Bullying affects most children in some way, as victims, bystanders, or bullies, during childhood. Children exposed to bullying may present with physical as well as psychological symptoms, and experience negative effects lasting into adulthood. This article provides information regarding bullying screening and interventions with pediatric and adolescent patients. Taking into account a child’s developmental stage, age-appropriate tactics are provided to address bullying, victimization, bystanding, and system “rules” that tolerate or foster bullying.
Bullying is defined as aggressive behavior perpetrated by those who hold and/or try to maintain a dominant position over others with the premeditated intention of causing mental and/or physical harm or suffering to another.1 Bullying is distinguished from “conflicts” or “teasing” where students of similar status (physical size, social status, etc) may have disputes and arguments but one party does not have a decidedly unfair advantage over the other. Moreover, unlike typical “conflicts” or “teasing,” bullying tends to focus on repeated actions by a student or students against the victim(s).2 Bullying can be physical, verbal, and/or social, and can occur not only in person but also in the cyber world. It can cause significant distress for a child and family, often leading to short- and long-term psychological sequelae. In fact, school bullying is so far-reaching that most states now have policy and legislation to address it.
Bullying Across the Ages
Table 1 dispels the long-held notion that bullying occurs among young children and diminishes as children age. Rather, children continue to describe feeling bullied in greater numbers as they reach middle and high school. As Table 2 shows, what does change is how children report being bullied. Physical aggression tends to be replaced by more insidious verbal aggression as taunts, name-calling, and laughing at students. In addition, as children become more proficient with computers and media, they use that tool as a way to establish dominance over others and/or to align other students against particular students.
Table 1. Percent of Children Reporting Being a Bullying Target by Grade
Table 2. Most Common Types of Bullying According to Grade Level
Consequences of Bullying
Bullying can result in significant mental health and functional impairment in affected students.4 Victims are commonly found to develop depression, anxiety, suicidality, eating disorders, and somatic symptoms, including headaches, stomachaches, colds, and sleep difficulties.5 Similar to their targets, bullies have more suicidal thoughts and attempts.6
The delineation between bullying involvement is not always clear because children involved in bullying often play different roles in different settings. Those who are involved in bullying, both as bullies and as victims of bullying, commonly called “bully-victims,”7 appear to have the most serious psychological problems.8,9 Bully-victims may struggle with a worldview where people are either in control of others or controlled by others, impeding comfortable, safe, and trusting relationship formation. They report having fewer friends and are more stigmatized by peers.10 Furthermore, when compared with students who were neither bullies nor bullying victims, both middle and high school bully-victims have been found to be three to four times as likely to report seriously considering suicide and intentionally injuring themselves.11
Children indirectly involved in bullying as bystanders are also affected negatively. Bystanding involves actively ignoring distressing incidents (a passive form of accepting a bully’s behavior), “encouraging on” of perpetrators (eg, laughing at the victim, joining in), and/or failing to intervene on behalf of victims.12 Bystanders may develop a sense of hopelessness as they struggle with how to respond around those who are defenseless.13 Not surprisingly, child bystanders have shown increased heart rate and higher reports of negative emotions amid bullying events.14
Bullying can signal other problems in a child’s life. Students witnessing family violence are three to seven times more likely to be involved in school bullying.11 Children experiencing sexual and/or physical abuse are also more likely to bully and be bullied compared with nonabused children.15 Being a bully-victim is a significant risk factor for earlier use of cigarettes and alcohol.16,17 Children may demonstrate school anxiety, depression, aggression, and defiant behavior as a way of coping with bullying. Youth who experience bullying are at higher risk for sleep issues and headaches.18 Health care providers should be attuned to the reciprocal relationship between bullying and somatic, psychological, and substance abuse concerns, and inquire about each if one emerges.
