Chapter 22. Literature Review2.1. Social withdrawal: Definitions and PerspectivesSocial withdrawal is not a new term. For example, the discipline of developmental psychology has been witnessing research study in the area of children and adolescents suffering from social withdrawal or social isolation, who are characterized by shyness, unsociability, aloneness and peer avoidance. Empirical studies informed by this theoretical perspective suggest that socially withdrawn children or students are more likely to lead a negative developmental trajectory, as they are at major risk of failing to develop social and interpersonal skills resulted from interactive experiences with peers. Such studies and theories frame children and youth who are socially disengaged from peers as moving away from the social environment, and thus efforts made in the promotion of a more supportive peer environment and cultivation of pro-social or interactive behavior on the side of individuals are considered important in preventing further moving away from the world from taking place. From a psychopathological perspective, social withdrawal behavior and the negative parenting style are largely the targets of professional intervention (Coplan, Prakash, O’Neil, & Armer, 2004).Being alone does not necessarily mean being lonely. Loneliness is conceptualized as negative solitude experience because of its painful and potentially harmful nature which entails more than social isolation and reflects the sufferings of not connected to and valued by others. However, solitude or aloneness, if it is planned and preferred may be productive in nature which may enhance one’s knowledge of one’s self and identity and the social environment, and provides relief from the pressures involved interacting with other people and living in the world. If it is the case of involving a greater understanding of oneself and the world and/or leading to a higher level of concentration, it may be a path to greater meaning and more rewards, which is conducive to generating positive benefit. For example, with a determination to finish their work, young authors of a middle-class background, or with sufficient backup of financial resources, may be able to tune out from social life for a long period of time without being trapped in hardship or poverty. This is of course a personal choice striving for a personal goal which is to be achieved or rewarded sooner or later. Nobody would define this as a social withdrawal problem to be intervened or tackled. In some cases, the benefit of solitude may be considered as ‘negative’ in the sense of retreating from unpleasant situation before or after one is burnt out. Productive solitude generating either positive or negative benefit in the form of withdrawal from social life may be interpreted as a personal choice of young people in managing the extent to which they want to engage with or disengage from others. No social work professionals can afford to overlook the agency of young people and their meanings attached to the experience of solitude. If not, they may fail to appreciate the productive side of social withdrawal at best, and acknowledge the intention or motivation behind solitude or seclusion at worst.  The discussion so far illustrates that the moving away of young people from the social environment may be desirable or undesirable. It all depends on which perspective one intends to take into consideration and the impact of the moving away on young people. However, the social environment can be conceptualized as moving away or even against young people who are confronted with increasing challenges not only in developing relations with their peers but also in participating in major social institutions deemed important to achieving the purpose of youth transitions to adulthood. Such an understanding goes against the thesis of ‘underclass’ in shaping the ideological ways of thinking about disaffected, dangerous, work-shy young men and irresponsible, promiscuous, immoral young women who, together, threaten ‘the survival of free institutions and a civil society’. More structurally-oriented perspectives of youth transitions or stronger forms of social exclusion emphasize the role of policy and organizational efforts in reducing the powers of exclusion against young people. Those young people who are not in education, employment or training (youth NEET), have personal, emotional, or behavioral problems, and experience discrimination through age lone or combined with other factors like race, ethnicity, disability, single parenthood, homelessness, etc.. Reaching a thorough understanding of disaffection experienced by vulnerable youth groups cannot go without deconstructing the social processes and structures leading to social exclusion. The term ‘social withdrawal’ was originated from the discipline of developmental psychology, which is obviously more individualist in nature, which places emphasis on assisting socially-withdrawn young people to rebuild self-image and regain self-confidence, and to encourage them to reestablish communication and interactions with their friends and peers in particular. This is precisely the solutions emphasized by the ‘weak’ version of social exclusion, which lie in altering those excluded