Feature

How PCPs can recognize signs of bullying

Mary Muscari
Mary Muscari
Robert Raspa
Robert Raspa

This Friday marks 19 years that many Americans watched the aftermath of the Columbine High School tragedy unfold on live television. In the hours that followed, viewers learned two students killed 12 students and a teacher, and injured another 23.

Although the Columbine Review Commission found that bullying was not the cause of the shooting, according to the Denver Post, it identified bullying as “a potential underlying problem in all schools that needs to be addressed.”

The scene that played out that April day in Colorado has become all too-familiar in the 24-hour news cycle. Places like Sandy Hook, Connecticut; Virginia Tech and Red Lake Minnesota have become reminders of the tragedy bullying can sometimes bring.

There are things primary care physicians can do to prevent or stop bullying, several experts told Healio Family Medicine.

“PCPs and health care providers are sometimes the only champions bullying victims and bullies will have. The more that PCPs can help their patients and their parents with resources to help prevent or stop bullying, the better suited the PCP is to change the child’s life,” Ingrid Donato, of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration, or SAMHSA, said in an interview.

“Bullying is intentional, interpersonal aggression — it is a form of violence — and should be treated as such. Children should feel safe at school, and in the case of cyberbullying, in their own homes,” Mary Muscari, PhD, a forensic psychiatric nurse and criminologist and associate professor, Decker School of Nursing, State University of New York at Binghamton, added.

“Bullying has been around a long time, long before tragedies like Columbine,” American Academy of Family Physicians board member, Robert F. Raspa, MD, told Healio Family Medicine. “We as family physicians need to do something about it.”

As a courtesy to its readers, Healio Family Medicine asked Donato, Muscari and Raspa to discuss the risk factors of young patients being bullied or becoming a bully, the warning signs that bullying might take a violent turn, when other professional help must be sought, and more. – by Janel Miller

Question: How can you tell if a child is being bullied?

Donato: PCPs need to ask themselves: does the patient have frequent somatic complaints like abdominal pain or headaches, musculoskeletal pain, changes in appetite or sleeping patterns? Bullying victims might also have problems with bedwetting or dizziness or show signs of bruising. Some of the emotional signs are depression, anxiety, PTSD, loneliness, suicidal thoughts and substance abuse problems.

PCPs have to ask questions like ‘Are you getting in trouble at school? Have you been suspended?’ As for kids who are witnesses to bullying in school, seeing their peers being victimized, they can also present with medical issues like somatic problems because this a toxic environment to them as well. They are witnessing it, likely fearful they will be next, and they will have some struggles, and the PCP is in a tremendously amazing role to intervene. Ask questions like ‘What are you seeing at school? What are you seeing online?’

Raspa: Other factors include being LGBTQ, having asthma, diabetes or a skin condition, having a food allergy that forces you to eat only certain foods, or being an outlier on the weight or height spectrum. But it is important to note that even children without risk factors can be bullied, and that many victims are often embarrassed, so they won’t say anything. As a family doctor, you can ask at annual wellness visits or sports physicals things like ‘How are things going at school’ or ‘How are things going at home?’ You can also ask about grades, if there is anything that they don’t like about school.

Q: What can PCPs tell their patients’ parents about how their child should respond to both bullying and cyberbullying?

Raspa: Tell parents to tell their child: ignore online and social media bullying; maintain a record and evidence of every threat or incident of bullying by taking a screen shot of whatever appears on the computer or phone; block the bully on their phone and social media; and report the behavior to school officials. If your child tells you they saw bullying, tell them next time to tell an adult immediately. Research shows that getting an adult involved quickly can eventually stop the bullying.

Encourage the parent to encourage their child to be more than a bystander if he or she witnesses bullying, report the behavior to a trusted adult, and help the victim get away from the bully and not to be part of the crowd standing and watching. If your child knows someone who is being cyberbullied, tell them not to forward gossip, mean comments, or inappropriate photos of others through email, text, or social media. Tell them to tell a trusted adult about what they received. Children should never be told to ignore bullying or being blamed for it. While many parents believe it’s helpful to contact the parents of the bully, it’s best not to as it usually can make the problem worse.

