Approach to bullying and victimization

Case 1

Sally’s mother brings her to her family physician because of recurrent stomach-aches that have caused Sally to miss several days of school. When the family physician questions Sally and her mother, they reveal that Sally has been sleeping more than usual and seems sad. Sally’s teachers have reported that she does not seem as interested in school as she used to be.

Case 2

Jimmy comes into his family physician’s office for his annual periodic health examination. His mother expresses concern that Jimmy has been caught drinking and smoking marijuana on several occasions. He has become increasingly aggressive with his younger brother, and over the past few months Jimmy’s grades have dropped.

Bullying is a form of abuse that can take various forms at various ages. In this article, we have limited our discussion to bullying among children and adolescents; however, bullying can occur within the family, in the workplace, or in any other setting and at any age.

Bullying is defined as the use of power and aggression to cause distress or control another.1–3 Although bullying was traditionally thought of as physical aggression, this is only one of many strategies that children use to control and distress others. Bullying can be broadly categorized into direct and indirect forms of aggression.2 Direct bullying is an overt expression of power and can include physical aggression (eg, hitting, kicking) and verbal aggression (eg, insults, racial or sexual harassment, threats). Indirect bullying (or relational aggression) is the covert manipulation of social relationships to hurt (eg, gossiping, spreading rumours) or exclude the individual being victimized. In recent years, cyberbullying has emerged with technology, involving the use of the Internet and text messaging to cause distress to individuals.

Two elements of bullying are key to understanding its complexity. First, bullying is a form of aggressive behaviour imposed from a position of power: Children who bully (note that we avoid labeling children as bullies or victims because these labels constrain thinking of the problem as solely a characteristic of the individual, rather than as a problem that emerges from complex social dynamics) have more power than the children they victimize, and this power is often not evident to adults. Children’s power can derive from a physical advantage (such as size and strength) or from a social advantage (such as a higher social status in a peer group or strength in numbers). Recent research indicated that children with special health care needs were more likely to be victimized, whereas those with chronic behavioural, emotional, or developmental problems were more likely to be involved in bullying others or in both bullying and being victimized.4 The second key element is that bullying is repeated over time, and with each repeated incident, the power dynamics become consolidated. Although formal definitions include repetition, children believe that even a single occurrence of the use of power and aggression should be identified as bullying.5 Research reveals bullying as a destructive relationship problem: Children who bully are learning to use power and aggression to control and distress others; children who are victimized become increasingly powerless and unable to defend themselves from this form of abuse. Interventions are required to support children, neutralize the power dynamics, and promote healthy relationships.

Sources of information

PsycINFO and MEDLINE databases were searched from 1980 to 2008 using the key words bully, health, physical health, mental health, prevalence, and intervention. Results were limited to peer-reviewed journals and those articles examining child-to-child bullying only. All research cited in this paper is based on levels II or III evidence; owing to practical and ethical constraints, level I evidence does not exist in this field of study. The authors’ own clinical and research experience was also incorporated.

Signs and symptoms

Bullying problems have been perpetuated by misconceptions that hinder the recognition of bullying as a critical issue affecting children’s development. These misconceptions include ideas such as “bullying only occurs in schools,” “bullying is a problem that children naturally grow out of,” and “bullying is harmless.” Although these ideas are refuted by research,6–8 their perpetuation contributes to the lack of recognition of bullying as a chronic problem for a substantial proportion of Canadian children and youth. National data gathered through the World Health Organization’s Health Behaviour in School-aged Children survey (level II evidence) have shown 5% to 8% of girls and 10% to 13% of boys aged 11 to 15 years have reported bullying others regularly; in the same age group, regular victimization has been reported by 9% to 19% of girls and 9% to 21% of boys.9

Research points to a strong association between involvement in bullying and substantial health problems. Both children who bully and those who are victimized experience increased physical and psychosocial health problems, although there is a stronger body of research on the health problems associated with victimization. Early indicators of health problems and their potential link to bullying might not come to the attention of parents and clinicians because of the covert nature of bullying and the shame and fear in reporting experiences of victimization. Given the prevalence of bullying involvement, physicians need to be aware of the variety of symptoms and problems that children might present with, to be able to include bullying and victimization in differential diagnoses. The health indicators for bullying and victimization are discussed below and summarized in Table 1 (level II evidence).

