SYMPOSIUM: SPECIAL NEEDS

The effects of bullying

Douglas Vanderbilt Marilyn Augustyn

Denition
The cultural context and understanding of what constitutes bullying may vary throughout the world. It is commonly thought of as the assertion of power through aggression that involves a bully repeatedly and intentionally targeting a weaker victim through social, emotional, or physical means. Child participants can move between being a bully, victim, bullyevictim (both a bully and a victim), or bystander. Table 1 outlines these denitions. Bullying is often direct, involving physical aggression such as hitting, stealing, and threatening with a weapon. Other direct bullying can be verbal aggression such as name-calling, public humiliation, and intimidation. Bullying can also be indirect and can involve relational aggression such as spreading rumours, social rejection, exclusion from peer groups, and ignoring. Technology is creating unique venues for cyberbullying on the Internet and through social networking that can be direct or indirect. In one study from the UKs National Childrens Home in 2005, 14% of adolescents reported being bullied specically by text messaging with the vast majority personally knowing the perpetrator. In the United States the increase in cyberbullying, which have resulted in several child deaths, has resulted in attention in the legislature and increased media focus.

Abstract
Bullying is a major problem for children. There are well-dened risk factors for bullying that are individual and social. Beyond the immediate trauma of experiencing bullying, victims are at high risk of later physical and emotional disorders. Bullies are the generators of this trauma but also suffer poor long-term effects as a result of their participation. Bystanders are also not immune from bullyings toxic effects nor innocent from its occurrence. While most often occurring at schools, paediatric clinicians can identify and support children suffering from bullying. They also have the unique opportunity to engage the schools and wider society on anti-bullying initiatives. This article will outline the risk, signs and symptoms of bullying to help clinicians identify and address these children in need.

Keywords bully; bullying; outcomes; schools; victim

Introduction
Bullying affects a large number of children and lays the groundwork for long-term risk for psychological, physical, and psychosomatic outcomes. Bullying is a common occurrence for schoolchildren worldwide. Bullying occurs in all countries, affecting from 9% to 54% of youth depending on the study. These rates vary across the world and UK. The large Health Behaviour in School-Aged Children study from 2006 shows the worldwide prevalence of bullying among 13 year olds ranges from 8.6% to 45.2% among boys and from 4.8% to 35.8% among girls. The low rates were in Sweden with the highest percentages in Lithuania. For the UK, Wales showed 14% of boys having involvement in bullying and 13.7% of girls with England showing 16.5% in boys and 12.1% in girls. In the UK, over half of students say that bullying is a problem. The 2006 National Bullying Survey from the charity BullyingUK found 69% of children reported being bullied, 20% reported bullying others, and 85% had witnessed bullying. Due to the consequences of bullying and the ready access to children during healthcare visits, paediatric clinicians are in a unique position to identify and ameliorate these effects.

Epidemiology and risk factors

There are age, gender, and social risk factors seen in bullying. Table 2 offers an outline of the common epidemiological trends and risk factors. Older children are less likely to talk about their victimization, with less than half of children conding in anyone. Boys are more frequently involved in physical bullying, but girls are more likely to use indirect bullying. Bullying occurs most frequently when there is minimal supervision and in places where the bully can be covert or anonymous. Social factors are critical in either encouraging or permitting this behaviour. Paediatric clinicians should consider family, peer group, school, community and societal factors that precipitate this behaviour. The common themes of promotion of violence or aggression and the lack of prohibition or supervision present themselves in these different levels of social interaction.

Denition for terminology used in describing bullying participants

Bullying Repeated and intentional direct or indirect aggression that targets a weaker individual or group Target of the bullying Individual who uses aggression to demonstrate power over another Both an aggressor and target in a bullying cycle

Douglas Vanderbilt MD is the DevelopmentaleBehavioral Pediatrics Fellowship Program Director in the Division of General Pediatrics at the Childrens Hospital, Los Angeles and Assistant Professor of Clinical Pediatrics at the Keck School of Medicine at the University of Southern California, USA. Conict of interest: none. Marilyn Augustyn MD is Associate Professor of Pediatrics at Boston University School of Medicine and Director, Division of Developmental and Behavioral Pediatrics at the Boston Medical Center, USA. Conict of interest: none.

