CLINICS IN INTEGRATED CARE
What is bullying? Key points
Joshua Kallman C Bullying is a common occurrence, affecting an estimated one
Jennifer Han third of children worldwide.
Douglas L Vanderbilt C Bullying is an unwanted aggressive behaviour by a person or
group against a targeted victim with the intent to harm
physically or emotionally and can take many forms including
Abstract verbal, physical, relational, and cyber.
Bullying is a major public health problem affecting 20% of children in
the United States and the United Kingdom. With the proliferation of C Long-term consequences of bullying victimisation are wide-
online electronic and social media use among children, cyberbullying spread and include increased rates of anxiety, depression,
has become more pervasive in recent years and poses its own unique PTSD, social isolation, and difficulties with interpersonal
challenges in detection and intervention. Both bullying and cyberbully- functioning.
ing cause long-term biological and psychological consequences for all
those involved including victims, bully/victims and bullies. Clinicians C Long-term consequences for bullies and bully/victims include
who treat paediatric patients play a crucial role in not only screening increased incidence of conduct and criminal behaviours,
for and addressing the impacts of bullying in their clinical settings, violence, and substance abuse.
but can also help advocate for evidence-based anti-bullying programs
and policies. In addition to clinicians, this issue demands the C Clinicians who treat paediatric patients play a crucial role in
concerted and coordinated efforts of all those who are concerned not only screening for and addressing the impacts of bullying
with the care of children including teachers, school administrators, ed- in their clinical settings but can also help advocate for
ucators, and policy makers. This article aims to offer an introduction to evidence-based anti-bullying programs and policies in schools
identifying and screening for bullying and cyberbullying as well as ap- and communities.
proaches to addressing these issues in our clinics, schools, and the
community at large.
Keywords bully/victim; bullying; bystander; cyberbullying;
HEEADSSS; primary care; psychosocial; upstander
Definitions
Bullying is an unwanted aggressive behaviour by a person or
group against a targeted victim that has the intent to harm either
physically or emotionally.2 This behaviour is repeated or has the
Introduction potential to be repeated over time and involves a real or
perceived power imbalance.5 Bullying participants are defined in
Bullying is a common occurrence affecting an estimated one third Table 1.
of children worldwide.1 Bullying can occur anywhere from
classrooms to online. Though at times it is dismissed as a
childhood rite of passage, bullying is a form of aggression that Types of bullying
can have long-lasting adverse health and psychological re- Bullying can take many forms including verbal, physical, rela-
percussions for all involved.2 Bullying not only inflicts harm on tional, and cyber. Verbal bullying involves teasing, name-calling,
the victim that results in physical, psychological, social or taunting, making inappropriate sexual comments, or making
educational consequences but can also have serious ramifica- threats. Physical bullying can involve hitting, tripping, kicking,
tions for the bullies, bully/victims, and bystanders involved.3 spitting, or taking or damaging someone’s possessions. Rela-
Clinicians are in a unique position to help identify and address tional or social bullying is a covert form of bullying that involves
the negative effects of bullying.4 hurting someone’s reputation or relationships by purposely
excluding the victim from a group, spreading rumours, or
embarrassing the person in public.6
Joshua Kallman MD is a Fellow in Developmental-Behavioral With the explosion of electronic devices and social media use
Paediatrics at Children’s Hospital Los Angeles in CA, USA. amongst youth, cyberbullying has become a reality for many.7
Competing interests: none declared. Cyberbullying is the use of the internet, cell phones, or other
electronic technology to send, post, or share negative, false, or
Jennifer Han MD MPH is a Fellow in Developmental-Behavioral
Paediatrics at Children’s Hospital Los Angeles in CA, USA. hurtful content about someone else. It also includes sharing
Competing interests: none declared. private or personal information to cause humiliation. Cyberbul-
lying happens via email, webcams, text messages, online chat
Douglas L Vanderbilt MD MS is the Developmental-Behavioral
rooms, social media, and gaming communities. Compared to
Paediatrics Section Director at Children’s Hospital Los Angeles and
Professor of Clinical Paediatrics (Educational Scholar) at Keck School traditional bullying, cyberbullying poses unique challenges as it
of Medicine of University of Southern California, USA. Competing can be done at any time, often anonymously, and can be spread
interests: none declared. quickly to large audiences. Electronic content is difficult to
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CLINICS IN INTEGRATED CARE
disability or chronic medical condition such as asthma, food al-
Definitions of bullying participants lergies, skin conditions, diabetes, learning disabilities, autism, or
Bullying: repetitive, aggressive behaviour directed toward an physical disability. Being an outlier in weight or height (on either
individual with the intent to cause harm or distress extreme) is also reported as a risk factor for being bullied.
