This article is more than 5 years old. Information may no longer be current.
Bullying: What a pediatrician should know
Click Here to Manage Email Alerts
Bullying is a public health issue that has captured the attention of many, especially after the recently reported suicides of children and adolescents who were bullying victims.
Several studies have shown that 20% to 30% of students in school are involved in bullying, either as a bully or a victim. When considering bystanders, a study of third-grade children showed that more than three-quarters of children have been involved in what is known as the “bullying circle,” according to Joseph Wright, MD, MPH, professor of pediatrics, emergency medicine and health policy at George Washington University, and senior vice president at Children’s National Medical Center.
“Our society has normalized bullying as part of growing up,” Wright told Infectious Diseases in Children. “We are beginning to recognize now that the consequences, especially the health consequences, are profound. The United States is just beginning to see the longitudinal effects of bullying as children grow into young adults.”
In a 2001 study published in the Journal of the American Medical Association, Nansel and colleagues reported that the frequency of bullying was higher among sixth- to eighth- graders compared with ninth- and 10th-graders. In the same study, the bullying was reportedly associated with poorer psychosocial adjustments, and that bullying had this effect on bullies and victims, although in different ways.
In 2009, the AAP issued a policy statement on the role of pediatricians in youth violence prevention. In the statement, pediatricians are encouraged to address the threat of youth violence, including bullying, and take an active role in its prevention.
Definition of bullying
In a position paper on bullying released by the Society for Adolescent Health and Medicine, the definition of bullying comprised three behavioral characteristics: behavior that is aggressive or intended to harm; behavior that is repetitive; and behavior that assumes that the bully is more powerful.
Bullying also can be categorized as direct bullying, which includes actions such as pushing, fighting and name-calling, or indirect bullying, which includes rumor-spreading, gossiping and cyberbullying. Indirect bullying is commonly also referred to as relational bullying.
“Direct forms of bullying are easier to identify and are more associated with boys,” Wright said. “Indirect forms of bullying are typically associated with girls and are harder to identify. Indirect bullying is especially worrisome.”
Bullying can take on four different forms, according to a 2009 study in the Journal of Adolescent Health: physical, verbal, social and electronic. In the study, Wang and colleagues found that 20.8% of children reported being a victim or bully in a physical manner; 53.6% in a verbal manner; 51.4% in a social manner; and 13.6% in an electronic manner. The physical and verbal types of bullying are categorized as a direct form of bullying, whereas social and electronic bullying are characterized as an indirect form.
It is not a problem that just pertains to children. Adults may play a passive role in bullying, as well, by not recognizing that the bullying is taking place. There are many adults who do not understand that bullying is a serious issue, Wright said, and thus, they do nothing when they observe bullying behavior.
Cyberbullying
Of particular relevance in this era is cyberbullying, which is sometimes called electronic bullying or online social cruelty. Cyberbullying includes spreading rumors or lies about a victim, tricking people into revealing personal information, sending and forwarding mean text messages and/or posting pictures of a victim without their consent.
Cyberbullying differs from traditional bullying in that it can occur any time; messages can be distributed quickly to vast audiences and the perpetrators can remain anonymous when they disperse the offensive materials.
In a 2007 study published in the Journal of Adolescent Health, Kowalski and Limber found that 11% of middle school students were bullied electronically at least once in the previous 3 months. The most commonly used methods for cyberbullying included instant messaging, chat rooms and e-mail. They also reported that girls are more likely to participate in cyberbullying, and the perpetrator’s identity often remained anonymous.
“Electronic bullying represents a problem of significant magnitude,” the researchers wrote in the article. “Although it would seem that one could apply what is known about traditional bullying to the electronic world, this is not entirely the case.”
Similarly, according to the Health Resources and Services Administration’s “Stop Bullying Now!” website, 15% of 13- to 18-year-olds had been bullied online and 11% had been bullied through cell phone messages. Other technologies that can be used for cyberbullying include blogs, social networking sites such as Facebook, web pages and text messaging.
Bullying signs
In a 2006 paper in Pediatrics, researchers from the Netherlands reported that children who are bullied are at a significantly higher risk for health symptoms developing during the school year. The ORs were highest for depression, anxiety, bedwetting, abdominal pain and feeling tense.
One sign that pediatricians should be aware of is sudden-onset attention-deficit/hyperactivity disorder, according to Robert Sege, MD, PhD, professor of pediatrics at Boston University School of Medicine.
“If a child who used to do well in school is suddenly distracted and not doing as well in school, this may be a clue that he or she is being bullied,” Sege said. “They may be concentrating on what is going to happen on the playground or on the school bus, and cannot concentrate on their schoolwork.”
In direct bullying, the signs are much easier to identify than those of indirect bullying, as there are often physical signs associated with direct bullying. But there are usually behavior changes that indicate bullying, such as changes in eating patterns, changes in sleeping patterns and changes in the child’s normal routine.