Victim Bully Bullyevictim

Table 1

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Contextual and participant risk factors associated with bullying

Age Gender Settings Peaks in middle childhood in second grade Boys: twice as likely as girls to be bullies Occurs most frequently at school where there is minimal supervision Decreases with age as more intense forms of victimization rise Boys: >3 times as likely to be bullyevictims Common times like during break, recess, and lunch. Common places like playgrounds, hallways, and neighbourhood to and from school Peer bystander: support bullying through acceptance or encouragement of the behaviour Older children are less likely to talk about their victimization Boys: twice as likely to be victims New frontier of internet facilitated social networking

Social

Family: - lack of consistent consequences - using discipline that is negative or physical - modelling bullying behaviours to their children Community: worse problems with more social chaos and community violence

School: more episodes of bullying if they ignore or tolerate such behaviour through weak supervision

Victim

Bully

Passive type: physically weak and emotionally vulnerable (learning disability or autism) External characteristics like obesity, physical deformities, chronic conditions More conduct problems

Society: media images and societal values can promote aggression and violence as normative and appropriate methods of social behaviour and conict resolution Provocative type: reactive and Often anxious, insecure, lonely and lacking ghts back when attacked social skills (ADHD or ODD) Single parent households Academic problems Higher social status, socioeconomic Lowest rates of adjustment problems status, and prestige

Bullyevictim Any of the above risks for victims and bullies Table 2

There are specic risk factors to consider for the three groups of victims, bullies or bullyevictims. Victims can be passive, provocative, or just in the wrong place at the wrong time. Some have distinguishing features but most are not seen as different than others. Bullies often have high social status, which gives them license to use their power on those weaker. They tend to have more conduct problems but may not show any adjustment symptoms despite their troubling externalizing behaviour. Alcohol use among boys and a history of physical abuse may be other risks that could precipitate bullying behaviour. The bullyevictim may be aggressive, passive and provocative simultaneously. They may learn maladaptive behaviours of using bullying strategies to cope with their victim status. Whether we were aware of it or not, at one time all of us were part of the 4th group, which are the bystanders to bullying behaviour. This is by far the largest group of children at any given time. Bullying cannot sustain itself without bystanders active encouragement or passive acceptance. Bystanders are also negatively affected by bullying in that the hostile environment distracts them from school and friendships. Recognition and activation of this bystander group is critical in changing school cultures against bullying.

Long-term effects
Bullying, whether as bullies, victims, and bullyevictims, is associated with poorer outcomes. Bullying involvement leads to

worse psychosocial adjustment, greater health problems, and poorer emotional and social adjustment. The likelihood of being diagnosed with a psychiatric disorder in early adulthood is raised if the child has been bullied or has committed bullying. Table 3 outlines the recurrent effects seen across many studies. Victims have more depression, psychosomatic complaints, medication use and suicidality. Long-term consequences in adulthood of being bullied as a child include psychosis, depression, poor self-esteem, and abusive relationships. In this group psychiatric diagnoses are often anxiety disorders. If one identical twin was bullied and the other was not, the exposed one is at higher risk of internalizing symptoms. This shows the powerful effect of environment exposure of this traumatic event. Bullies who acknowledge their behaviour have higher rates of depression and psychological distress as compared to those who deny their bullying. All bullies have higher negative attitudes towards school and are at higher risk of dropping out of school. Bullies, as a consequence of their activities, are more likely to have more social problems, aggression, and externalizing behaviours. Bullies tend to have psychiatric diagnoses of antisocial personality, substance abuse, and anxiety disorders. They engage in high-risk behaviour such as using more tobacco, alcohol and other drugs. Childhood bullies have a fourfold increase in criminal behaviour by early adulthood. They have more problems with being employed and having stable long-term romantic relationships.

