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Journal of Adolescent Health 54 (2014) 618e620

Letters to the editor

Cyberbullying and Psychological and Behavioral Health Problems

To the Editors:

We have read with great interest the recent editorial “Cyber- disadvantages; in this case, we recognize the consideration made
bullying among adolescents: Implications for empirical research” by Patchin and Hinduja, and we agree it would have been more
[1] by Justin W. Patchin and Sameer Hinduja in the Journal of consistent with traditional definitions of cyberbullying [7] to
Adolescent Health. We think that they raise important issues, one include in these groups (“only victims” and “bully-victims”) just
of which is using a consistent operationalization of cyberbullying adolescents with multiple experiences of cyberbullying.
to advance the study of occurrence and correlates of this problem. Nonetheless, in the main analyses on the relations between
They also make a number of observations about our article victimization and psychological and behavioral health problems, we
published in the Journal of Adolescent Health: “Longitudinal and used a continuous variable that reflects the number of times that
reciprocal relations of cyberbullying with depression, substance each participant was a victim of cyberbullying. In this case, we did
use, and problematic Internet use among adolescents” [2]. We not combine single experiences of victimization with multiple ones;
agree with many of their comments; however, we think that it is instead, our approach took into account the dimensionality and
necessary to clarify some issues raised in their editorial. variability of the construct. And what we get by analyzing cyber-
First, it is pointed out that the relations found between bullying as a continuous variable is that adolescents with multiple
cyberbullying and other behavioral and health problems could experiences of cyberbullying (compared with those who have no
be simply spurious. In the strict sense, this claim is mainly experience or just a few experiences) present a higher risk of psy-
applicable to cross-sectional studies, in which it is not possible to chological and behavioral health problems. In other words, our
establish causeeeffect relationships between variables. Although findings show a “doseeresponse” relationship between experiences
our longitudinal results do not imply causal relations between of victimization and several health problems in adolescence. Thus,
the variables, findings contribute notably to the understanding of we maintain that these analyses are adequate, preserve the vari-
temporal relationships among cyberbullying, depression, and ability of the construct, and provide important information about
other psychological problems using a prospective design and the relations of cyberbullying and the health problems analyzed.
examining reciprocal relationships among them, which had been Finally, the editorial pointed out that “students could have been
not done to date. In addition, the results are theoretically and reporting the same incident(s) at Time 1 and Time 2, thereby
empirically meaningful according to well-established theoretical confounding the results and subsequent interpretation” (p. 432).
models (Stress Generation Model [3] and Problem Behavior We do not agree with this statement. By controlling for the effect of
Theory [4]) and empirical evidence on traditional bullying (e.g., a specific variable at Time 1 on the same variable on Time 2 (i.e., the
[5,6]). We agree with Patchin and Hinduja that the more time inclusion of autoregressive paths), we analyzed the extent to which
points available to examine the relationships, the better. Future the rest of Time 1 predictors accounts for the residual change in a
research should progress in this direction. given Time 2 variable over time [8]. When we asked adolescents at
Second, Patchin and Hinduja note that research studies on Time 2 for their experiences of cyberbulling “ever,” they are also
bullying often “combine single experiences with multiple ones in reporting more recent experiences (i.e., during the last 6 months).
a way that makes it impossible to disaggregate the two” (p. 431). This, in turn, allows examining the variables that predict this re-
We acknowledge that they make a reasonable point that studies sidual increment of cyberbullying from Time 1 to Time 2.
of bullying should include multiple instances of aggression. In conclusion, we agree with Patchin and Hinduja that research
When analyzing differences between “only victims” and “bully- in this field must further refine conceptual and methodological
victims,” to create the groups we used a lenient criterion that issues. A range of such issues are debated in two recent collections
included “just once or twice” experiences of victimization. As [9,10]. Research in cyberbullying has gathered pace very rapidly
noted in the article, what is interesting in this approach is that in the last few years, and discussion of these issues serves an
even using this lenient criterion, we found highly significant important purpose in improving research and ultimately helping
differences among bully-victims, only victims, and noninvolved those involved in cyberbullying behaviors.
adolescents. We think that this in itself is an important finding, as
it signals that even quite low-level involvement in cyberbullying Manuel Gámez-Guadix, Ph.D.
may be a risk factor for the health problems considered. Never- University of Deusto
theless any analytical decision brings some advantages and Bilbao, Spain

1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Letters / Journal of Adolescent Health 54 (2014) 618e620 619

