Featured Report: Bullying Behaviors Among Children and Adolescents (A-02) Full Text

Introduction and Overview

Bullying is a form of antisocial behavior that is pervasive in schools, neighborhoods, and homes throughout this country and the world.^1,2 Children experience bullying in many forms. They may be teased, physically hit or attacked, ignored, socially isolated, or called names; have personal property stolen or defaced repeatedly; have rumors spread about them; or be publicly or privately humiliated and embarrassed. Bullying behavior cuts across social, economic, and racial lines. The extent to which it occurs depends on the psychology of the bully; the possible support or ambivalence of peers, parents, teachers, and other responsible adults; the victim’s response; and an institutional structure that may or may not condone or tolerate this behavior. Unless it is addressed and modified early in life, bullying behavior may be the beginning of a generally antisocial and rule-breaking behavior pattern that can extend into adulthood.³

Bullying among children and adolescents typically occurs at school or on the way to and from school.^3-6 Most children are required to attend school and do not have the option of staying home or changing environments to avoid bullying and other peer aggression. Surveys indicate that half of all students in the United States are bullied at some time during their school years and at least 1 in 10 is bullied on a regular basis.⁷ A recent nationally representative survey showed that youth, aged 8 to 15 years, rank bullying as more of a problem in their lives than racism, pressure to use alcohol and other drugs, and pressure to have sex.⁸ In 1999, the US Departments of Education and Justice estimated that almost 1 million students (4%), aged 12 through 18 years, reported fear of being attacked or harmed in the school vicinity during the previous 6 months.⁹ During the same period, about 5% reported that they avoided 1 or more places in school; 13% reported being targets of hate-related language.⁹

In recent years, bullying has come under increased scrutiny in the United States amid reports that it may have been a contributing factor in mass school shootings. The National Threat Assessment Center found that in more than two thirds of 37 shootings, the attackers felt "persecuted, bullied, threatened, attacked, or injured by others," and that revenge was an underlying motive.¹⁰ For a number of perpetrators, their experience with bullying at school appeared to play a major role in precipitating the attack.

In the United States, bullying has largely been overlooked or minimized by adults, being viewed as an inevitable part of growing up. Accumulating research indicates that bullying and peer harassment may be pathologic behaviors, indicative of psychiatric disorders, which may have profound social and emotional health consequences for children and adolescents.^2,3,11 Such effects require attention from physicians and other health care professionals. This report summarizes the nature and scope of this problem, identifies programs that have succeeded in recognizing and preventing bullying behaviors, and addresses the important role of physicians in prevention and intervention. 
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Methods

MEDLINE and PsychInfo databases were searched for English-language articles published from 1985 to 2002 using the key words aggressive behavior, bullying, conduct disorder, peer harassment, peer victimization, school violence, violence prevention, and youth violence. Searches also were performed on databases maintained by the Educational Resource Information Center and the National Criminal Justice Reference Service. Additional articles were derived by manual review of references listed in pertinent articles, textbooks, and reports. This included review of a comprehensive compendium of youth violence prevention resources maintained by the National Library of Medicine.¹²

Letters requesting information for this report were sent to the Center for Mental Health Services (Substance Abuse and Mental Health Services Administration), Maternal and Child Health Bureau (Health Resources and Services Administration), National Center for Injury Prevention (Centers for Disease Control and Prevention), National Institute of Child Health and Human Development, National Institute of Mental Health, US Department of Education, US Department of Justice; medical specialty societies (American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, American College of Obstetricians and Gynecologists, American College of Preventive Medicine, American Psychiatric Association); other professional and academic organizations (American Psychological Association, Center for the Prevention of School Violence, Center for the Study and Prevention of Violence, Hamilton Fish Institute on School and Community Violence, National Assembly on School-Based Health Care, National Association of School Nurses, National Association of School Psychologists, National Collaboration for Youth, National Education Association, National Mental Health Association, National School Safety Center); and nationally recognized researchers.
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Defining the Problem

 Bullying generally involves 3 groups of participants: the child or group doing the bullying, the child or group who is victimized, and peers and other bystanders who play a variety of roles as witnesses to the incident (eg, as instigators, passive onlookers, defenders). There is no one clinical type of bully or victim or any clear cutoff point for classifying children into these categories.¹³ Bully, victim, and bystander roles are not necessarily fixed, and some children can alternate among them.¹⁴ Caution is therefore needed to avoid labeling or stereotyping children as "bullies" or "victims," which can stigmatize them and ascribe personal blame for behaviors they display.¹⁵