or isolated individuals’ disabling characteristics so as to enhance their social inclusion or social integration. The studies on the positive and negative notions of solitude or aloneness can inform youth work practitioners the importance of agency in assigning meanings to withdrawal experience and the policy makers and social welfare organizations alike in designing measures and delivering programs that are more tailor-made to serving the specific needs of each youth. That is, youth should not be taken as a homogeneous group, and they are in reality characterized by differences and diversity that should not be ironed out both in terms of policy formulation and service intervention. The stronger version of social exclusion can shed light on understanding how social environment at large moves away or against young people experienced with their transition trajectories characterized by ups and downs and fractures. Nevertheless, the emphasis of research in western societies has been placed on examining or tackling the problems of young people who are behaviorally anti-social or aggressive (at least in the eyes of adults and the authority), homeless or of criminal background, etc.. There has not been any study in the West explicitly using the social exclusion perspective to study the newly emerging yet growing phenomenon of social withdrawal experienced by young people. Before arguing that social withdrawal is an extreme form of social exclusion, the next two sessions discuss the research methodology of the study and then in what way youth in social withdrawal are different from those young people being disconnected, disengaged or excluded from social institutions understood in a conventional sense (Coplan, Prakash, O’Neil, & Armer, 2004). 2.2. Shyness, inhibition, and social withdrawalDiscussions of the study of shyness, inhibition, and social withdrawal have often begun with the proviso that this research area is plagued by a lack of conceptual clarity. This confusion has been contributed to by the use of a plethora of terms that are defined inconsistently. Moreover, at various times, these terms have been employed (often interchangeably) to refer temperamental and personality traits, motivational and interpersonal processes, and/or observable behaviors. (Rubin & Burgess, 2001) were the first to attempt to organize these varied constructs in a psychologically meaningful manner. Their conceptual and definitional model provided the “theoretical backbone” for this research area. Herein, we restate the core components of this conceptual taxonomy while at the same time updating various components to reflect the current state of theoretical and empirical knowledge We begin with the broad notion of behavioral solitude, which encompasses all instances of children spending time “alone” (i.e., a lack of social interaction) in the presence of peers (i.e., potential play partners). (Rubin & Burgess, 2001) originally proposed the distinction between two causal processes that may underlie children’s lack of social interaction. The first is active isolation, which denotes the process whereby some children spend time alone (in the presence of available play partners) because they are actively excluded, rejected, and/or isolated by their peers. There is a large and growing literature related to a wide range of factors that may lead to active isolation by peers, with perhaps the most attention paid to the display of non-normative, socially unskilled, and/or socially-unacceptable behaviors (e.g., aggression, impulsivity, social immaturity. The second is social withdrawal (which was originally labeled as passive-withdrawal), and refers to the child’s removing himself/herself from the peer group (for whatever reason). In this regard, social withdrawal is viewed as emanating from factors internal to the child.In more recent years, a potentially complex relation between these two processes has been delineated. It now seems clear that whereas some children may initially remove themselves from social interaction (i.e., socially withdraw), they also come to be excluded by peers. Indeed, the two processes likely become increasingly related through transactional influences over time.We would maintain that it is of important conceptual interest to distinguish between social withdrawal and active isolation. Notwithstanding, the joint and interactive contributions of both of these processes should be considered over time.  We have come to construe social withdrawal itself as an umbrella term used to describe removing oneself from peer interaction for a variety of different “motivations”. As depicted in Figure 1, researchers have focused primarily on two broadly defined “reasons” why children may withdraw from social interaction. The first reason concerns aspects of emotional deregulation specifically related to fear and anxiety, whereas the second reason relates to a non-fearful preference for solitary activities. This latter construct has only recently begun to receive attention in the developmental literature; it has become increasingly apparent that some children engage in less social interaction because they are socially disinterested (or unsociable) and may simply prefer to play alone. Among adults, the preference for