Q: What other professionals can be called into assist in handling patients who are bullied or are a bully, and when?

Muscari : PCPs should contact mental health specialists whenever they feel a behavioral issue is beyond their management abilities, such as anxiety or depression that has risen beyond moderate levels, suicidality, and signs of comorbid psychiatric disorders (eating disorders, personality disorders, conduct disorders, etc.). Law enforcement is not as straightforward, as there are jurisdictional differences. PCPs can check state and local statutes or check with the AAP or AAFP.

Raspa: When other nonviolent activities to build up self-esteem like sports, arts and crafts and counseling don’t work, you should consider bringing in a trained behavioral or mental health professional to help your young patient.

Donato: PCPs need to know it is OK to refer their young patients to behavioral or mental health professional. When the child is in their office, and he or she says, or shows signs of being depressed and anxious and you’ve ascertained bullying to be the cause, the PCP should be thinking about referring out.

Muscari : Consequences of bullying and cyberbullying can be long acting into adulthood if left unresolved, thus the importance of early recognition and intervention. Dependent upon other factors (personal, family, social), victims can suffer low self-esteem, depression, anxiety, phobias, PTSD, suicide and homicide. Bullies can develop conduct disorder, delinquency, school dropout, inability to hold jobs, relationship failures, and antisocial and criminal behaviors in adulthood.

Q: How can PCPs advise parents to raise a child to not become a bully?

Muscari : Though there is no one right way to raise children, even those within the same family, some general guidelines include knowing what’s normal and what’s not throughout the developmental stages; give them plenty of love, time and attention; build health self-esteem; talk with them, not at them; know what your child is doing in the real world and cyberspace. Parents also need to set clear rules and limits; teach responsibility; promote problem solving and healthy decision-making; help them minimize and manage stress; teach self-control and conflict/anger management; foster tolerance; enforce family values; minimize the effects of negative peer pressure; monitor media usage; encourage them to stay away from drugs (all types, including alcohol); practice firearm safety; be an effective role model; get involved with their children’s school; watch for warning signs; decrease bullying behaviors; and get help when needed.

Q: Acknowledging that most bullies will not be forthcoming and admit they are one, how can you tell if a patient is a bully?

Raspa: Even though we have a good idea of the profile of a bully, it is very hard to catch someone in the act. A lot of parents will also bring their child in, saying they think he or she has ADHD. Ask questions and if you hear things that suggest anti-social, hitting and abusing behavior, seriously consider that the child is a bully.

Muscari : Bullies often have one or more of the following traits: they experience social competence and academic challenges; view violence as positive; think poorly or negatively of others; display difficulty in following rules; show difficulty problem solving with others; be aggressive or easily frustrated; prefer friends who bully; and perceive school as negative. Bullies don’t want to get caught, and they receive satisfaction from their behaviors, so they may keep their behavior hidden from their parents.

Q: Even if a child does not show signs of being bullied or being a bully, how can the topic of bullying be addressed with parents and the patients of parents?

Muscari : Bullying is as much a part of anticipatory guidance as are toilet training and puberty. Approach it the same way you would any topic — with confidence and compassion. The trick is to be comfortable talking about it, and that comes with knowledge and knowing one’s own issues.

Donato: At SAMHSA we are working on a project called the ‘Bullying Prevention Campaign for Physicians.’ This will provide tips on when PCPs should have the conversation, how do you talk to the parent, and how to get the school involved. AAP and other physician groups are vetting it so it isn’t available yet, but in the meantime, bring up bullying during wellness visits. One in five kids is bullied, one in four young girls is bullied, making this a public health problem.

Q: Some parents may be in denial that their child is being bullied or is a bully. What would you say to such parents?

Muscari : As long as the child is not in imminent danger, work to gain the parent’s trust. Apples don’t fall far from trees, and bully children may very well have bully parents who don’t see a problem with their child’s behavior. Work with the consequences, and then work toward the underlying behaviors. PCPs should also know that some parents may truly be unaware that their children are bullies or victims.