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Common outcomes seen with participants of bullying

Victim - Lower social status - Higher social - Marginalization - Poor self-esteem - Isolation Fourfold increase in criminal behaviour by their mid twenties - Emotional disorders - Psychosis - Suicides Adulthood: - depression - abusive relationships - Poor physical health outcomes - More drug use - Negative attitudes toward school - Higher rates of depression and psychological distress if they self-identify - Highest rates of depression, loneliness, substance use, psychosis

Bully

Bullyevictim

- Most problems with peer relationships

- Higher risk of dropping out of school - Carrying weapons - Fighting - Avoided by peers - Precursor to more violent acts

Table 3

The bullyevictim has problems with higher rates of depression, loneliness, alcohol use, and weapon carrying and poorer peer relationships. They often see justication in bringing a weapon to school. Bullyevictims also have higher rates of anxiety and antisocial personality disorders. Most troubling is the fact that amongst intended or conducted perpetrators of school shootings in the United States, 2/3 were bullied and had violent ideation prior to accomplishing their violent acts.

Role of the paediatric provider

One may assume that because most bullying happens in school that the schools should take the lead in identication and antibullying prevention. Despite this view, the paediatric provider has several important roles to play in helping the individual patient and addressing the bullying climate. Table 4 lists these potential areas of intervention. We will consider them each subsequently. Proactive identication of the problem Red ags for bullying: paediatric clinicians are in a unique position to screen, treat, and advocate for reducing the impact of bullying by assisting those affected and seeking to prevent further occurrences. Table 5 lists the common signs of a child being bullied and those who may be bullying. The victim can show a host of problems in the ofce. They include physical complaints such as insomnia, stomachaches, headaches, and new onset enuresis. Psychological symptoms such as depression, new onset fears, loneliness, and suicidal ideation may elicit concerns. Behavioural changes such as

irritability, poor concentration, school avoidance, and substance use are common. History of taking long or illogical routes to school may signal trouble in the neighbourhood. School problems such as academic failure, social problems, and lack of friends are red ags. Additional vigilance must be made for those children with chronic medical illnesses like obesity or severe eczema, physical deformities like cleft lip and palate, and neurodevelopmental problems like learning disabilities or autism spectrum disorder who may be potential targets. A bully may be more difcult to identify due to the bullys desire to obscure the behaviour. Children who are aggressive, overly condent, lacking in empathy, and having conduct problems may need careful screening. Exploring the family discipline use and social stressors could bring out the social risks to bullying. Differential diagnosis: due to the victims shame and the bullys intentional obfuscation, bullying must be considered on a wide list of differential diagnoses. The physical, behavioural, psychological, and school symptoms of bullying may overlap with other conditions such as medical illness, learning problems, and psychological disorders. For example if a family brings a child in for problems with attention or hyperactivity at school, ADHD may rst jump to mind. But a detailed history of onset, duration, and location of the symptoms could bring out concerns of bullying. Table 6 provides specic questions to ask of children and parents to clarify the differential diagnosis. Screen for psychological comorbidities The poor outcomes seen with those involved with bullying work primarily through psychological mechanisms. Assessing for these psychological concerns, is critical to short circuit bullyings corrosive effects. Universal and targeted psychosocial screening may be a solution to this prevalent problem. If used in either fashion, the validated Pediatric Symptom Checklist can bring up these psychosocial concerns that may have bullying as an aetiology. Its routine use in practice has been shown to increase mental health referrals, decrease child symptom scores, and increase parental satisfaction. Other checklists can be used to probe for psychological problems that warrant further attention. In the US, the National Initiative for Childrens Healthcare

Paediatric provider role in identifying and managing the effects of bullying

C C C C

Proactive identication of the problem Screen for psychological comorbidities Counsel the families and child Advocate for bullying prevention

Table 4

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Red ags for identifying bullying participant status

