarding the home visitation program, 75.6% of the parents, 48.7% of the caseworkers, and 43.9% of the participants had positive responses.
The caseworkers reported the following degrees of improvement: a little bit improved, 51.2%; no changes, 31.7%; moderately improved, 14.6%; and greatly improved, 2.4%. Participants' average GAF scores increased significantly after the home visitations (44.6 [SD = 11.1] vs 53.4 [SD = 13.2]; P < 0.001; Fig. 3). However, 48.8% of the SWY showed no change in GAF score.
To our knowledge, this is the first study to conduct a home visitation program for SWY. The most challenging parts of this study were recruiting the SWY and selecting participants by means of our research criteria. The number recruited was smaller than we expected, and we excluded one-third of the initial recruits due to not being severely withdrawn and/or having symptoms suggestive of psychiatric disease. The other difficulties were participants' resistance to home visits and to interviews. However, through this home visitation study, we could comprehensively understand SWY characteristics and examine the home visitation program's potential as an SWY treatment modality, despite the short study duration.
At present, clinically defined social withdrawal or hikikomori lacks diagnostic validity. In fact, the term ‘social withdrawal’ does not automatically imply a pathological status. Short-term social withdrawal could be for resting, avoiding interference, or recharging one's energy. However, long-term social withdrawal is an especially serious problem during youth. The previous Korean study's target population was the SWY latent or at-risk group, rather than the core SWY, so we defined SWY as any youth under 25 years of age who stayed at home all day, due to being severely socially withdrawn, for more than 3 months, and without a specific reason. The definition of SWY in Korea requires ‘more than 3 months' ’ duration, while the definition of hikikomori in Japan requires ‘more than 6 months' ’ duration. Our recruited SWY were younger than Japanese hikikomori would be. Therefore, although the duration of social withdrawal before diagnosis in adolescents is relatively shorter, as compared to adults, events such as school refusal by adolescents may have a profound negative impact on functional impairment in youths.
Cooley described the importance of childhood peer relationships in the development of socialization, and Sullivan concluded that close relationships with same-sex peers during childhood not only affect interpersonal relationships after adolescence but also could make up for any relationship deficiencies experienced during early development. Rubin proposed that social relationship deficiency had two causative processes: ‘active isolation’, a preference for playing alone, and ‘social withdrawal’, due to anxiety and lowered self-esteem. In our study, active, isolated participants were rare, because most participants wanted more friends, disliking their present status, and showed high levels of anxiety, depression, and lowered self-esteem in interpersonal relationships. Like this study, Lee et al. reported, in a Korean hikikomori adolescents' psycho-sociologic characteristic study, that hikikomori adolescents had higher levels of projective discomfort, anxiety, depression, and distrust than normal adolescents had and experienced greater distress that was psychological.
There are many theories about the reasons for social withdrawal in adolescence, which can be summarized as follows: the developmental outcome of a particular temperament; a behavioral index of the child's isolation, exclusion, or rejection by a peer group;[30, 31] the preference for object manipulation and construction over social motivation; and the behavioral expression of internalized thoughts and feelings of social anxiety or depression. The results of our study were quite compatible with these theories, except for the preference for object manipulation over social motivation. Over 50% of SWY had either passive or indifferent relationships with peers and parents in early life, which may correlate with the temperamental outcome of their present status. Also, 56% of SWY had experienced school bullying, and most participants had hints of one or more psychiatric diseases (Fig. 2).
Currently, socially withdrawn groups are not well defined, classified, or categorized. In the DSM-IV and ICD-10 diagnostic systems, the phenomenon is a symptom rather than a syndrome or disorder. A previous Korean study used only phenomenological description and classification by degree of withdrawal, without comment about the mental disorder. However, from the treatment perspective, detecting or differentiating SWY's mental disorders is very important. In terms of our study, we propose that the suggested SWY mental disorders are as follows: (i) from the psychic trauma aspect, many SWY had PTSD from school bullying or caretaker violence; (ii) from the disease aspect, SWY commonly had anxiety disorder, social phobia, depression, eating disorder, body dysmorphic disorder, schizophrenia spectrum disorder, and/or Internet addiction; and (iii) from the temperament-personality aspect, many SWY showed avoidant, dependent, and/or oppositional tendencies.