solitude has been referred to as a solitropic orientation.All of these terms describe various iterations of the process of withdrawal from social interactions because of underlying fear, anxiety, and social wariness. Is it possible to reconcile these somewhat different (but clearly overlapping) constructs? One approach is to integrate these constructs within a developmental perspective. In this regard, we present an albeit simplified version of this model herein.Approximately 15 percent of infants come into the world with an inherent biologically based predisposition to respond with wariness and distress in the face of novelty (i.e., behavioral inhibition). In early childhood these wary responses become particularly pronounced in the context of meeting new people (i.e., fearful shyness). With the further development of the self-system and perspective-taking skills, this social wariness extends to include feelings of embarrassment and concern in the face of perceived social evaluation (i.e., self-conscious shyness). As such, and with the onset of formal schooling (and its increasing social stresses), many shy children continue to feel socially ill-at-ease even after the school environment becomes more familiar. As a result, these children withdraw from social interactions and display overt signs of anxiety with peers at school (i.e., social reticence or anxious-solitude). For a smaller proportion of these children (perhaps at the most extreme end of the distribution), these feelings of anxiety continue to escalate over time and become a debilitating psychological disorder (i.e., social phobia) in later childhood or early adolescence.From a theoretical perspective, we certainly acknowledge that it may be conceptually useful to offer “fine-grained” distinctions among these different terms. However, it is also important to assess the practical utility of distinguishing between behavioral inhibition, shyness, and anxious-solitude. For example, in a sample of preschool-aged children, consider the implications of empirically identifying “extreme groups” of inhibited, fearfully shy, self-consciously shy, and anxious-solitary children. Employing this person-oriented approach, would we not expect a significant amount of overlap in the membership of these various groups? Indeed, we find it difficult to envision many instances where these extreme groups would not coalesce. If this is the case, does the field require the use of these different terms? In this regard, it is also important to consider issues related to the differential assessment of these different constructs (Coplan, Prakash, O’Neil, & Armer, 2004).2.3. Status of the HIV/AIDS epidemic HIV affects humans irrespective of age, race and gender. According to (Ethiopian Public Health Institute (EPHI), 2017) currently, i.e. 2017, there are 665,116 people living with HIV aged 15 and more in Ethiopia. This number is estimated to rise and reach 717,153 in the year 2021. With respect to gender currently there are 256,079 males and 409,037 and females living with HIV. In the year 2021 this numbers are estimated to rise to 275,576 and 441,576 respectively. The number of new HIV infection per annum is 21,551 in 2017 and is expected to reach 20,551 , 20,300 , 20,130 and 19,999 in  2018,2019,2020 and 2021 respectively for people aged 15 and more (Ethiopian Public Health Institute (EPHI), 2017).Ethiopia’s HIV/AIDS epidemic pattern continues to be generalized and heterogeneous with marked regional variations. At the national level, the epidemiologic trend over the past eight years has been stable. However, HIV prevalence appears to be declining in urban areas, according to analysis of data from ANC sites that collected data consistently for more than ten years. For example HIV prevalence among pregnant women attending ANC in Addis Ababa has declined from 23% in 1996 to 10% in 2007. Peri-urban and small market town residents, young females are the most at risk individuals and affected segments of the population by the epidemic.The AIDS epidemic is one of the most serious epidemics known to mankind in causing social and economic challenges. The effect of the disease is not only pathological but also psychological. Due to this HIV patients experience a multitude of psychosocial problems including stigma and discrimination. The stigma and discrimination in turn encourages patients to be withdrawn from society and prefer solitude. In a report that studied psychosocial aspects of living with HIV/AIDS, it is identified that people living with HIV/AIDS experience fear, loss, grief, hopelessness and helplessness syndrome, guilt and self-esteem, anxiety and depression, denial, anger, aggression and suicide attempts (Fabianova, 2011).2.4. Psychosocial Aspects of People Living with HIV/AIDSPeople living with HIV/AIDS (PLWHA) feel uncertainty and they have to cope with the situation. Feelings of insecurity have its origin in the fear from the upcoming future and the people focus on their families and their fob. They feel even more uncertain and are more concerned because of the quality of life and life expectancy as well the treatment´s outcome and the reaction of the society. All concerns are unpredictable, and therefore they should be discussed. Above all, positive