Bullying effects also can persist into adulthood.19,20 Individuals chronically bullied in youth experience lower self-esteem and greater depression into adulthood.21,22 Adults involved in bullying have a higher likelihood of fist-fights and domestic abuse against a partner.23
Screening for Children at Risk for Bullying
Students who are victimized often report vague somatic symptoms, refuse to go to school, and experience difficulty in academic achievement before they report bullying. When they do describe their experiences, younger students of victimization are more inclined to turn to others than are older victims. Girls are more willing to seek help than boys.24–27 Victims of verbal bullying (such as name-calling) are least likely to disclose bullying, followed by indirect bullying victims (such as being excluded, having rumors spread about them), whereas victims of direct bullying (such as physical violence, having property stolen or damaged) are most likely to seek help.28,29 Victims turn to different people, including their friends, teachers, and parents, depending on their age, gender, and social situation.28–30
As pediatricians are the primary health care providers for children, they will see the majority of the bully-victim population for related or unrelated medical and/or psychological problems. Pediatricians need quick screening tools to investigate potential bullying in their patient panels, and psychiatrists can help train them on utilizing these questions and suggest when it is appropriate for a referral to a specialist, such as during grand rounds or coordination of care. These tools may also help psychiatrists during evaluations to rule out bullying as an etiology of a child’s psychiatric presentation. Table 3 contains questions to ask children and parents that can quickly discern bullying problems. It is important to evaluate all roles of bullying and its severity. Simply asking screening questions may inherently solve the problem as it allows children an opportunity to share concerns and develop a plan with their guardians and doctors.
Table 3. Screening Questions for Experiences with Bullying
Rarely do individuals play only “one” role. In one situation, a student may feel “targeted,” whereas the same student in another setting may feel powerful or instead a bystander. Students may feel “cornered” into their roles of bully, bystander, or victim as a result of their experiences of the “rules” of the system. For instance, bullying may be modeled by adults in the way that they interact with each other and with students, leaving students feeling that they have to act in a certain way to get their needs met. Differences in behavioral expectations in different venues further complicates the picture as students learn to navigate social interactions. For example, what is modeled as acceptable behavior at a professional sporting event is likely different than what students are expected to do at recess or in class.
Techniques to help students get out of these bullying roles vary by the developmental status of the students, as well as the developmental status of the system itself. Victims and bullies usually require multiple interventions involving multiple adults (school staff, parents, clinicians) that focus on coping skills (including problem solving, emotion regulation, anger management), social skills training, attention to treating psychiatric disorders and trauma-related symptoms, and/or academic support. Specific tactics for students and parents to use to alter bullying, victimization, and bystanding are described in Table 4, with an understanding that what will work with elementary students up to fifth and sixth grades (telling adults) is not always viable for secondary students in seventh to 12th grades (where “snitching” often is seen as worse than almost anything else at that developmental level). Pediatricians and parents can refer to www.stopbullying.gov31 as a resource for additional information and ways to effectively intervene in a bullying situation.
Table 4. Office-Based Interventions for School Bullying
Psychiatrists can be effective allies for primary care providers, patients, and their families in altering the bullying behaviors and responses that affect many children and adolescents. Children presenting with acute mood/behavioral, social, or academic changes/difficulties alongside somatic complaints are at particularly high risk of involvement in bullying. Pediatricians must be able to employ quick screening tools that can help detect bullying during visits. Once they have identified children affected by bullying, pediatricians and psychiatrists can cooperate to create developmentally sensitive approaches that empower patients and their parents to effectively cope with and address the problems. An additional layer of bringing attention to the system’s role and response to bullying can enhance bullying interventions.
- Morita Y. Sociological Study on the Structure of Bullying Group. Osaka, Japan: Osaka City University; 1985.
- Karna A, Voeten M, Little T, Poskiparta E, Alanen E, Salmivalli C. Going to Scale: A Nonrandomized Nationwide Trial of the KiVa Antibullying Program for Grades 1–9. J Consult Clin Psychol. 2011;79(6):796–805 doi:10.1037/a0025740 [CrossRef] .
- Englander EK. Research Findings: MARC 2011 Survey Grades 3–12. InMARC Research Reports. Paper 2. 2011. Available at: vc.bridgew.edu/marc_reports/2. Accessed Feb. 20, 2013.
- Kumpulainen K, Raanen E. Children involved in Bullying at Elementary School age; Their psychiatric symptoms and deviance in adolescence. Child Abuse Negl. 2000:24(12):1567–1577 doi:10.1016/S0145-2134(00)00210-6 [CrossRef] .
- Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behavior and associations with psychosomatic complaints and depression in victims. J Pediatr. 2004;144(1):17–22 doi:10.1016/j.jpeds.2003.09.025 [CrossRef] .
- Macklem G. Bullying and Teasing: Social Power in Children’s Groups. New York, NY: Plenum Publishers; 2003 doi:10.1007/978-1-4757-3797-4 [CrossRef] .
- Schwartz D. Subtypes of victims and aggressors in children’s peer groups. J Abnorm Child Psychol. 2000;28(2):181–192 doi:10.1023/A:1005174831561 [CrossRef] .
- Kim YS, Koh Y, Leventhal B. School bullying and suicidal risk in Korean middle school students. Pediatrics. 2005;115(2):357–363 doi:10.1542/peds.2004-0902 [CrossRef] .
- Menesini E, Modena M, Tani F. Bullying and victimization in adolescence: concurrent and stable roles and psychological health symptoms. J Genet Psychol. 2009;170(2):115–133 doi:10.3200/GNTP.170.2.115-134 [CrossRef] .
- Holt M, Finkelhor D, Kantor GK. Hidden forms of victimization in elementary students involved in bullying. School Psychol Rev. 2007;36(3):345–360.
- CDC. Bullying among middle school and high school students—Massachusetts 2009. MMWR. 2011;60(15):465–471.
- Jimerson SR, Swearer SM, Espelage DL, eds. Handbook of Bullying in Schools: An International Perspective. New York: Routledge/Taylor & Francis Group; 2010.
- Kowlaski RM, Limber SP, Agatson PW. Cyberbullying: Bullying in the Digital Age. Malden, MA: Blackwell Publishing; 2008 doi:10.1002/9780470694176 [CrossRef] .
- Barhight L, Hubbard J, Hyde C. Children’s physiological and emotional reactions to witnessing bullying predict bystranger intervention. Child Dev. 2013;84(1):375–390 doi:10.1111/j.1467-8624.2012.01839.x [CrossRef] .
- Shields A, Cicchetti D. Parental maltreatment and emotion dysregulation as risk factors for bullying and victimization in middle childhood. J Clin Child Psychol. 2001;30(3):349–363 doi:10.1207/S15374424JCCP3003_7 [CrossRef] .
- Weiss J, Mouttapa M, Cen S, Johnson CA, Unger J. Longitudinal effects of hostility, depression, and bullying on adolescent smoking initiation. J Adolesc Health. 2011;48(6):591–596 doi:10.1016/j.jadohealth.2010.09.012 [CrossRef] .
- Radliff K, Wheaton J, Robinson K, Morris J. Illuminating the relationship between bullying and substance use among middle and high school youth. Addict Behav. 2012:37(4):569–572 doi:10.1016/j.addbeh.2012.01.001 [CrossRef] .
- Biebl S, DiLalla L, Davis E, Lynch Ka, Shinn SO. Longitudinal associations among peer victimization physical and mental health problems. J Pediatr Psychol. 2011:36(8):868–877 doi:10.1093/jpepsy/jsr025 [CrossRef] .
- Spivak H. Bullying: why all the fuss?Pediatrics. 2003;112(6):1421–1422 doi:10.1542/peds.112.6.1421 [CrossRef] .
- Kim YS, Leventhal BL, Koh Y, Hubbard A, Boyce WT. School bullying and youth violence: causes or consequences of psycho-pathologic behavior?Arch Gen Psychiatry. 2006;63(9):1035–1041 doi:10.1001/archpsyc.63.9.1035 [CrossRef] .
- Peters R, McMahon RJ, Quinsey VL. Aggression and Violence Throughout the Life Span. London: Sage Publications; 1992.
- Holt MK, Finkelhor D, Kantor GK. Multiple victimization experiences of urban elementary school students: associations with psychosocial functioning and academic performance. Child Abuse Negl. 2007;31(5):503–515 doi:10.1016/j.chiabu.2006.12.006 [CrossRef] .
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- US Department of Health and Human Services. Stop Bullying. Available at: www.stopbullying.gov. Accessed Feb. 28, 2012.
