Bullying is common in our society and has become a public health emergency. It is a form of repeated peer aggression that is intentional and involves a power differential between the bully and the victim.
It is often subtle and hidden, profoundly affecting many children. The information in the following activity will provide clinicians with tools for increased awareness and early recognition of bullying; this, in turn, will likely result in developing strategies for prevention and intervention concerning this significant societal issue. This activity reviews the cause, pathophysiology, and presentation of patients that are victims of bullying and the role of the interprofessional team in evaluating and managing these patients.
Objectives:
- Identify the etiology and epidemiology of bullying.
- Discuss the presentation and signs and symptoms suggestive of bullying.
- Outline strategies for the treatment and prevention of bullying.
- Recognize that strategies for addressing bullying may be different for bullies and their victims.
- Introduction
Bullying is a prevalent, complex, and potentially damaging form of violence among children and adolescents. Bullying is unwanted, aggressive behavior involving an actual or perceived social power imbalance. The behavior is repeated or has the potential to be repeated over time (therefore, the definition excludes occasional or minor incidents). These actions are purposeful and intended to hurt or make the victim uncomfortable.
Bullying may manifest itself in many forms. It can be physical, verbal, relational, or cyber; it can be subtle and elusive. The most common form of bullying for boys and girls is verbal bullying, such as name-calling. Although bullying is more common in schools, it can occur anywhere. It often occurs in unstructured areas such as playgrounds, cafeterias, hallways, and buses. Cyberbullying has recently received increased attention as electronic devices have become more common. Although prevalent, bullying through electronic means ranks third after verbal and physical bullying. In general, bullying is a common type of social experience that children refer to as "getting picked on."
Etiology
The etiology of bullying is complex and may depend on multiple issues, including individual, social, and family issues. Understanding these hidden causes that increase the risk of bullying is essential.[2]
Victims
Although there are many causes of bullying, certain risk factors may attract bullies to their victims.
- Children who are different from their peers
- Weaker children (than bullies)
- Children who are socially isolated, less popular, and have few friends
- May have underlying feelings of personal inadequacy
- Bullies
These children may have the following characteristics:
- Increasingly aggressive behavior and can be easily frustrated
- Tendency to blame others for their issues
- Unable to accept responsibility for their actions
- They may be overly competitive and worry about their reputation or popularity.
- May have friends who bully others
- May perceive hostile intent in the action of others
- May have a desire for power or dominance
- A bully does not need to be more substantial than their victim. The power imbalance can be due to many things, including popularity, strength, or cognitive ability. Bullying behavior may be used to gain social status.
Epidemiology
According to the National Center for Educational Statistics (2013), 1 in 3 children (27.8%) report being bullied during the school year. Bullying is reported to be more prevalent among boys than girls. It occurs with greater frequency among middle school children. For boys, both physical and verbal bullying is common, whereas for girls, verbal bullying and rumors are more common. African American youth report being bullied significantly less frequently than white or Hispanic youth.[4] Bullying peaks in early adolescence and then gradually declines as adolescence progresses. However, recent research suggests that this is for more overt forms of bullying, whereas covert bullying continues through adolescence.
Pathophysiology
The issue of bullying in children is a complex problem that emerges from social, physical, institutional, and community contexts, as well as the individual characteristics of the children who are bullied and victimized. A bullying interaction occurs not only because of the individual characteristics of a particular child who is bullying but also because of the actions and attitudes of peers, teachers, and school staff and the physical characteristics of that particular environment. Family dynamics, cultural factors, and even community response also play a role in the occurrence of bullying interaction.
History and Physical
Sure signs may indicate that a child has been a victim of bullying, including:
- Injuries or illnesses without a physical explanation
- Lost or damaged belongings, such as books or clothes
- Frequent somatic symptoms, changes in habits, difficulty sleeping, or frequent nightmares
- Avoidance of school or social situations
- Feelings of helplessness or decreased self-esteem
- Hurting himself/herself or expressing suicidal intent
Evaluation
Bullying is a severe problem for both the bully and the victim. The first step is recognizing bullying as a problem for a child. It is also essential to identify bullying interactions at an early stage.
Assessment of bullying: Many tools are available to assess bullying and determine the frequency and locations of bullying behavior. See the Centers for Disease Control and Prevention's compendium for measuring bullying, victimization, and bystander experience.
It may also be necessary to assess other risk and protective factors, such as depression, suicide risk, and internal and external resilience sources, to determine best the interventions and supports needed.
Treatment / Management
Since bullying is a very complex problem, there is no "quick fix" to prevent or intervene with this issue. It is essential to understand the issues that are unique to the individual and the context in order to develop and implement interventions. Here we describe essential elements for intervention to address this issue.
To stop bullying, remember that prevention is the best intervention.
- Assist child and family in providing a supportive and safe environment
- Assure the child that bullying is not his or her fault
- Work with school and other agencies as applicable to protect the victim
- Defuse or de-escalate an acute situation
- Addressing bullying is a multi-step process.
Teach children not to bully; discourage bullying.
- Improve supervision in commonly under-supervised areas such as a playground, cafeteria, hallway, and bus.
- Bullying prevention strategies should be clear and visible to other children.
- Educate children about the consequences of bullying and letting him/her know that bullying is wrong and a serious act.
- Apply consistent disciplinary consequences (e.g., removal of privileges, reparation).
- Enforce penalties such as requiring community service as "payback" for unacceptable behavior.
- Be aware that punishment-based strategies (suspension and expulsion) should be reserved for severe disruptive and aggressive behavior. There may be more effective strategies.
Engaging the Victim
- Empathetic listening to the child; trying to understand the child's view
- Provide emotional support to child and family
- Obtain permission for a discussion with school officials
- Discuss when to contact parents; consider parents as partners
- Psycho-educational counseling
- Long-term support and intervention
- Engaging Bullies
Explore the basis of bullies' behavior: It is also important not to label them as bullies.
- Listen to their perspective. Remain non-confrontational; share a concern for the victim and ask for suggestions for improvement.
- Set the boundaries between acceptable and unacceptable behavior; communicate that this behavior is unacceptable.
- Children may quit bullying when they become aware of the hurt they have caused and learn alternative coping methods.
- Team approach: Many researchers believe that bullying is a group process. Therefore, interventions against bullying should be targeted at the peer-group level rather than at individual bullies and victims. Research has shown that the most successful programs use multi-level interventions.
- Involve parents; determine the best time and most effective method of involving parents.
- Family therapy is one effective method of reducing anger and improving interpersonal relationships.
- Encourage schools to develop an anti-bullying policy that should be included in the student code of conduct.
- Pediatricians should consider screening children for their potential involvement in bullying activities and encourage youth to prevent and intervene with bullying in safe ways (even as bystanders)
Bullying is a learned behavior that may be preventable. School-based interventions have significantly reduced bullying by up to 20%. These interventions included the following:
- Changes in the school and classroom climate to increase awareness about bullying. Increase teacher and parent involvement. Improved supervision
- Setting clear rules against bullying. Providing support and protection for bullied children.