Recently, as I was reading the book Cyber Bullying: Bullying in the Digital Age (Kowalski, Limber, & Agatston, 2008), my 11-year-old son asked, “Mom, why do nurses care about cyberbullying?” In answer to his question, I responded, “Cyberbullying is a type of bullying or repeated hurtful behavior that can cause serious problems with children or adults, and as a nurse I have a responsibility to help patients with not only physical issues they face but also mental health issues that affect them.”
Cyberbullying has been in the media for several years; most recently, the cases involving suicide have received considerable attention. In February 2010, a 15-year-old girl, Phoebe Prince, took her life after continued harassment by a cyberbully through text messaging and a social media site (Davis, 2011). If a psychiatric-mental health (PMH) nurse had been involved with this student, either at school or in a clinical setting, could there have been a different outcome? Early recognition of cyberbullying is an important step for nurses in preventing this life-threatening situation. The purpose of this article is to discuss the population at risk for cyberbullying, as well as specific strategies PMH nurses can use to prevent and detect this growing problem. All nurses need education in regard to the mental and physical health outcomes of cyberbullying as well as how to help someone who is experiencing this public health problem.
Cyberbullying is defined by experts as “electronic bullying through cellphone texting, email, instant messages, chat rooms or website postings of harmful words or photographs of an individual” (Kowalski et al., 2008, p. 1). Cyberbullying most commonly occurs outside of the school setting, whereas traditional bullying is more common within the school environment. In a study by Juvonen and Gross (2008), 73% of students were confident they knew the identity of their perpetrator; however, Li (2006) indicated that the cyberbully may remain anonymous and often is difficult to locate or prosecute. Adolescents tend to say things online that they would not say face to face due to the feeling of hidden identity behind the Internet (Aricak et al., 2008). Furthermore, a cyberbully can send messages at any time, day or night, in essence, following the victim home (Juvonen & Gross, 2008). Many times these two experiences (traditional bullying and cyberbullying) overlap, putting the victim under constant distress (Beran & Li, 2007; Williams & Guerra, 2008). Cyberbullying has caused many harmful consequences to victims, the worst of which is suicide and homicide (Hinduja & Patchin, 2010). Traditional bullying defined by Olweus (2001) is similar to cyberbullying in that one or more students take negative actions that involve repetition and a power imbalance toward a victim.
During the past 20 years, bullying has become an international concern, with studies conducted in the United States, Canada, Australia, New Zealand, Germany, Finland, Switzerland, and Turkey (Aricak et al., 2008; Katzer, Fetchenhauer, & Belschak, 2009). Researchers have studied methods of interventions with traditional bullying, the most frequently used being the Olweus™ Bullying Prevention Program, also known as the whole-school approach (Olweus, 2001). Cyberbullying, however, presents new problems due to nature of this behavior taking place on the Internet or phone and in the context of a social situation (Vandebosch & Van Cleemput, 2008). Katzer et al. (2009) studied more than 1,700 students in Germany in grades 5 through 11 and found that victims of cyberbullying are frequently unpopular with peers and have a lower self-concept than nonvictims. As adolescents use technology in positive and negative ways, PMH nurses must be aware of the dangerous interactions that can occur online and possibly lead to future consequences (Valkenburg & Peter, 2011). Issues such as low self-esteem, depression, social anxiety, psychosomatic complaints, and other long-term medical and mental health issues may arise (Patchin & Hinduja, 2010; Sourander et al., 2010).
Population at Risk
Adolescents are at an age where impulsivity and risk-taking behaviors are at an all-time high (Ybarra et al., 2008). They are struggling with developmental issues and also trying to navigate a social system that is primarily online or in the digital world. Lenhart (2010) found that adolescents consider texting a favorite way to communicate. In fact, it provides them with the majority of their social interaction. As of May 2010, approximately 75% of children ages 12 to 17 in the United States own a cell phone (Lenhart, 2010). Lenhart (2010) found that 93% of teens also use the Internet as a way of interacting with friends. In addition, social media websites continue to increase in popularity, with 55% of teens having a profile on sites such as Facebook or MySpace. The Cyberbullying Research Center (2010) shows that from June 2004 to February 2010, the numbers of cyberbullying victimizations have varied between 18.8% and 40.6%. In regard to gender, adolescent girls are more likely to have experienced cyberbullying as a victim (25% versus 16%); they are more likely to tell an adult (21% versus 18%); and their type of bullying is different from boys. Girls tend to spread rumors in cyberspace, and boys tend to post photos (Li, 2007). Cyberbullying can start as early as age 10, may continue into the young adult years, and rarely happens in the school setting, as strict rules usually apply to this environment (Tokunaga, 2010). As soon as an adolescent leaves the school grounds, the cell phone is turned on. Once the child is home, he or she is logging onto Facebook, MySpace, chat rooms, and instant messaging services. Some adolescents are blogging routinely and may have even set up websites to denigrate an individual; whether it be about a fellow student or a teacher, the harmful effects are the same (Kowalski et al., 2008).