For this report, bullying is defined as a negative behavior that involves (1) a pattern of repeated aggression; (2) deliberate intent to harm or disturb a victim despite apparent victim distress; and (3) a real or perceived imbalance of power (eg, due to age, strength, size), with the more powerful child or group attacking a physically or psychologically vulnerable victim.^3,16,17 As described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), bullying is one criterion of conduct disorder, which is a specific psychiatric diagnosis characterized by a repetitive and persistent pattern of behavior "in which either the basic rights of others or major age-appropriate societal norms or rules are violated."¹⁸ Conduct disorder embodies a complex group of behavioral and emotional problems in children and adolescents.

Bullying and violence are subcategories of aggression or aggressive behavior. Violent behavior involves the use of physical force or power to inflict injury or discomfort on another individual (eg, homicide, robbery, aggravated assault, forcible rape).¹⁹ When carried out by physical means, bullying can be considered violent behavior. Much bullying, however, occurs without physical violence and involves verbal and emotional tactics to threaten, harass, or harm a victim.

Bullying can be direct or indirect.^3,16 Direct bullying involves physical contact, verbal taunts, or use of obscene, threatening gestures. Indirect bullying involves more passive-aggressive actions such as spreading of rumors, intentionally excluding someone from a group, or getting other children to assault a victim. Whether it is direct or indirect, bullying is distinguished from other aggressive behaviors by occurring repeatedly over time in an ongoing pattern of harassment, intimidation, and abuse.

Physical bullying involves harm to another’s body or property.^3,14 In most cases, this takes the form of hitting, shoving, poking, tripping, or slapping. Physical harm can be but is usually not severe. Serious injury to a victim may prove detrimental for the bully by generating sympathy for the victim and punishment for the perpetrator.¹⁴ Rather than inflict severe harm, the bully aims to humiliate a child in the presence of peers. Dunking the head of a child in a toilet, putting obnoxious signs on the back of clothing, sexual grabbing, and other forms of touching and poking are common examples of physical bullying; defilement of clothing or other personal items is a less direct form of this behavior.

Verbal bullying involves harm to another’s self-esteem and usually occurs in the presence of an audience.^3,14 Verbal bullies use name-calling, insults, put-downs, racist remarks, and constant teasing to hurt or humiliate another person. Teasing is often said to be "in fun" but is rarely enjoyed by the victim, despite the bully’s claim that the teasing is meant in jest.¹⁴

Relational bullying involves social manipulation to harm another’s acceptance by a group.^3,20,21 Social bullies try to convince their peers to exclude or reject a certain person or persons and cut those victims off from their social connections. The most devastating effect with this type of bullying is rejection by the peer group at a time when most children highly value their social connections.

Bullying may involve children and adolescents who are characterized as aggressive, provocative, or reactive victims ("bully/victims").^3,22-24 These children can be aggressors as well as victims. They are typically hot-tempered, restless, emotionally reactive youth who create tension by irritating and teasing others and who attempt to fight back when attacked. These children are often the most difficult to identify because at first they seem to be victims of other bullies. Reactive victims often taunt bullies and physically bully others. A reactive victim may provoke a bully into action, fight back, and then claim self-defense.
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Epidemiology of Bullying

Much of the formal research on bullying has taken place in Scandinavian countries, Great Britain, Australia, Japan, Canada, and the United States.^1-3,16 Differences in definitions and methodologies for assessing bullying preclude direct comparisons of prevalence rates and risk factors. In all of these countries, problems associated with bullying have been identified wherever formal schooling environments exist. General estimates suggest that bullies represent about 7% to 15% of the sampled school-age population; victims represent about 10% and reactive victims from 2% to 10%.^3,4 Racial composition and school setting (eg, urban, rural) are not predictive for the occurrence of bullying.

While roots of aggression can be traced into the preschool years,^25,26 virtually no data exist on the extent of bullying behaviors in preschool, kindergarten, and first grade. Estimates of bullying among siblings are equally sparse.