Bullying victims are often socially isolated and lack a consistent
Bully: the perpetrator of bullying behaviour
friend group. Victims tend to have more anxiety and depression
Victim: the target of bullying behaviour
symptoms and report a lower self-esteem compared to non-
Bully/Victims: both a perpetrator and target of bullying behaviour victims.15
Bystander: a witness to bullying behaviour including onlookers, By contrast, bullies may be popular and of higher social sta-
supporters of bullies, or upstanders who intervene tus. They usually have positive attitudes toward violence and are
Upstander: a witness to bullying behaviour who chooses to act to impulsive. The more emotional support the bully receives from
support the victim and/or intervene in the bullying behaviour friends regarding their bullying behaviour, the more likely they
are to continue engaging in bullying behaviour. Contrary to
Table 1 popular belief, bullies tend to have average to above-average
self-esteem. Bully/victims are more aggressive and emotionally
remove, and cyberbullying is difficult for adults to discover and reactive, less sociable, and more likely to react provocatively to
intervene.7 bullying. Like victims, bully/victims tend to have low self-
esteem.15
Epidemiology and risk factors for bullying
Long-term effects of bullying
The UNESCO Institute of Statistics reports that bullying among
Long-term consequences of bullying victimisation are wide-
youth ranges from 7% in Tajikistan to 74% in Samoa.1 Nearly
spread and include increased rates of anxiety, depression, PTSD,
20% of children in the United States and United Kingdom report
social isolation, and difficulties with interpersonal functioning.
having been bullied in the previous year.8,9 Over 10% of children
Bullying victims also have more difficulties with job stability and
have suffered from chronic bullying lasting at least 6 months.10
higher rates of unemployment later in life.5,16 Long-term conse-
Rates of bullying victimisation are similar between boys and
quences for bullies and bully/victims include increased incidence
girls and tend to decline over time, with bullying being twice as
of conduct and criminal behaviours, violence, and substance
common among 9 to 13-year-old children compared to 14 to 16-
abuse.15
year-old children. Bullying victimisation is a risk factor for
persistent bullying over time. Studies show that close to half of
children who experienced bullying in primary school continue to Diagnosis and screening of bullying
experience bullying in secondary school.11 Nearly 10% of chil- Clinicians who manage paediatric patients play an important role
dren reported having bullied others at some point, while 4.5% in screening for and addressing the impacts and consequences of
report being bully/victims.10 Both bullies and bully/victims are bullying. Clinicians should set aside time in the visit to discuss
more likely to be male. Cyberbullying has become an increas- the child’s psychosocial environment, including interpersonal
ingly significant problem, particularly among adolescent chil- relationships in the home, school, and community. The clinician
dren. Nearly 15% of children report having been cyberbullied in should explicitly ask the child and caregiver about bullying and
the previous year. In contrast to traditional bullying, cyberbul- cyberbullying. They should clarify whether the child has been
lying rates are higher among girls.8 involved as a victim, bully, bully/victim, or bystander, and in
Bullying tends to take place in settings with low adult su- which environments these interactions have taken place. Making
pervision of youth. In school, this includes secluded areas of the time for a confidential interview between the clinician and child
playground, hallways, or restrooms during times with relative can help to facilitate such discussions. Allowing the parent to
lack of adult supervision such as before and after school, step outside the room should be standard practice for adolescents
lunchtime, or between classes. Outside of school, bullying may over 12 years of age.4
occur while children are walking to and from school, while riding The way in which bullying is asked about and framed is of
the bus, or at parks near the home.12 Cyberbullying occurs via critical importance. Normalizing the conversation and letting the
electronic media or the Internet where there is often very little to child know that they are in a safe space in which they can share
no adult supervision. Cyberbullies can hide behind anonymity information is key to ensuring that the child feels comfortable
making it difficult to identify perpetrators.13 The school climate, sharing. Children are often hesitant to disclose their involvement
which includes teaching practices and attitudes, organizational in bullying for fear of retaliation, shame, or the belief that it is
structures, and norms and values, also plays a critical role in the their fault.17 In addition, some children may not understand their
perpetuation of bullying. Bullying occurs more frequently when involvement in or effects of bullying. As a result, it may be
teachers and administrators are less attuned to the signs of prudent to initiate the conversation without directly utilizing the
bullying or less willing to intervene.14 terms “bullying” or “cyberbullying”.4 Instead, ask about the
The prevalence of bullying victimisation among lesbian, gay, child’s general psychosocial environment, as outlined in Table 2.