Mental Health Issues
Researchers have investigated bullying and its effect on mental health over the years (Kaltiala-Heino, Rimpelä, Rantanen, & Rimpelä, 2000), and today, in light of recent media coverage of suicides in the United States, we are beginning to see more studies investigating the mental health issues related to cyberbullying (Hinduja & Patchin, 2010). As Walsh (2004) discussed, an adolescent’s brain is not fully developed in the prefrontal cortex, the area that controls the assessment of risk behaviors and consequences related to these risks. This may lead to sharing personal information with others on the Internet that may put the adolescent at risk for ridicule or danger of revelation to unknown individuals who do not have the adolescent’s best interest at heart. While some adolescents are more emotionally developed than others, anyone who is unable to escape the torment of a cyberbully is likely to have mental health issues (Baird, 2010). Donahue (n.d.) discussed that when an adolescent experiences depression, it is often trivialized or not taken seriously, which may cause the teen to slip further into isolation and despair. This clinical psychologist further states that adolescents may post information that discusses their dark and depressed feelings, and parents may never actually read what is posted. During periods of high emotions, adolescents do not always think clearly or rationally, which may limit their judgment or decision-making ability. According to Nishina, Juvonen, and Witkow (2005), two tested models have shown that self-reported symptoms of depression, social anxiety, low self-esteem, and loneliness relate to peer harassment.
Students usually do not seek support from parents or other adults because they believe that adults do not know enough about technology and cyberbullying to help them resolve their issues (Slonje & Smith, 2007). Adolescents are often concerned that if they inform their parents or teachers of the problem, they may lose privileges such as use of the Internet, cell phone, or video games (Li, 2007).
Girls report significantly more social anxiety (Li, 2006), and many times cyberbullying victims exhibit decreased energy and lack of interest in previously enjoyed activities (Ybarra, 2004). Substance abuse is also an area of concern: Goebert, Else, Matsu, Chung-Do, and Chang (2010) found that alcohol and marijuana use is 2.5 times more common in those who are victimized compared with those who are not. Cyberbullies may turn to drinking or smoking, which may extend into adulthood; there is also the possibility that cyberbullies may participate in future criminal activity (Ybarra & Mitchell, 2004). PMH nurses are in a unique position to recognize depression, anxiety, or substance abuse in adolescents and help them by reaching out to address their concerns (Larson, 2011).
Physical Health Issues
Several researchers have found that bullying, as well as cyberbullying, links to physical health and psychosomatic symptoms (Kaltiala-Heino et al., 2000; Katzer et al., 2009; Sourander et al., 2010; Ybarra, 2004). A school nurse’s office or a local clinic are some of the first places these physical or psychosomatic complaints are revealed. According to Judy Vessey, PhD, RN, a national expert on bullying, a nurse’s office is often a designated safe place for students to go when they are feeling sick or uneasy on any given day (Larson, 2011). Chronic fear and anxiety causes a “biological burden” as the body tries to adjust to repeated stressors (Djuric et al., 2008, p. 7), which can have profound and long-lasting consequences on behavioral and psychological function (Turner & Lloyd, 2004). Changes in structure and function can occur in certain areas of the brain, such as the hippocampus, medial prefrontal cortex, and amygdala. These changes could ultimately lead to permanent damage or “neuronal loss” (McEwen, 2000, p. 729). Stress can also increase susceptibility to infection, such as the common cold (Cohen & Williamson, 1991); therefore, the higher number of stressful events an individual experiences or stressors lasting longer than 1 month can lead to greater opportunity for infections (Stone et al., 1992).
In a recent study examining peer aggression and victimization, Vernberg, Nelson, Fonagy, and Twemlow (2011) reported that students are more likely to visit the school nurse with somatic complaints rather than psychiatric symptoms when involved in aggressor-victim interactions. PMH nurses have the training in physical assessment, as well as psychosocial and mental health assessment, to identify when an adolescent is involved in aggressor-victim interactions. Informing parents and teachers to intervene in chronic stress situations is important. Continuous severe stress in adolescence may lead to health-related issues in adulthood, such as heart disease, diabetes, mental impairment or depression, autoimmune diseases, or inflammatory conditions (Dempsey & Storch, 2010).