In 2001, the National Institute of Child Health and Human Development (NICHD) published the first nationally representative research on this problem for the United States.¹⁷ Researchers queried 15,686 public and private school students, grades 6 through 10, on their experiences with bullying. The study was part of a collaborative cross-national research project on child health involving 30 countries that was coordinated by the World Health Organization. Almost 30% of US school children surveyed reported they had been involved in some aspect of bullying during the school year: as a bully, the target of a bully, or both. One out of 10 students (10.6%) reported being bullied "sometimes" or more often; 13.0% reported bullying others "sometimes" or more often during the current school term. An additional but smaller group (6.3%) not only perceived themselves as victims of bullying but also self-identified themselves as aggressors. In sum, more than 19% of the full sample reported bullying others and almost 17% reported being victims of bullying.

The NICHD results are consistent with extant literature, which indicates that bullying is more common among boys than girls.^2-5 The prevalence of students who are victims or bullies is consistently higher for boys than girls in elementary schools, but for each gender the prevalence decreases during the junior high school years and continues to decrease into high school.³ Boys tend to use both physical and verbal bullying while girls employ more subtle and psychologically manipulative bullying behaviors such as alienation, ostracism, and character defamation that affect relationships or friendships.^3,20,21 Because it is often indirect, relational bullying may be more difficult to detect and identify as compared to overt aggression. The prevalence of bullying among girls may therefore be underestimated if survey instruments are not sensitive to detecting relational aggression.^20,21 
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Key Behavioral Determinants

Numerous factors affect a child’s vulnerability and resiliency to bullying. These may include aspects of innate biology and temperament, as well as influences from the child’s family, friends, and environment. Current research indicates that a complex mix of individual, social, and environmental risk and protective factors interact to determine the etiology of bullying and other aggressive behaviors throughout childhood development.^19,25,27-29

Individual Factors. Children who are victimized regularly by bullies are likely to display internalizing behavior characteristics.^3,4,17,23,30 They may appear passive, sensitive, and quiet; may be seen as different, weak, or insecure; appear to do nothing to provoke attacks; and will not retaliate if attacked or insulted. Generally, these children lack confidence, have lower self-esteem, regard themselves as less competent, are more depressed and anxious, and have fewer friends than children who are not bullied. Nevertheless, exceptions to these patterns occur. For example, academically advanced students are often abused or teased (because of their academic success) by students who are academically challenged. Lesbian, gay, bisexual, and transgendered students are at particular risk of being bullied and harassed at school and in their communities.^31,32

Research suggests that bullies also may be victims of violence and abuse.^{3-5,19,25,26,28} Bullies tend to expect others to pick on them and misattribute hostile intentions by seeing threats where none exist.^5,26 They attack before being attacked as justification and support for their aggressive behavior. Students who regularly display bullying behaviors may be antisocial and defiant or oppositional toward adults.^3,6 Many bullies are physically strong, with good or inflated self-esteem. They feel little or no responsibility for their actions, and often feel the need to control, dominate, or win. Most critically, they are unable to understand and appreciate the emotional experiences of others.¹⁴ Ultimately, the bully may learn that "might makes right" and that being cruel is the means to social status and acceptance. Individual temperaments and acquired biological deficits may contribute to children’s aggressive tendencies (eg, antisocial personality disorders, attention deficit hyperactivity disorder).^{19,25,26-28,30}

Family Influences. Bullying may be an imitation of aggression experienced at home.^{3,23,25,26,29,33} Many childhood bullies are abused by a parent or witness parental abuse of a spouse or siblings. Some also are bullied by their siblings.³⁴ Living with family members who are overly punitive or verbally or physically abusive teaches children that aggression and violence are effective and appropriate means to attain a goal. Such children learn to strike back as a way of handling problems. In addition to experiencing inadequate or inappropriate discipline, bullies are likely to lack parental involvement, supervision, and nurturing during childhood.³

Role of Peers. A child’s peer group can have a key role in the development and maintenance of bullying and other antisocial and deviant behaviors.^{14,19,23,25-28,35,36} The presence of a peer audience is positively related to the persistence of bullying episodes. In studies of playground bullying, peers are substantially involved, whether as active participants or bystanders who are unable or unwilling to intervene.³⁵ Participants typically involve "assistants," who physically help the bully; "reinforcers," who incite the bully; "outsiders," who remain inactive and pretend not to see what is happening; and "defenders," who provide help for the victim and confront the bully. By their presence, peers may give power to bullies by giving them popularity and status.¹⁴