Peter K. Smith, Ph.D. problematic Internet use among adolescents. J Adolesc Health 2013;53:
[3] Gibb BE, Hanley AJ. Depression and interpersonal stress generation in
University of London children: Prospective impact on relational versus overt victimization. Int J
London, United Kingdom Cogn Ther 2010;3:358e67.
[4] Jessor R. Risk behavior in adolescence: A psychosocial framework for un-
Izaskun Orue, Ph.D. derstanding and action. J Adolesc Health 1991;12:597e605.
University of Deusto [5] Kaltiala-Heino R, Fröjd S, Marttunen M. Involvement in bullying and
depression in a 2-year follow-up in middle adolescence. Eur Child Adolesc
Bilbao, Spain Psychiatry 2010;19:45e55.
[6] Tharp-Taylor S, Haviland A, D’Amico EJ. Victimization from mental and
Esther Calvete, Ph.D. physical bullying and substance use in early adolescence. Addict Behaviors
University of Deusto 2009;34:561e7.
Bilbao, Spain [7] Smith PK, Mahdavi J, Carvalho M, et al. Cyberbullying: Its nature and
impact in secondary school pupils. J Child Psychol Psychiatry 2008;49:
[8] Little T. Longitudinal structural equation modelling. New York: Guilford;
References 2013.
[9] Bauman S, Walker J, Cross D. Principles of cyberbullying research:
[1] Patchin JW, Hinduja S. Cyberbullying among adolescents: Implications for Definition, methods, and measures. New York & London: Routledge;
empirical research. J Adolesc Health 2013;53:431e2. 2013.
[2] Gámez-Guadix M, Orue I, Smith PK, Calvete E. Longitudinal and recip- [10] Smith PK, Steffgen G. Cyberbullying through the new media: Findings from
rocal relations of cyberbullying with depression, substance use, and an International network. Hove: Psychology Press; 2013.

A Child Rights and Equity-Based Framework to Advance Policy and Practice

Related to Adolescent Consent to Vaccines
To the Editors:

Ensuring minors can legally consent to vaccines, as dis- laws. Current policy fulfills the rights of minors to seek diagnosis
cussed in the recent position paper on adolescent consent for and treatment of sexually transmitted infections independently
vaccination [1], is critically important. However, the paper’s sole but does not fulfill their right to prevention.
focus on ethical and legal arguments will constrain our capacity Fulfilling adolescents’ rights does not subvert parental rights
to advance such enlightened public policies. The principles of or responsibilities. Child rights principles emphasize the role
child rights and equity provide a complementary approach to of parents as primary caregivers and protectors of the rights of
analyze and revise policies and practice. As rights-bearers, their children. Ideally these should be informed joint decisions.
children have the right to access vaccines that will optimize Increasing a child’s autonomy according to their evolving capac-
their survival and development. As duty-bearers, physicians ities is not a threat to parental authority but an opportunity for
and advocates are responsible to ensure those rights are communication between the parent and child.
fulfilled. Applying rights and equity-based principles to address adoles-
The United Nations Convention on the Rights of the Child cents’ rights to consent to immunization will expand our capacity
(CRC) [2] provides the framework to support a child rights and for advocacy. Physicians can begin by (1) establishing rights-
equity-based approach to advance policy and practice related to respecting practices; (2) posting a children’s rights charter;
youth consent to vaccines. In particular, the CRC: (3) routinely obtaining children’s assent to immunization; (4)
developing vaccine information sheets that reflect children’s
 Article 2 defines obligations to protect children from evolving capacities; and (5) implementing rights and equity-based
discrimination. approaches and policies that secure the ability of adolescents to
 Article 3 requires that all societal decisions consider their best consent to vaccines.
 Article 6 obligates the State to ensure a child’s optimal survival Rita Nathawad, M.D.
and development. Jeffrey Goldhagen, M.D., M.P.H.
 Articles 12/13 ensure rights to express opinions freely. Division of Community and Societal Pediatrics
 Article 16 ensures the child’s right to privacy. Department of Pediatrics, University of Florida
 Article 17 ensures children have access to information. Jacksonville, Florida
 Article 24 ensures the child’s right to the highest standard of
health and healthcare.

Despite the United States’ failure to ratify the CRC, it is [1] Society for Adolescent Health and Medicine, English A, Ford CA, Kahn JA,
nevertheless as relevant to American children as to other chil- et al. Adolescent consent for vaccination: A position paper of the Society for
dren across the globe. Adolescent Health and Medicine. J Adolesc Health 2013;53:550e3.
[2] UN GA Res 44/25. Convention on the rights of the child. Available at:
Human papilloma virus vaccine provides an example of the Accessed December
paradox of contemporary vaccine policy and adolescent consent 24, 2013.