“Health care providers can think of bullying on a continuum of harassment, and look for the same signs they would note for any other type of abuse, including physical injury, depression/anxiety/other mental health concerns and somatic complaints,” Marla Eisenberg, ScD, MPH, assistant professor of pediatrics in the division of adolescent health and medicine at the University of Minnesota, told Infectious Diseases in Children. “Certainly, if a child discloses that others are being hurtful in some way, this should be taken seriously and followed up, rather than minimized along the lines of ‘kids will be kids.’”
Underlying cause of other symptoms
If a child reports symptoms such as frequent headaches, stomachaches and feeling depressed frequently, the pediatrician must recognize these symptoms and consider the possibility that the child is being bullied, according to Jorge Srabstein, MD, medical director for the Clinic for Health Problems Related to Bullying at Children’s National Medical Center.
“When school-aged children and adolescents visit their pediatrician, the pediatricians should incorporate questions about bullying by asking about these symptoms, and inform the patients and parents that they are concerned about the possibility of bullying,” Srabstein said in an interview. “Both bullies and victims can be affected.”
The effects of bullying are not always just short-term. In a 2009 study published in the Archives of General Psychiatry, researchers in Finland reported that females who were frequent victims of bullying were more likely to need psychiatric hospital treatment later in life and/or use antipsychotic, antidepressant and anxiolytic drugs.
However, there should not only be concern for the victims.
“Too often, we ignore the kids who are the bullies, when they need help as well,” Wright said. “If a child exhibits aggression toward animals or siblings, these may be signs that indicate the child is a bully. One of the premises of a bullying prevention program is to treat bullies, as well as the victims.”
According to Sege, children who are likely to have long-term problems are the bullies themselves. Without receiving help, bullies are less likely to finish school, less likely to hold down a job and less likely to hold down a stable adult relationship.
“One of the focuses needs to be how to help a bully develop more appropriate behavior,” Sege said. “Many kids who are bullies actually have a lot of leadership potential, and we should help them develop their empathy skills and help them turn around. This is a complicated process and involved individual counseling and coaching for parents to understand this.”
What pediatricians should do
“Pediatricians need to be aware that bullying is a pervasive issue,” Wright said. “Many pediatricians and health care professionals, in general, deal with children involved with bullying and are simply not aware of the cues. Before they can begin to help, they have to identify the issue. There is no way that pediatricians can practice without incorporating bullying and its consequences into their thinking.”
According to Srabstein, pediatricians must take the time to explain to children what bullying is, and then ask the children if they are being bullied or if they are bullying others.
“If a child is being bullied, then the pediatrician needs to help the parents to communicate with the school so that the bullying stops, not just by punishing the perpetrators but by advising the perpetrators that what they are doing is hurting the victim,” Srabstein said. “I do not advise that pediatricians tell kids to fight back, to ignore it, or to become stronger. The bullying needs to be stopped, not by punishing the perpetrator, but by helping the perpetrator.”
Besides detecting bullying, Srabstein said pediatricians should become part of an overall community effort to prevent bullying, by raising awareness of the negative effects of bullying in town meetings. They should also advocate for the implementation of programs to prevent bullying in schools and other social settings. Pediatricians also must report bullying situations to the schools, so that the schools can implement appropriate intervention by counseling the perpetrators and protecting the victim.
Pediatricians should encourage parents to listen to, believe and support their child in the face of bullying, Eisenberg said.
“Health care providers may be able to frame the issue for parents as a health concern requiring their attention and commitment, rather than ‘just’ a social concern,” Eisenberg said. “Parents may think a social concern would be more likely to ‘work itself out’ than would a health concern.”
Sege suggests helping bullying victims find other social situations in which they can be successful. One of the ways that being a victim of bullying affects students is that they feel they are the problem, rather than the bully. If they are in an environment where they can be successful, such as boy/girl scouts, a church-based group or sports, it will help them understand that they are a normal child.
“Helping bullying victims has two parts,” Sege said. “First is to work with the school to prevent the bullying from happening in the first place. The second part is working with the parents and child to help them understand that the bully has the problem, not the victim.”
Bullying: an epidemic?
Bullying is not new. The numbers of bullying incidents have been consistent over time, and it has not yet become an epidemic.
“There hasn’t been a spike of bullying, there’s been a spike in media attention,” Wright said. “What has evolved are the mechanisms with which kids bully one another, specifically in the technology domain. What we are recognizing now are the health and mental health issues that result from bullying.”
The United States has only recently begun to realize the consequences of bullying, something that has been recognized in Europe for many years, Wright said. In Europe, more countries have adopted bullying prevention programs, which have been implemented in the United States with less success.