While peers can be a negative influence by supporting a bully, they can also be a positive influence through friendship and acting on behalf of victims.^19,24,25,28 Peers who witness bullying, however, may remain silent or be reluctant to intervene. Silence may result from denial, a psychological defense against anxiety evoked by the situation, as well as from fear that telling someone or defending the victim will provoke retaliation.^3,37 Failure to act is likely to reinforce bullies who may interpret ambivalence or inaction as condoning bullying behavior.³⁶

School Factors. School practices and policies can strongly influence student interactions, activities, and behaviors.^{3,19,27,28,37-41} Bullying and aggression are more likely to occur in schools with low staff morale, high teacher turnover, unclear standards of behavior, inconsistent methods of discipline, poor organization, inadequate supervision, and a lack of appreciation of children as individuals.⁴¹ The attitudes and actions of teachers can be critical influences against bullying by helping students shift their behaviors into more productive and socially acceptable channels. Schools can further influence student and staff behavior by creating a normative climate that promotes peace, respect, and intolerance of bullying and other aggressive behaviors.^3,38 By ignoring bullying or failing to intervene, school staff unwittingly reinforce this behavior by creating an environment that condones harassment and aggression as a means of resolving conflict and responding to actual or perceived threats.

Media. The portrayal of aggressive behavior on television and video appears to be associated with aggression in some children and adolescents.^19,28,42-46 This influence may be particularly strong for those with emotional, behavioral, learning, or impulse control problems.²⁸ Research suggests that children exposed to media violence may learn to expect and anticipate violence in their daily lives, become desensitized to it, develop positive attitudes toward the use of violence, fail to fully appreciate the negative consequences of violence and abusive behavior, and come to view violence as a source of social status or an effective way to solve problems.⁴² Although no studies have directly investigated the impact of media violence on bullying, media images and messages that promote stereotypes, disrespect, and social ridicule of certain people or groups may contribute to the perception that bullying humor is popular and acceptable behavior.⁴³ 
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Consequences of Bullying

Research consistently shows that both bullies and victims demonstrate poorer psychosocial functioning than noninvolved peers.^{3,17,23,30,47-49} Those who are both bullies and victims appear to be at particular risk for persistent social and behavior problems, including social isolation, failure in school, and involvement in problem behaviors such as smoking and drinking.^17,22,23,49 Bullying also may affect the climate of schools and, indirectly, the ability of all students to learn optimally.^3,5,30 While considerable research (based predominately on cross-sectional studies) suggests that bullying has negative psychosocial implications for involved individuals, longitudinal studies are needed to better describe the persistence of such effects and whether such difficulties are causes or consequences of this behavior.

Impact on Bullies. Some children begin to display patterns of aggressive behavior in early childhood.^19,25,26 Studies suggest that aggressive behavior during childhood (from ages 6 to 13 years) may be a risk factor for future problems with violence and delinquency.^{3,19,26,50,51} Research on the development of antisocial behavior in boys places bullying as an entry level behavior for physically aggressive acts.⁵² Some youths may progress from the first step of annoying or bullying others, to the second step of fighting with individuals or gangs, to the third step of engaging in more violent behavior (physical assault, rape). Bullying behavior has been linked to other forms of antisocial behavior, such as vandalism, shoplifting, skipping and dropping out of school, fighting, and use of drugs and alcohol. Some bullies also face peer rejection and social isolation, which may contribute to an increased risk of depression and suicidal behavior.⁴⁷ As adults, they may experience more alcoholism, antisocial personality disorders, and need for mental health services.⁵⁰ Childhood bullies also are at increased risk for criminal convictions and involvement in serious, recidivist crime in adulthood.^3,51