bisexual, and transgender (LGBT) youth is a significant concern, For adolescents, one screening tool that can help guide the
with close to a third of LGBT children reporting bullying vic- conversation and also identify potential coexisting mental health
timisation (either traditional or cyberbullying) in the past year.8 concerns and psychosocial risk factors is the HEEADSSS (home
Other risk factors for bullying victimisation include having a environment, education/employment, eating behaviours,
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CLINICS IN INTEGRATED CARE
Clinician questions to elicit bully exposure
What do you like/not like about school?
How do you get along with other students and teachers at school?
Do you have friends at school? Outside school? What do you like to do with your friends?
Do you feel safe at school? At home? In your neighbourhood?
What makes you feel safe/unsafe at school? At home? In your neighbourhood?
Has anyone teased you or been mean to you at school? Outside school? Through social media or phone/texting?
Have you ever teased or been mean to anyone at school? Outside school? Through social media or phone/texting?
Have your marks changed recently?
Is there anyone at school or at home who you can trust to talk to about how you feel?
Many young people experience bullying at school, at home, or in other settings. The bullying can be in-person, via text messaging or phone calls, or
via social media (often referred to as cyberbullying). Is this something that you or someone you know has been affected by? How does this make you
feel?
Adapted from4,17,18
Table 2
activities with peers, drug use, sexuality, suicide/depression, States Department of Health and Human Services, the Bullyin-
safety) assessment.4 It is vital to reassure the adolescent that the gUK website from Family Lives, and the Cyberbullying Research
information they disclose will be kept confidential unless there is Center website.19,20 Prompt and appropriate referral to mental
a safety issue (risk of harm to self or others or concerns for child health professionals should be made for coexisting conditions.4
abuse or neglect). Further interventions for bullying victims include participation
A host of behavioural changes, somatic complaints, mood and in extracurricular activities that encourage positive peer re-
anxiety concerns, and clinical findings may be indicative of lationships and promote self-esteem such as sports, school clubs,
bullying victimisation. Several behavioural patterns and familial and community service organizations.18
risk factors can be associated with perpetration of bullying as
well.15 These findings are outlined in Table 3. Children affected School-based interventions
by bullying should be screened for common coexisting mental Clinicians can work with schools and communities to advocate
health conditions such as depression and suicidality, anxiety, for bullying prevention and intervention programs. A systematic
PTSD, and ADHD. Because of the high likelihood of bullies being review of bullying interventions found that whole-school anti-
victims themselves, it is advised that all children affected by bullying programs were most effective in reducing bullying.21 A
bullying (whether as a bully, victim, bully-victim, or bystander) whole-school approach entails a collaborative action plan
be screened for such mental health conditions. Broad-based involving the entire school community including senior school
screening checklists such as the Pediatric Symptom Checklist leadership, teachers and staff, parents, and students.21 These
(PSC) or the Child Behavior Checklist (CBCL) may be useful to interventions can include teacher trainings, increased supervi-
screen for psychological impairment in general.18 More specific sion of students’ outdoor activities, consistent reporting and
screening measures such as the Revised Children’s Anxiety and response strategies, classroom curriculum, conflict resolution
Depression Scale (RCADS), Patient Health Questionnaire (PHQ- training, individual counselling, and school policies that foster a
9) modified for teens, Beck Depression Inventory, and the NICHQ positive social climate of anti-bullying on campus.21,22
Vanderbilt Assessment Scale may be of utility if there are con- Interventions empowering bystanders to become upstanders
cerns for a specific mental health diagnosis. also decrease bullying and are less resource-intensive than
whole-school approaches.23 There is a witness in 80% of
Interventions for bullying bullying situations, and if that witness intervenes there is a 50%
Clinical interventions chance of stopping the bullying act.24 Upstanders can be taught