Internet addiction in youth is now an especially polemical social issue in Korea. The theme of most mother–child conflicts is Internet use, and it is one cause for school dropout. Research has not elucidated well whether Internet addiction is a primary reason for social withdrawal or a secondary result of social withdrawal. In our study, SWY's daily computer use time was twice as long as that of normal controls, and their main use for the computer was gaming. They preferred FPS and RPG. Recent study results have revealed such games have higher addictive tendencies for adolescents. The SWY's mean Internet addiction score was also significantly higher than that of the normal control group, for 56.3% of SWY were in the high-risk addiction group, and 9.4% were in the addicted group, although this measure is not standardized in Korea yet. This might be a unique feature of Korean SWY. Further studies about the correlations between SWY and computer games are needed.
Research suggests parents' reaction styles to SWY have a great impact on maintaining or aggravating socially withdrawn behavior. In this study, SWY families had lower scores in cohesion, active-recreational orientation, organization, and control as compared to normal control families, which may indicate the familial problems of SWY. Tyerman's and Humphrey's study on psychiatric outpatient families reported low scores in cohesion and active-recreational orientation, similar to our study. Lower scores in organization and control indicated difficulties in setting family rules and systems. Further study is needed to evaluate this result regarding whether familial problems are a primary reason for, or secondary result of, social withdrawal.
In our study, only 50% of participants had experienced therapeutic help prior to the home visitations, and most study participants enrolled per psychiatrists' recommendations. This indicated that in Korea, SWY still receive less social attention in the general population than they receive in Japan, and there is a lack of social support systems to manage SWY. We initially designed five separate home visits for the therapeutic approach, but participants averaged two or three counseling visits, due to difficulties in arranging their interviews. Just one or two more visits led to parents reporting greater satisfaction with the counseling. If participants had received more counseling, they might have experienced greater satisfaction. After their home visit counseling, most participants showed increased social activities and GAF score improvements, despite the counseling's short duration.
Due to the many persons and families involved in hikikomori, the term is a well-known, hot-button social issue, though researchers had regarded it as a phenomenon unique to Japan. Nowadays, several case reports have arisen not only in Japan but also in other parts of Asia, Australia, and the USA. The current explanations of the Japanese sociocultural factors in hikikomori are as follows. In a highly competitive society, many people drop out socially and hide at home, and, in an advanced society, one's own room is a convenient refuge from daily life, which includes one's parents' support. Moreover, advanced IT means one need not endure other people intruding. From the sociocultural view, Korea is similar to Japan in many aspects, so we suggest that in the near future, SWY might become an important social issue in Korea, as the issue of hikikomori is in Japan.
The present study has some limitations. First, no gold standard regarding social withdrawal diagnostic or structural interview criteria for hikikomori exist, although a previous study used our criteria. Notably, our duration criterion is of shorter duration than the Japanese criterion is. Second, there is a lack of outcome evaluation, because we only employed the self-rating scale at the first visit, and we could not investigate via follow-up rating scales, besides the GAF and CGI, at the final visits. In addition, the sample size was small; therefore, we cannot insist that home visit psychotherapy may be an effective treatment for SWY. Further large, longitudinal studies are needed to clarify whether SWY-specific treatments, such as a home visitation program, are required. In spite of these limitations, this study shows that a home visitation program could be helpful in the management of SWY.
In conclusion, this is, to our knowledge, the first study of a home visitation program for SWY. The most difficult problem in this SWY treatment was gaining therapeutic access to the participants. Therefore, we suggest the home visitation approach, by well-trained caseworkers with structured manuals, is a good gateway tool for solving this problem. SWY are a heterogeneous group that has many kinds of mental problems, so aiding them well requires the establishment of a therapeutic network between psychiatric clinics and community mental health centers.
D.H. Ahn, MD, PhD, B.N. Kim, MD, PhD, and M.S. Shin, PhD recruited participants for this research and prepared a manual for the home visitation program. This article was presented at the Ashahi Newspaper-Wakayama University joint Hikikomori Symposium in Osaka, 6 February 2010. This study was supported by a grant from the National Youth Commission, Republic of Korea, 2006. The authors report that they