Effects on Victims. Victims of regular bullying experience more physical and psychological problems than peers who are not chronically harassed by other children.^{17,30,47-49,53-57} Repeatedly victimized children experience real suffering that can interfere with social and emotional development and academic performance. They may feel humiliated and develop a fear of going to school. Chronically victimized children can display symptoms similar to those of victims of chronic domestic violence.¹⁴ This includes despairing acceptance of their victimization and development of an attitude of self-reproach, which may lead victims to feel they deserve to be taunted, teased, and harassed. Children who are bullied demonstrate poor social and emotional adjustment; have greater difficulty making friends; and have low self-esteem, higher levels of insecurity, and greater feelings of sadness and loneliness.^{17,20,47-49,53-55} These children also may be more likely to manifest psychosomatic symptoms such as sleep disturbances, enuresis, and unexplained abdominal discomfort or headaches.^30,48,56,57

Children who are bullied may perceive the world as a threatening, unsafe place and become suspicious, withdrawn, or joyless. Cynicism may develop if they believe that authority figures have let the problem persist by disregarding or completely ignoring it. Some students who are habitually bullied or harassed may retaliate in a violent manner to get revenge.^10,58,59 In rare cases, bullying is a contributory factor in causing victims to harm themselves or consider suicide rather than endure continual harassment and humiliation.^3,48,53 Research also suggests that victims of frequent bullying during childhood are at increased risk of suffering depression and poor self-esteem later in life.³
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Prevention and Intervention

Problem Assessment. School officials may believe, in the absence of local data, that bullying is not a problem in their schools, despite evidence to the contrary for other communities and the country as a whole. One reason is that bullying is often unseen and underreported. Collection of local data on student and adult attitudes, behaviors, and beliefs about bullying is critical to evaluate the extent of the problem, justify and build support for intervention efforts, and serve as benchmarks for measuring outcomes once an intervention is in place. Information can be determined through interviews with children, self-report or peer nomination surveys, or direct observation of bullying and victimization. Ideally, such information should be collected periodically (eg, every 2 years) to reinforce the need for ongoing intervention and to measure the impact of new policies and programs.

Questionnaires that identify both student and adult attitudes about and experiences with bullying are valuable tools in identifying possible problems. A widely used instrument to measure bullying behaviors in school-aged children is the Olweus Bully/Victim Questionnaire.^60,61

A number of other survey instruments that attempt to measure violent and aggressive behaviors of children and adolescents are available.^62-64 Better instruments have good test-retest reliability and high internal consistency, have been administered for several years, and have been independently evaluated to assess reliability and validity. Strengths, limitations, and applications of these tools are described elsewhere.^62,65,66

Strategies to Prevent Youth Violence and Aggression. Numerous youth violence prevention programs have been developed to enhance skills or change individual attitudes toward aggressive and violent behaviors by involving parents, children, schools, and communities.^19,67-74 An underlying presumption of many youth violence prevention programs is that, by targeting behaviors that predict violence, more serious manifestations of aggression will be prevented. Most intervention programs target youth with specific risk factors (eg, poor academic performance, early aggression, victimization as a child, and weak family bonding); others address a much broader and more universal audience (eg, all students in a school). Despite the number of youth violence prevention programs available, few have evaluated reduction in bullying as a specific outcome measure.

Many youth violence prevention programs are school-based. They generally focus on developing social competencies and training in cognitive problem-solving skills for interpersonal conflict; others focus on reducing risk factors or conditions that lead to risk. The success of most school-based programs is uncertain, as rigorous evaluations have not been conducted.⁷⁵ At this time, research findings are more supportive of skill-development programs and programs designed to build family involvement, but caution should be exercised in generalizing from one program to the next.⁷⁵ Even where short-term studies have shown positive outcomes, long-term evaluations are lacking.

Promising Approaches to Prevent Bullying. Three adaptive systems are important in the development of youth competence and resiliency against bullying and other aggressive behaviors: (1) involvement of caring parents and other adult caregivers; (2) development of skills for self-regulation of attention, emotion, and behavior; and (3) development of good cognitive skills and intellectual functioning.⁷⁶ Some children develop these coping skills and mechanisms better than others; this may be related to innate qualities such as a positive sense of self-worth. A child’s age, gender, and developmental phase also can be factors in mediating a positive response to psychological trauma. In addition, strong social systems involving closeness to family members, attachment to school personnel, and membership in a positive peer group (eg, sports team, community service group) can be sources of support for students who are being bullied.^{19,24,25,30,41}

Because the pattern of bullying can begin at an early age, preventive actions should be started at home before a child enters school. Parents and other caregivers have the important task of preparing children to fit into the world socially. By the time they start school, children should have mastered aggression and impulse control. Some parents with poor styles of interaction with their children can benefit from training programs to learn more developmentally appropriate parenting skills. Promising programs exist to help parents and other caretakers develop positive parenting skills, as well as to help families deal with children who display aggressive and violent behaviors.^19,71-74 Whereas some parents and caregivers may benefit from more focused training, Table 1 suggests practical methods that all adults can use to protect children and adolescents from bullying.