thinking and faith of is recommended. The situation is very special for children, who have lost their family and home. The HIV positive child must react to this uncertainty and make several decisions to adapt to the current situation. Even if it seems, that the child does not react at all, it can be the very adaptation to the illness by denying it. People begin their adaptation process from the day they learnt about it. Their daily life reflects the tension between uncertainty and coping with the situation. It is the tension, which raises a lot of psychosocial responses of bigger and smaller intensity.Fear of HIV/AIDS is closely associated with fear of our own death, which belongs to the most basic of fears. It is the fear which most of us are trying to fight with by constantly running away from the idea of self-termination or by inventing a series of comforting ideas. Escape and rationalization will help only to cultivate the fear of death. Above all, people have to be settled with self-extinction, with own death and thus perhaps would help those who just need help in the process of dying. In countries with high rate of infected people are found amongst doctors and other healthcare staff. PLWHVA are pushed to the margins of the society, and are isolated. They are forced to leave their job, they, lose their homes, often their family and friends. They are not given adequate health care and by the provided health care they are confronted with rejection. All of this happens because of an illness which cannot be transmitted by common contact. This attitude of professionals who are unable to overcome prejudices and refuse to provide health care is a deep misunderstanding of their mission. The reasons for this kind of handling is fear of being infected with HIV and, ultimately, fear from death itself. Another aspect associated with HIV/AIDS is a loss. People in the developed stage of AIDS are worried because of the loss of their life, their ambitions, physical performance and potency, sexual relations, loss of their position in the society, financial stability and independence. With the increasing essential need of systematic tendency they lose their sense of privacy and control over their lives.  Perhaps the most problematic issue is the loss of confidence. It may affect the future, anxiety originating from a relationship with a loved one or caregiver and negative reactions from the society. For many people finding out about their HIV/AIDS status it is the first opportunity, to realize their mortality and psychological vulnerability. They face social isolation due to the inability to perform all daily activities which they used to do. Relationships within the family change more frequently, one loses their colleagues and the attitude of acquaintances and friends changes frequently as well. Many are afraid of the loss of memory, their concentration and ability to make decisions. Death of a relative, who dies of a deadly disease, presents an extreme burden for each human being. He tends to surrender the pressure of the situation, which seems to be insolvable. Mental failure is accompanied by significant behavior, changes in physiological and psychological processes in the body, which have sometimes permanent effects on health. This persistent extreme burden leads to disruption of relationships with the social environment.Some people react to news about their HIV/AIDS status by denying it. For some of them, such refusal may present a constructive way to handle the shock of the diagnosis. However, if this condition persists, the denial can become unproductive, because these people refuse also the social responsibility associated with HIV positivity. This reaction is typical for children, in the case of the death on a parent. Anger and aggression are typical aspects which accompany people in situations of bereavement. Some individuals become angry and aggressive. They are often very upset about their fate. They continuously have the feeling, that they are not treated decently and tactfully enough. Anger can sometimes escalate into self-destruction: suicide. Aggression is one of the most frequently reported reactions in frustrating situations. In the frustrating situations, an individual may focus his anger, remorse, indignation, outrage, hostility on other people that are considered as suitable object. There is another possibility, presented by the concept of self-accusation, which the aggressive reaction are aimed at oneself. There is an increased risk of suicidal attempts for HIV positive people. They may see the suicide as a way out from pain and difficult situation, out of their shame and grief for their loved ones. Suicide may be active (e. g, causing a fatal injury) or passive (planning or preparation of such a situation, which could result in fatal complications of HIV/AIDS). HIV positivity presents a risk factor, particularly amongst adolescents. There are significant complications in the development of personality in adolescence age and it can be perceived as an unacceptable problem. Suicidal behavior is associated with a wide range of mental disorders, HIV positive children and adolescents suffer primarily from depression (Fabianova, 2011)

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