Victim Physical complaints: - insomnia - stomachaches - headaches - new onset enuresis Behavioural changes: - irritability - poor concentration - school refusal - substance abuse Desire to obscure the problematic behaviour Psychological symptoms: - depression - loneliness - anxiety - suicidal ideation/gestures Unique features: - children with chronic medical illnesses - physical deformities - students in special education Features: - aggressive - overly condent - lack empathy - oppositional or conduct problems School problems: - academic failure - social problems - lack of friends Physical examination: - torn or damaged of clothing or belongings - unexplained cuts, bruises, and scratches

Bully

High-risk families: - physical punishment - model violent behaviour in conict resolution

Table 5

Quality Vanderbilt ADHD rating scale is another widely available tool that can elicit concerns. Further work-up or referrals can be triggered for children who display problems on this scale in all domains or ones associated with being a victim or bully such as internalizing or conduct problems. Counsel the families and child Management of bullying involves comprehensive interventions with parents, victims, bullies, and the school. Once the clinician identies the victim or bully, interventions should begin with supporting family and those children involved with bullying. Table 7 gives specic words that the paediatric provider can use to counsel the victim and bully. For the victim, the clinician should listen to the child empathetically to empower and reassure him or her. The clinician should avoid blaming the victim or trivializing the childs concern. As outlined in the 2003 Department for Education and Skills report, Tackling bullying: listening to the views of children

and young people, children need to strategize how to connect with friends and minimize the risks of involving adults like teachers or administrators. The provider should give advice on avoidance of situations where the bullying may occur. Roleplaying an encounter can be helpful for the child to learn to stand up for yourself. Extracurricular activities like sports, music groups and drama clubs can be used to help to bolster the childs self-esteem. The clinician should identify safety issues such as suicidal ideation and plans, substance abuse, and other high-risk behaviours. Once a bully is identied, the clinician should screen for the risk factors for this behaviour such as family dysfunction or conduct problems. The provider should educate the parents and child about the seriousness of the behaviour and its potential consequences. The clinician should label the behaviour as the problem and not the child. Helping the family and child to acknowledge the behaviour as hurtful, is critical to curtailing its continuation. The school and parents should ensure

Key questions
Children 1. Have you ever been teased or bullied at school? 2. Do you know of other children who have been teased? 5. What kinds of things do children tease you about? 6. Have you ever been teased because of your illness/disability? . for not being able to keep up with other children? . about looking different from them? 7. At recess do you usually play with other children or by yourself? 8. Have you ever changed schools because you had problems with the some students? 4. Do you suspect that your child is being harassed or bullied at school for any reason? If so, why? 5. Has your child ever said that other children were bothering him or her?

3. How long has this been happening? 4. Have you ever told the teacher about the bullying? Parents 1. Do you have any concern that your child is having problems with other children at school? 2. Does your child go to the school nurse frequently for physical complaints? 3. Has your childs teacher ever mentioned that your child is often alone at school?

Table 6

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Words to use in counselling

Victim No one deserves to be treated this way. You are not alone. Your parents and I will work together to help things get better for you. The bullying will stop very soon. Walk, Talk, and Squawk

Walk e ignoring the hurtful remarks Talk e making condent yet nonprovocative statements to the bully Squawk e disclosing the episodes to adults

Bully

Do you feel bad when other children hurt your feelings? Bullying hurts other childrens feelings.