Children who are victimized are more likely to report experiencing physical symptoms (such as headaches or stomachaches) or psychosomatic symptoms (such as difficulty sleeping or bed-wetting) than nonvictimized children10,11; children who bully are as likely as victimized children to report these types of symptoms, and children who both bully and are victimized might be at greatest risk.12,13 Children who bully are also more likely to report alcohol and substance use.14 Psychological symptoms are more strongly associated with bullying involvement than physical symptoms are.10 Depression and anxiety symptoms are more likely to be reported by children who bully or are victimized, and especially by those involved in both roles, compared with children not involved in bullying.10,11,13,15 These children are also at higher risk of suicidal thoughts.13,15

Although physical, psychosomatic, or psychological symptoms might be the first to present to a physician, there are other concomitant indicators that might be identified with further questioning of the child or parents. Children involved in bullying are at risk of poor school functioning, as measured by attitudes toward school, grades, and absenteeism.16–18 Children who are victimized are more likely to dislike and avoid school16; physically aggressive children are more likely to drop out of school.17 Children with serious psychosocial problems might experience problems associated with attention, behaviour, and emotional regulation, which interfere with their abilities to learn at school.18

Screening

The relatively high prevalence of bullying and victimization identified by the World Health Organization survey among Canadian children suggests that primary care practitioners are likely to encounter this problem frequently. Although there are currently no clinical practice guidelines or research findings within a primary care context, the health symptoms described above are serious enough to warrant intervention. In the absence of established guidelines, we present a potential strategy and rationale for screening and management of children’s involvement in bullying (level III evidence).

Physicians can incorporate screening for bullying involvement into their practices in a number of ways. First, be aware of the health and social symptoms commonly associated with bullying and victimization, as discussed above and in Table 1. Presentation of any of these symptoms can be followed up with questioning about peer relationships and school functioning; physicians can be straightforward and ask children if they are being bullied or bullying others in school, in sports, in recreational activities, or in their neighbourhoods. Awareness of the home environment is also important, as children who are exposed to domestic violence are almost twice as likely to be involved in bullying or victimization.19 Screening can also be incorporated into routine visits or periodic health examinations by asking children directly about bullying involvement and inquiring about the presence of any of the associated symptoms. The goal is to ensure that the child has a trusted adult to turn to if bullying or victimization occurs.

Once bullying involvement is suspected or identified, the physician should attempt to elicit more detail from the child and family with 4 additional questions, summarized in Table 2.

Management

Identification and assessment of the extent of involvement is the first step to helping children and parents address problems associated with bullying and victimization. While symptoms or injuries requiring immediate attention must be appropriately attended to, long-term strategies for managing bullying involvement require addressing the underlying issue: peer relationships. Because bullying is a relationship problem, the interventions to address bullying must comprise relationship solutions. Children who bully require interventions to stop their aggressive behaviour, promote empathy and prosocial behaviour, and reduce reinforcement patterns within the peer groups for bullying. Children who are victimized might need support in developing assertive strategies, as well as friendship skills and opportunities. Parents of children exposed to domestic violence might require support to model healthy relationships for their children.

Management of bullying involvement is a multidisciplinary effort, involving parents, teachers and school officials, primary care physicians, and mental health specialists. The physician’s role in these interventions might involve helping other adults to recognize the physical and psychological symptoms associated with bullying involvement; supporting the children; directing parents toward resources; advocating on behalf of the children to school officials or other community agencies; providing referrals to treatment settings as appropriate; encouraging parents to take an active role in monitoring their children and engaging them in positive school and community activities.

Case 1 resolution

The family physician asks Sally if she is being bullied. Sally reports that in the past year a group of girls in her class have been bullying her through gossip, text messaging, and the Internet. On a couple of occasions there have been physical confrontations after school. Sally confesses that she is afraid to walk home after school and sometimes hides in the washroom until the other girls have left. The family physician provides Sally and her mother with some on-line resources to help deal with bullying, advises Sally’s mother to contact school officials, and refers Sally for counseling. She encourages Sally to return for follow-up anytime.

Case 2 resolution

When Jimmy is questioned, he admits to bullying his brother and some of his peers at school, using verbal threats and physical violence. His mother admits that Jimmy has been exposed to domestic violence at home. The family physician refers both Jimmy and his mother for counseling and provides them with online resources.

Conclusion

Physicians play an important role in promoting the health and well-being of Canadian children and youth. With an increased understanding of bullying as a health problem, and motivation to identify and support children who are at risk of these relationship problems, physicians can be catalysts in promoting healthy relationships and social change. With the potential to help children, their parents, schools, and communities, small efforts by physicians to help children at risk because of bullying or victimization can have profound systemic effects in promoting healthy relationships in all of the contexts in which children and youth live, work, and play.