Donato: That has been a very tough nut to crack, that is, how to engage the parent who is suspected of being the bully, especially if the child is witness to bullying at home. Work with the parent to help them understand the impact of their behavior would be, that they run the risk of their child being in trouble with the law is incredibly important and it’s important to keep on top of these parents. The more a child who is bullying is given a path to witness or perform bullying without being reprimanded, the more the child will think it is OK. The PCP needs to take the stance that what is going on isn’t right and opens the door to change the behavior for the better.

For more information:

Evans CBR, et al. Aggress Violent Behav. 2014;doi:10.1016/j.avb.2014.07.004. (This is a systematic review of school-based bullying prevention programs.) Accessed April 6, 2018.

www.familydoctor.org/helping-kids-deal-bullies. Accessed April 6, 2018.

www.stopbullying.gov Accessed April 6, 2018.

References:

BBC.co.uk. “Sandy Hook shootings: Four things revealed by the FBI files.” http://www.bbc.com/news/world-us-canada-41749336. Accessed April 6, 2018.

CNN.com. “Debunking the myths of Columbine, 10 years later.”

http://www.cnn.com/2009/CRIME/04/20/columbine.myths/. Accessed April 6, 2018.

Denverpost.com. http://extras.denverpost.com/news/col1202.htm. “Tales of bullying outlined.” Accessed April 6, 2018.

NBCnews.com. “High school classmates say gunman was bullied.”

http://www.nbcnews.com/id/18169776/ns/us_news-crime_and_courts/t/high-school-classmates-say-gunman-was-bullied/#.WsfSMYjwaUl. Accessed April 6, 2018.

NYTimes.com. “Signs of danger were missed in a troubled teenager’s life.” https://www.nytimes.com/2005/03/24/us/signs-of-danger-were-missed-in-a-troubled-teenagers-life.html. Accessed April 6, 2018.

Disclosure: Neither Mascari nor Raspa report any relevant financial disclosures. Healio Family Medicine was unable to determine Donato’s relevant financial disclosures prior to publication.

Mary Muscari
Mary Muscari
Robert Raspa
Robert Raspa

This Friday marks 19 years that many Americans watched the aftermath of the Columbine High School tragedy unfold on live television. In the hours that followed, viewers learned two students killed 12 students and a teacher, and injured another 23.

Although the Columbine Review Commission found that bullying was not the cause of the shooting, according to the Denver Post, it identified bullying as “a potential underlying problem in all schools that needs to be addressed.”

The scene that played out that April day in Colorado has become all too-familiar in the 24-hour news cycle. Places like Sandy Hook, Connecticut; Virginia Tech and Red Lake Minnesota have become reminders of the tragedy bullying can sometimes bring.

There are things primary care physicians can do to prevent or stop bullying, several experts told Healio Family Medicine.

“PCPs and health care providers are sometimes the only champions bullying victims and bullies will have. The more that PCPs can help their patients and their parents with resources to help prevent or stop bullying, the better suited the PCP is to change the child’s life,” Ingrid Donato, of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration, or SAMHSA, said in an interview.

“Bullying is intentional, interpersonal aggression — it is a form of violence — and should be treated as such. Children should feel safe at school, and in the case of cyberbullying, in their own homes,” Mary Muscari, PhD, a forensic psychiatric nurse and criminologist and associate professor, Decker School of Nursing, State University of New York at Binghamton, added.

“Bullying has been around a long time, long before tragedies like Columbine,” American Academy of Family Physicians board member, Robert F. Raspa, MD, told Healio Family Medicine. “We as family physicians need to do something about it.”

As a courtesy to its readers, Healio Family Medicine asked Donato, Muscari and Raspa to discuss the risk factors of young patients being bullied or becoming a bully, the warning signs that bullying might take a violent turn, when other professional help must be sought, and more. – by Janel Miller

Question: How can you tell if a child is being bullied?

Donato: PCPs need to ask themselves: does the patient have frequent somatic complaints like abdominal pain or headaches, musculoskeletal pain, changes in appetite or sleeping patterns? Bullying victims might also have problems with bedwetting or dizziness or show signs of bruising. Some of the emotional signs are depression, anxiety, PTSD, loneliness, suicidal thoughts and substance abuse problems.