Table 7

accountability for the childs subsequent behaviour. Parental mental health and resource risk factors should also be addressed with community support referrals. For both of these groups, proper screening is essential to nding those who need further referrals. Those children with special educational needs are eligible for services under the local education authority as outlined in the Code of Practice. Those with mental health symptoms need referrals to mental health professionals for further diagnosis and management. For any child and family, there are many websites that provide general information and support such as US Department of Health and Human Services, Beatbullying empowerment website, and The UK Anti-bullying Charity. Professional resources can be found at those sites and also through the American Academy of Pediatrics Connected Kids: Safe, Strong Secure Program. Advocate for bullying prevention Beyond child and family based interventions, paediatric clinicians must engage the school and community. The evidence is mounting that the whole school approach is the most effective way to stem the bullying tide. Clinicians can advocate for the use of evidence-based systemic bullying prevention programs. Targeted school curriculums and general social skills group interventions have not been found to reduce bullying in several well-done studies. Successful interventions involve school wide approaches that involve multiple disciplines. Olweus rst proposed these systemic approaches. These multifaceted programs simultaneously include school wide rules together with bullying sanctions, teacher training, classroom curriculum, conict resolution training, and individual counselling. Social workers and mentoring programs in schools can also be helpful in reducing bullying. These evidence-based programs are reviewed in a recent systemic review. On the community level, paediatric provider advocacy is needed to protect children. Addressing access to weapons, involving community organizations and parents, enhancing the built environment of schools and community, and supporting youth self-esteem are important in forging an anti-bullying environment. Targeting larger societal risk factors of violence in the neighbourhood and wider culture are also avenues for improving school violence. In Denmark an intensive national school policy has lead to the substantial reduction in school bullying prevalence.

Summary
Bullying is clearly prevalent and impacts childrens lives across the globe. The Practice Points review the important points in this article. The risks of victimization and aggression are known and can be identied in practice. The damaging effects of experiencing or committing such behaviours are immediate and long lasting along the dimensions of psychological and physical effects. Paediatric clinicians must be proactive in identifying and assessing the presence of bullying among their patients be they victims, perpetrators or silent witnesses. Once identied, the provider has the opportunity to support the victim and to create limits for the bully. In depth screening and referrals can break the persistence of toxic later effects. In all situations, the provider must understand the role of the school environment and role of the bystander in keeping bullying impact to a minimum. A

FURTHER READING Craig Wendy, Harel-Fisch Yossi, Fogel-Grinvald Haya, et al, the HBSC Violence & Injuries Prevention Focus Group and the HBSC Bullying Writing Group. A cross-national prole of bullying and victimization among adolescents in 40 countries. Int J Public Health 2009 Sep; 54: 216e24. http://www.bullying.co.uk/ http://www.ncsl.org/default.aspx?tabid12903 http://psc.partners.org/psc_order.htm http://www.nichq.org http://stopbullyingnow.hrsa.gov, http://www.beatbullying.org/index.html http://www.aap.org/ConnectedKids Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ, the Health Behaviour in School-aged Children Bullying Analysis Working Group. Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment. Arch Pediatr Adolesc Med 2004; 158: 730e6. NCH and Tesco Mobile. Putting U in the picture: mobile bullying survey 2005. Accessed at: www.lemaker.co.uk/educationcentre/./Mobile_ bullying_report.pdf; 2005. Oliver C, Kandappa M. Tackling bullying: listening to the views of children and young people. Summary report (PDF). London: DfES and

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ChildLine. Accessed at: http://www.dcsf.gov.uk/research/data/ uploadles/RR400.pdf; 2003. Olweus Dan. Bullying at school: what we know and what we can do. Blackwell Publishers, 1994. Ronning JA, Sourander A, Kumpulainen K, et al. Cross-informant agreement about bullying and victimization among eight-year-olds: whose information best predicts psychiatric caseness 10e15 years later? Soc Psychiatry Psychiatr Epidemiol 2009; 44: 15e22. doi: 10.1007/s00127-008-0395-0. Vanderbilt D. Bullying. In: Parker S, Zuckerman B, Augustyn M, eds. Behavioural and developmental pediatrics: a handbook for primary care. Lippincott Williams & Wilkins, 2004: 141e4.

Vreeman RC, Carroll AC. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med 2007; 161: 78e88.

Practice points
C C C C

Know the prevalence and risks to bullying and school violence Be proactive in identifying and assessing a bully or victim Provide support for a victim and consequences for a bully Suggest evidence-based approaches to improve school environment

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