The clinician should provide support, counselling, and appro- to safely intervene by telling a teacher or helping the victim
priate referrals for the child or adolescent who is impacted by escape the situation.23
bullying. The first step is to emphasize to the youth that they The KiVa anti-bullying program,25 a whole-school interven-
have demonstrated great courage in disclosing this information tion from Finland, has been adopted by many U.K. schools and
and that there is help available. For victims, it is important to offers online toolkits. The All Together Online Hub from the Anti-
highlight that the bullying they are experiencing is in no way Bullying Alliance26 helps schools create action plans and audit
their fault. Let them know that they are not alone and encourage their current anti-bullying practices (see Key References). Some
them to disclose their experiences to their caregivers or other ineffective practices to avoid include large anti-bullying assem-
trusted adults. Provide children and parents with clear, up-to- blies, zero tolerance policies, disciplinary actions such as sus-
date information and resources about bullying and its impacts.4 pensions, or direct peer mediation between the bully and
Examples include the Stop Bullying website from the United victim.22
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CLINICS IN INTEGRATED CARE
Red flags for identifying bullying participant status
Victim Physical complaints: Psychological symptoms: School problems:
-insomnia -depression -academic failure
-abdominal pain -loneliness -social problems
-headaches -anxiety -lack of friends
-new-onset enuresis -suicidal ideation/gestures
Behavioural changes: Unique features: Physical examination:
-irritability -children with chronic medical illnesses -torn or damaged clothing or belongings
-poor concentration -physical deformities -unexplained cuts, bruises, and scratches
-school refusal -students in special education
-substance abuse
Bully Attitude toward behaviour: Features: High-risk families:
-desire to obscure the problematic -aggressive -physical punishment
behaviour -overly confident -model violent behaviour in conflict
-lack empathy resolution
-oppositional or conduct problems
Bully-Victim Physical complaints: Psychological symptoms: School problems:
-Psychosomatic complaints -externalizing behaviour and conduct -school disengagement and academic
(insomnia, headaches, abdominal disorder problems failure
pain, etc.) similar to victims. -depression and anxiety -social isolation and exclusion by peers
-suicidality -increased likelihood of bringing
-substance use or abuse weapons to school
Bystander Psychological symptoms: School problems:
-anxiety -academic difficulties
-depression -school avoidance
-suicidal ideation -feeling unsafe at school
Adapted from4,22,30
Table 3
Educating youth and parents about cyberbullying is important access to weapons, improving built environments, and support-
for prevention. A meta-analysis summarized promising school- ing programs that build youth self-esteem, empathy and resil-
based cyberbullying intervention programs.27 Parents should be ience to help foster an anti-bullying culture in the community.22
advised to keep home computers in easily visible places, discuss
expectations for responsible online behaviour, and encourage Summary
their children to notify adults immediately of cyberbullying.
Bullying is a public health issue affecting youth across the globe.
Clinicians should advise families to document harmful posts,
The harmful ramifications of bullying experiences often extend
report the cyberbullying to online platforms, and if a potential
beyond childhood and adolescence. Clinicians need to remain
crime is occurring then notify police.28
informed to better identify and intervene in cases of bullying.
This can be through performing screenings, providing counsel-
Policy and advocacy
ling and resources, and advocating for bullying and cyberbully-
Clinicians should be aware of government laws surrounding ing prevention and intervention programs in schools and in the
bullying to help advocate for families. In the U.K., by law all state community. Clinicians can play a role in reducing harm associ-
schools must have a behaviour policy preventing all forms of ated with bullying and cyberbullying. A
bullying among students. Schools must also follow anti-
discrimination laws to prevent harassment, discrimination, and
victimization in the school (gov.uk, 2020).29 In the U.S., each REFERENCES
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INTCAR 5:C 100046 Ó 2021 Elsevier Ltd. All rights reserved.
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