The Olweus Bullying Prevention program, which was originally developed and evaluated in Norway, is currently the best documented and most effective program to reduce bullying among elementary and junior high school students.^3,16,77 The program is promoted or endorsed by a number of professional organizations and federal agencies,^19,67,78,79 and was recently identified as an Exemplary Program by the Center for Substance Abuse Prevention. The University of Colorado’s Center for the Study and Prevention of Violence identifies it as 1 of 11 model violence prevention programs that meet a high scientific standard of program effectiveness.^74,77 These programs, called Blueprints, have been shown to reduce adolescent violent crime, aggression, delinquency, and substance abuse.

The Olweus Bullying Prevention program aims to alter social norms by changing school responses to bullying incidents.⁷⁷ Interventions are directed at school-wide, classroom, and individual levels. In addition to explicit anti-harassment policies, the program is designed to improve the social awareness and interaction of students and staff. Classroom interventions are designed for all students (not only bullies and victims) and include a series of exercises that give students and teachers an opportunity to discuss issues related to bullying and peer relations. Rules regarding bullying are provided and enforced and efforts are made to protect and support victims. The impact of this program was evaluated in a quasi-experimental design involving several cohorts of students. Over a 20-month period (involving 2,500 youths in 42 schools), students’ self-reports indicated that the program led to a 50% or greater reduction in bullying across all grades (1 to 9), fewer new victims, less antisocial behavior, a better climate of cooperation, and greater pupil satisfaction with school life. Effects were evident for boys and girls. In addition, several antisocial behaviors such as theft, vandalism, and truancy, which were not focused on directly, decreased as well.

This research demonstrates that a comprehensive and coordinated approach to prevent and reduce bullying can be effective, using strategies and interventions involving many levels of participation. All members of the school community (students, teachers, parents, administrators, support staff) were involved in the development of clear rules and consequences that discouraged all forms of aggression. Creating an awareness of bullying and declaring that bullying is unacceptable allowed children to talk more freely about this behavior. In such an environment, children might be more confident to intervene if they felt adults would follow through and protect them when bullying occurs.

Olweus’ anti-bullying program has been replicated in other countries (albeit with more modest effects) and remains the model for many efforts around the world.^1,2,77 While research in Europe, Australia, Japan, and Canada indicates that a comprehensive whole-school intervention can be beneficial for elementary, middle, and junior high school students, the effectiveness of this approach in secondary schools is uncertain. This model has undergone little independent evaluation in the United States. A pilot study conducted several years ago in South Carolina that followed 6,388 students (grades 4 through 6) in 39 schools over a 2-year period showed a 25% reduction in bullying in schools that adopted the program.⁷⁷ The project has now been expanded and is under further evaluation.

Another anti-bullying program, the CAPSLE program (Creating a Peaceful School Learning Environment), adds a physical education component to teach elementary school children self-defense and self-control skills.^80,81 It also involves zero tolerance for bullying; a school discipline plan for modeling appropriate behavior; and a mentoring program for adults and children to help children avoid becoming bullies, victims, or observers. A 4-year pilot study involving 2 inner-city elementary schools showed positive results in reducing discipline-related referrals and improving academic performance. The program is now being evaluated in a randomized, controlled study involving 11 elementary schools in Kansas.
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Implications for Physicians

Physicians should recognize bullying as a complex behavior that may signal the presence of multiple problems and difficulties in the child’s development. Bullying can be a cautionary signal indicating significant psychiatric problems (eg, depression, conduct disorder, anxiety) and risk factors (eg, exposure to family violence, school dysfunction, social isolation). When addressing this problem, physicians have 4 key roles³⁰:

1. Identifying at-risk individuals
2. Screening for psychiatric comorbidities
3. Counseling families about the problem, including prevention and intervention
4. Advocating for violence prevention