PAGE BREAK

PCPs have to ask questions like ‘Are you getting in trouble at school? Have you been suspended?’ As for kids who are witnesses to bullying in school, seeing their peers being victimized, they can also present with medical issues like somatic problems because this a toxic environment to them as well. They are witnessing it, likely fearful they will be next, and they will have some struggles, and the PCP is in a tremendously amazing role to intervene. Ask questions like ‘What are you seeing at school? What are you seeing online?’

Raspa: Other factors include being LGBTQ, having asthma, diabetes or a skin condition, having a food allergy that forces you to eat only certain foods, or being an outlier on the weight or height spectrum. But it is important to note that even children without risk factors can be bullied, and that many victims are often embarrassed, so they won’t say anything. As a family doctor, you can ask at annual wellness visits or sports physicals things like ‘How are things going at school’ or ‘How are things going at home?’ You can also ask about grades, if there is anything that they don’t like about school.

Q: What can PCPs tell their patients’ parents about how their child should respond to both bullying and cyberbullying?

Raspa: Tell parents to tell their child: ignore online and social media bullying; maintain a record and evidence of every threat or incident of bullying by taking a screen shot of whatever appears on the computer or phone; block the bully on their phone and social media; and report the behavior to school officials. If your child tells you they saw bullying, tell them next time to tell an adult immediately. Research shows that getting an adult involved quickly can eventually stop the bullying.

Encourage the parent to encourage their child to be more than a bystander if he or she witnesses bullying, report the behavior to a trusted adult, and help the victim get away from the bully and not to be part of the crowd standing and watching. If your child knows someone who is being cyberbullied, tell them not to forward gossip, mean comments, or inappropriate photos of others through email, text, or social media. Tell them to tell a trusted adult about what they received. Children should never be told to ignore bullying or being blamed for it. While many parents believe it’s helpful to contact the parents of the bully, it’s best not to as it usually can make the problem worse.

PAGE BREAK

Q: What other professionals can be called into assist in handling patients who are bullied or are a bully, and when?

Muscari : PCPs should contact mental health specialists whenever they feel a behavioral issue is beyond their management abilities, such as anxiety or depression that has risen beyond moderate levels, suicidality, and signs of comorbid psychiatric disorders (eating disorders, personality disorders, conduct disorders, etc.). Law enforcement is not as straightforward, as there are jurisdictional differences. PCPs can check state and local statutes or check with the AAP or AAFP.

Raspa: When other nonviolent activities to build up self-esteem like sports, arts and crafts and counseling don’t work, you should consider bringing in a trained behavioral or mental health professional to help your young patient.

Donato: PCPs need to know it is OK to refer their young patients to behavioral or mental health professional. When the child is in their office, and he or she says, or shows signs of being depressed and anxious and you’ve ascertained bullying to be the cause, the PCP should be thinking about referring out.

Muscari : Consequences of bullying and cyberbullying can be long acting into adulthood if left unresolved, thus the importance of early recognition and intervention. Dependent upon other factors (personal, family, social), victims can suffer low self-esteem, depression, anxiety, phobias, PTSD, suicide and homicide. Bullies can develop conduct disorder, delinquency, school dropout, inability to hold jobs, relationship failures, and antisocial and criminal behaviors in adulthood.

Q: How can PCPs advise parents to raise a child to not become a bully?

Muscari : Though there is no one right way to raise children, even those within the same family, some general guidelines include knowing what’s normal and what’s not throughout the developmental stages; give them plenty of love, time and attention; build health self-esteem; talk with them, not at them; know what your child is doing in the real world and cyberspace. Parents also need to set clear rules and limits; teach responsibility; promote problem solving and healthy decision-making; help them minimize and manage stress; teach self-control and conflict/anger management; foster tolerance; enforce family values; minimize the effects of negative peer pressure; monitor media usage; encourage them to stay away from drugs (all types, including alcohol); practice firearm safety; be an effective role model; get involved with their children’s school; watch for warning signs; decrease bullying behaviors; and get help when needed.