Legally, many questions are left unanswered in regard to cyberbullying. One of the main legal concerns is the First Amendment’s protection of free speech. This law prohibits schools from using discipline such as suspension or expulsion if the student is speaking online, not on school property, and the abuse does not cause disruption of school-based learning activities (Mason, 2008; Shariff, 2005). The goal for teachers, parents, school nurses, and administrators is to keep students safe at all times, but there are concerns that intervention against a cyberbully may infringe on the First Amendment, therefore causing a lawsuit against the school (Holladay, 2010). In 1969, Tinker v. Des Moines Independent Community School District established that schools could not stop student expression unless it hindered the classroom environment or interfered with student rights; therefore, in regard to cyberbullying, a school can take action when a student’s speech online “causes… substantial and material disruption at school or interference with rights of students to be secure” (Willard, 2007, pp. 1–2).
Legislators, judges, and attorneys have also recognized cyberbullying. One such case was that of Ryan Halligan, a 13-year-old who took his own life due to unending cyberbullying. After Ryan’s death, his father lobbied the Vermont state legislature, helping to pass the first law in the United States against cyberbullying, the 2004 Vermont Act 117, also known as Vermont’s Bully Prevention Law. Since then, 44 states have created cyberbully laws (Cyberbullying Research Center, 2010). Federally, a bill, entitled the Megan Meier Cyberbullying Prevention Act, was presented to the House of Representatives in April 2009 but has not gone further at this date. Juvonen and Gross (2008) expressed that cyberbullying should be the responsibility of schools by making intimidation of any kind intolerable. National involvement occurring as recently as March 2011 continues, with a White House conference addressing the issue of cyberbullying. The goals were to discuss of the negative effects and best practices of ways to prevent and respond to this issue (Justin, 2011).
How Can PMH Nurses Help?
Any nurse has an ethical obligation to help someone who is reaching out for assistance. However, PMH nurses—because of their scope and standards of practice—have the unique ability to address the biopsychosocial needs of individuals who are or have been cyberbullied. What are some principles nurses need to guide their actions and involvement with prevention and response to cyberbullying?
First, early detection is central to prevention of long-term effects of cyberbullying. A major obstacle to early detection is that adults are sometimes the last ones to become aware of a cyberbullying situation (Bauman, 2009). According to Agatston, Kowalski, and Limber (2007), students are unlikely to report cyberbullying to adults at school but are more likely to report this threatening behavior to parents. The best thing any adult can do is to listen to the adolescent, as well as his or her friends and family. The information obtained in active listening then becomes the basis for the assessment and intervention activities.
Second, PMH nurses need to determine whether certain individuals are repeatedly seeking help for routine somatic complaints such as headaches, stomachaches, or related symptoms. These adolescents might be at risk (Vernberg et al., 2011) and need assessment.
Third, PMH nurses must know the school policies regarding bullying and cyberbullying. This is essential knowledge for all nurses and volunteers (e.g., parents, grandparents, clergy) in the setting. It is important that PMH nurses communicate these policies to the volunteers. If a PMH nurse is working in a school, does the school have a bullying program that addresses the whole school (Kowalski et al., 2008)? When working with students, it is important that both the cyberbully and the victim know there are legal consequences, as most states have enacted laws regarding cyberbullying (Willard, 2007).
Fourth, PMH nurses need to facilitate the interdisciplinary team. Each member of the team is key in the response to cyberbullying. The nurse’s leadership role in fostering a team approach is critical. Again, the active listening skills of nurses as well as their clinical knowledge can be invaluable to the team’s understanding and response to a cyberbullying situation. In addition, PMH nurses can be instrumental in recognizing and assessing signs and symptoms related to mental distress and illness.
Fifth, PMH nurses can develop educational programs for staff, students, and parents. Kowalski et al. (2008) suggested training staff in a school setting on how to handle a bullying episode, how to report it, and how to access resources. Teaching students about cyberbullying during class time shows that the school is behind efforts to prevent the behavior. Parents may or may not understand the problem of cyberbullying and the nature of this serious issue, and PMH nurses are in a prime position to provide this education. Kowalski et al.’s (2008) book is an excellent resource for educational materials on cyberbullying. The authors share different templates available for schools to use, including sample letters for parents, sample policies, sample accountability scripts for speaking to students, and many other ideas to help tackle the problem. The materials can be adapted to any school setting.
Finally, PMH nurses need to identify resources for both immediate and long-term treatment of the effects of cyberbullying. This process requires the implementation of community assessment skills. Identification and evaluation of resources is a community health skill that all nurses use, most frequently in collaboration with the interdisciplinary team.
As technology use increases, our society must confront situations new to the 21st century. Cyberbullying is one situation that will not go away any time soon. Policies and laws provide society safeguards, but the technology is a readily accessible vehicle for negative human behavior. PMH nurses must balance the response to the negative outcomes of technology use with the merits of technology, while ensuring the safety of all individuals, including the most vulnerable populations. PMH nurses have an obligation to educate themselves, students, parents, teachers, school administrators, and the community in ways to handle this emerging issue.
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