“One thing that is quite clear is that we are much more aware of bullying and responding to bullying than people were in the past,” Sege said. “Because of that, it may seem that there is a lot more bullying than there once was, but I’m not convinced that’s true.” – by Emily Shafer
Disclosures: Drs. Eisenberg, Sege, Srabstein and Wright report no relevant financial disclosures.
For more information:
- AAP. Pediatrics. 2009;124:393-402.
- Eisenberg ME. J Adolesc Health. 2005;36:88-91.
- Fekkes M. Pediatrics. 2006;117:1568-1574.
- Kowalski RM. J Adolesc Health. 2007;41:S22-S30.
- Nansel TR. JAMA. 2001;285:2094-2100.
- Sourander A. Arch Gen Psychiatry. 2009;66: 1005-1012.
- Wang J. J Adolesc Health. 2009;45:369-375.
How can a pediatrician help
prevent bullying?
The bully
One act of bullying does not condemn a child to a lifetime of violent offending. Try to discover the reason for the behavior – was this pseudo-bullying, true bullying or provocative victimization?
- Pseudo-bullying is when a child mimics aggressive behaviors witnessed in society. Pseudo-bullying lacks either the underlying imbalance of power or the intentionality that define bullying. The child may be bored, frustrated, have poor social skills or is testing limits.
- True bullying is abusing social, intellectual, political or physical power to intentionally hurt a specific person or group of people. The underlying causes may also be boredom or frustration, but in this case, there is an intention to hurt.
- Provocative victimization is when a victim counters bullying with aggression. Provocative victims are of special concern because they are at greater risk for mental health disorders, such as substance abuse or weapon carrying.
Step 1: Call the behavior bullying – don’t sugarcoat it. Giving the behavior a name makes it real.
Step 2: Listen carefully. Do not jump to conclusions or rush for a fix (you may do more harm than good). Deconstruct any victim blaming. Deconstruct depersonalization of the victim. Help the perpetrator to see the victim as a real person with basic human rights of safety and security. Deconstruct any perceived admiration from bystanders. Differentiate between feigned respect out of fear and true respect due to admiration.
Step 3: Empower the victim. Ask privately, what he/she feels are appropriate consequences. If both parties are willing, facilitate an apology, keeping the victim safe.
Step 4: Implement natural consequences — restitution, maintain a distance between the perpetrator and the victim, follow up with potential henchmen. Do not bully the perpetrator, as this only teaches the perpetrator and bystanders to strive toward becoming a bigger bully.
Step 5: Set clear and consistent expectations for future behavior.
Step 6: Continue monitoring the perpetrator, victim and henchmen.
Step 7: Provide alternative opportunities that put the perpetrator’s leadership skills to (carefully monitored) pro-social use.
A final caveat is to avoid the most common mistakes. Do not bully an already aggressive child. Do not allow yourself to be manipulated into acting as a henchman. Some bullies manipulate adults into punishing provocative victims, further perpetuating bullying. Do not believe that one conversation or one program is a magic pill and it will never happen again. Bullying is addressed by using the same techniques as good parenting, set clear and consistent expectations, allow natural consequences, model respectful, caring and inclusive behavior. Supervise children to protect them from making poor choices.
Sally Kuykendall, PhD, is an assistant professor of health services at Saint Joseph’s University in Philadelphia. Disclosure: Dr. Kuykendall reports no relevant financial disclosures.
The bullying victim
After health care professionals are clear that the child is being bullied, privately ask the parent or guardian what has been done regarding reporting the situation to school officials. Some helpful points for health care professionals to keep in mind include:
- Provide the parent with documentation stating how being bullied is affecting the child’s social-emotional or physical functioning. A parent can use this documentation to leverage school officials to provide a complete intervention.
- Provide the parent with the state’s anti-bullying law, which can be found at www.bullypolice.org.
- Encourage parents to find what their child’s student handbook states regarding the steps school officials will take to respond to reported bullying.
- Inform the parent that reporting the incident solely to the secretary, teacher or school counselor does not guarantee the disciplinarian will know what is occurring. Make all communication directly to the principal.
- Ask parents to inquire if the bully’s parents were notified. Often, school officials will talk to the bully but forgo notifying the parent.
- Remind the parent that their child (the target of the bullying) can avoid being re-victimized by the school’s intervention (eg, taken out from recess or having her/his locker moved to another hall). The bully(ies) need to be held accountable, not the victim(s). Pediatricians need to remind the victim that it’s not his/her fault.
- With written parent permission, the child’s health care provider can place a call to the school’s disciplinarian, asking that the concern be noted and placed in the child’s school file.
If all these attempts fail to bring results, parents can voice their concern to the school superintendent and further, at the monthly school board meeting.
James Brown, PhD, is an assistant professor of social work at the University of Wisconsin-Oshkosh. Disclosure: Dr. Brown reports no relevant financial disclosures.