PAGE BREAK

Q: Acknowledging that most bullies will not be forthcoming and admit they are one, how can you tell if a patient is a bully?

Raspa: Even though we have a good idea of the profile of a bully, it is very hard to catch someone in the act. A lot of parents will also bring their child in, saying they think he or she has ADHD. Ask questions and if you hear things that suggest anti-social, hitting and abusing behavior, seriously consider that the child is a bully.

Muscari : Bullies often have one or more of the following traits: they experience social competence and academic challenges; view violence as positive; think poorly or negatively of others; display difficulty in following rules; show difficulty problem solving with others; be aggressive or easily frustrated; prefer friends who bully; and perceive school as negative. Bullies don’t want to get caught, and they receive satisfaction from their behaviors, so they may keep their behavior hidden from their parents.

Q: Even if a child does not show signs of being bullied or being a bully, how can the topic of bullying be addressed with parents and the patients of parents?

Muscari : Bullying is as much a part of anticipatory guidance as are toilet training and puberty. Approach it the same way you would any topic — with confidence and compassion. The trick is to be comfortable talking about it, and that comes with knowledge and knowing one’s own issues.

Donato: At SAMHSA we are working on a project called the ‘Bullying Prevention Campaign for Physicians.’ This will provide tips on when PCPs should have the conversation, how do you talk to the parent, and how to get the school involved. AAP and other physician groups are vetting it so it isn’t available yet, but in the meantime, bring up bullying during wellness visits. One in five kids is bullied, one in four young girls is bullied, making this a public health problem.

Q: Some parents may be in denial that their child is being bullied or is a bully. What would you say to such parents?

Muscari : As long as the child is not in imminent danger, work to gain the parent’s trust. Apples don’t fall far from trees, and bully children may very well have bully parents who don’t see a problem with their child’s behavior. Work with the consequences, and then work toward the underlying behaviors. PCPs should also know that some parents may truly be unaware that their children are bullies or victims.

PAGE BREAK

Donato: That has been a very tough nut to crack, that is, how to engage the parent who is suspected of being the bully, especially if the child is witness to bullying at home. Work with the parent to help them understand the impact of their behavior would be, that they run the risk of their child being in trouble with the law is incredibly important and it’s important to keep on top of these parents. The more a child who is bullying is given a path to witness or perform bullying without being reprimanded, the more the child will think it is OK. The PCP needs to take the stance that what is going on isn’t right and opens the door to change the behavior for the better.

For more information:

Evans CBR, et al. Aggress Violent Behav. 2014;doi:10.1016/j.avb.2014.07.004. (This is a systematic review of school-based bullying prevention programs.) Accessed April 6, 2018.

www.familydoctor.org/helping-kids-deal-bullies. Accessed April 6, 2018.

www.stopbullying.gov Accessed April 6, 2018.

References:

BBC.co.uk. “Sandy Hook shootings: Four things revealed by the FBI files.” http://www.bbc.com/news/world-us-canada-41749336. Accessed April 6, 2018.

CNN.com. “Debunking the myths of Columbine, 10 years later.”

http://www.cnn.com/2009/CRIME/04/20/columbine.myths/. Accessed April 6, 2018.

Denverpost.com. http://extras.denverpost.com/news/col1202.htm. “Tales of bullying outlined.” Accessed April 6, 2018.

NBCnews.com. “High school classmates say gunman was bullied.”

http://www.nbcnews.com/id/18169776/ns/us_news-crime_and_courts/t/high-school-classmates-say-gunman-was-bullied/#.WsfSMYjwaUl. Accessed April 6, 2018.

NYTimes.com. “Signs of danger were missed in a troubled teenager’s life.” https://www.nytimes.com/2005/03/24/us/signs-of-danger-were-missed-in-a-troubled-teenagers-life.html. Accessed April 6, 2018.

Disclosure: Neither Mascari nor Raspa report any relevant financial disclosures. Healio Family Medicine was unable to determine Donato’s relevant financial disclosures prior to publication.