Percent of Children Reporting Being a Bullying Target by Grade
Most Common Types of Bullying According to Grade Level
|Type of bullying
||Elementary school children
||Middle school children
||High school children
|Excluded / Rumor
|Hitting / Physical
|Name Calling / Taunted
Screening Questions for Experiences with Bullying
||Open with, “Sometimes kids tell me they get picked on…” then go through the BORRIS questions:
If children state yes or physician has concerns, proceed to ask:
Have you been Bullied or Bullied anyone anywhere?
Have you Observed bullying going on?
How did you Respond?
Do you feel like you are Repetitively singled out as a bully or a victim?
Have you sent or received things over the Internet that you think may represent bullying?
Do you feel Stuck in bullying situations?
What are the “rules” in your school, in town sports, and at home about bullying/hazing? What really goes on?
Who do you talk with about bullying? How do adults in your school and at home react to bullying?
||Open with “Sometimes kids bully or are bullied, which can have a big impact on their health and functioning” then go through the WART questions:
Have you Witnessed or heard about your child being picked on or picking on other kids?
Have there been any recent changes in your child’s Attitude at school or home, school attendance, attention and concentration at school, grades, behavior, mood, socializing, etc?
What are the “Rules” in your school/town sports/home regarding bullying/intimidation/hazing? Do policies need revision in structure or in implementation?
Has your child Talked with you about getting picked on at school, or seeing other kids being bullied?
Office-Based Interventions for School Bullying
|Interventions for Victims
||Establish that any type of bullying is not OK or normal and should be addressed with trusted adults.
|Help students identify people at school they can quickly access if they are being bullied.
|Help them practice what to say/do next time they are bullied:
Elementary: walk away and tell a trusted adult, may consider confronting (standing tall, making eye contact, verbalizing that bullying is not OK) and accessing peers depending on situation.
Secondary: confront, change topic, seek peer recommendations, seek support and guidance from trusted adult
(May need to develop a script on how to handle “hypothetical situations”).
||Educate parents about the dangers of bullying and the importance of their intervening by talking with other parents, school counselor, and principal/administration.
|Provide guidance about how to respond to bullying in the form of providing support and building resiliency and assertiveness. Encourage active engagement in pro-social activities that can help establish a peer network and build a sense of mastery.
|Encourage parents to monitor use of technology.
|Interventions for Bullies
||Establish that bullying is inappropriate and identify alternatives for interacting with peers.
Define what makes good friends and create empathy (how it felt for victim).
Ask about what makes them want to bully others.
Discuss how it feels to make others feel good.
Provide education regarding consequences of bullying (others avoid being around you, the victim’s big siblings or other peers may challenge you, school policies).
Discuss how to include others in social circles.
Model how to lead effectively and how to respond to feeling left out.
Why are they using bullying as a way of control?
Discuss consequences of bullying, both good (power, control) vs. bad (others dislike, avoid).
||Empower parents as their child’s role models; they can help teach their children to learn effective ways of interacting with people.
|Encourage parents to set clear expectations for how their child will interact with other children, and to reinforce sharing, cooperative, empathic behaviors.
|Encourage use of nonphysical, nonshaming discipline (such as loss of privilege and what’s needed to earn it back).
|Work with school staff to gain support for the child in coming up with alternative behaviors at school.
|Consider further evaluation to understand what is underlying the behavior.
|Interventions for Bystanders
||Clarify that observing or tolerating is not appropriate. Brainstorm actions they can take when they observe bullying.
|Help identify staff to approach bullying if they cannot alter it. Encourage them to seek help from other students, teachers, and parents.
Step in alone or with peers to change the situation (eg, introduce a new game or say it is time to leave).
Confront and label the bullying behavior (including to staff).
Examine reactions of peers as to how to intervene.
Provide tools such as shifting the conversation, invoke humor and/or consider “win-win” options for the bully and victim.
Consider intervention options with staff and other adults.
||Clarify that bystanding is inappropriate and discuss interventions children can employ when they experience it.
Parents can provide examples in real-life to help to think about alternative ways for their child to address bullying.
|Discuss steps to take to access appropriate adults.
|Review and rehearse tactics to confront, shift conversation, or help victim leave.