No screening or assessment tool has been validated for identifying bullies or victims. There is no accepted psychological profile or assessment method to predict this behavior. In the absence of a validated assessment tool, physicians can use traditional rating scales to screen for mental health problems such as depression, conduct disorder, and suicidality that may involve bullying.^82-84 Clinical interviews and rating scales also may be helpful to guide intervention. In addition, clinical assessment can include interviews with parents, teachers, and others about the child’s behavior and possible risk factors. Physicians can use this information along with a careful developmental history to look for signs of bullying and other psychological stressors. Warning signs that may be suggestive for bullying or other psychological problems in children and adolescents are:

• Avoidance of certain situations, people, or places
• Increased frequency of absence from school due to illness
• Changes in behavior such as being withdrawn or passive, being overly active and aggressive or self-destructive, lack of concentration, unexplained bouts of rage or sullenness
• Frequent crying
• Signs of low self-esteem
• Unwillingness to speak or showing signs of fear when asked about certain situations or people
• Signs of injuries
• Lack of empathy toward others
• Alcohol or other drug abuse
• Suicide ideation
• Sudden changes in social or academic functioning
• Recurrent unexplained physical symptoms such as enuresis, sleep problems, headaches, and abdominal pain

Physicians should bring screening questions and anticipatory guidance about bullying and other aggressive behaviors into their practices, especially if problems are suspected.^79,85-88 Patterns of such behavior can be identified as early as the preschool years. Parents of children as young as 4 years of age should be asked how they would advise their child to handle a bully.⁸⁸ Parents also can be asked about their use of intimidation with young children. Pre-adolescent and early adolescent well-child examinations provide an opportunity for discussing how to demonstrate caring, show respect, and resolve conflicts nonviolently. Information can be provided on how to prevent bullying and respond if such behavior occurs. As suggested in Table 2, physicians should ask young patients, parents, or other caregivers directly about bullying. Open-ended questions should be asked about relationships with peers and how to resolve conflicts, followed by questions about specific behaviors (pushing, hitting, being afraid, being hurt).^30,88

If the bullying behavior does not stop, or if the bullying (or being bullied) interferes with a child’s functioning at school or with friends, he or she should be referred for a comprehensive evaluation by a trained and qualified mental health professional. When bullying is identified, patients should be screened for conduct disorder and various externalizing and internalizing comorbidities.^{18,30,83,84,89} If a pattern of victimization is suspected, physicians can screen for separation and generalized anxiety disorder, dysthymia, depression, and panic disorder.³⁰ Particular attention is needed to identify youth who are both bullies and victims, as they may experience higher levels of psychosocial pathology and be at increased need for psychiatric consultation.^17,23,47

A diagnosis of conduct disorder can be made, as appropriate, when externalizing behavior problems (ie, rule–breaking behaviors, conduct problems such as physical and verbal aggression, defiance, lying, stealing, truancy, delinquency, physical cruelty, criminal acts) become repetitive and persistent and occur in a variety of settings such as the home, school, or community.^18,84,89 Factors that may contribute to conduct disorder include brain damage, child abuse, genetic vulnerability, school failure, and traumatic life experiences. Many children with conduct disorder have related mood disorders, anxiety, post-traumatic stress disorder, substance abuse, attention deficit hyperactivity disorder, learning problems, or thought disorders. For cases of conduct disorder, behavior therapy and psychotherapy may be indicated to help the child appropriately express and control anger. Parents also may need expert assistance.

If children say they are being bullied, they should be believed and reassured that they have done the right thing in talking about the problem. Parents should be informed and advised to discuss the matter with school personnel. Affected children can be advised of simple measures to protect themselves (eg, ignoring name calling, making friends with a child who is not involved, telling a responsible adult). Children can be encouraged to develop new abilities and interpersonal skills through such activities as team sports, music groups, or social clubs. When children feel good about how they relate to others, they can feel better about themselves and are less likely to be bullied.⁹⁰

As consultants to schools and police departments, physicians can emphasize the importance of identifying and referring symptomatic children and adolescents. They can educate others who interact with children about the broad impact of bullying behaviors on youth development. Physicians can advocate for school-based services that address physical, mental, emotional, and social health needs of students in an integrated approach. Such services can identify youth for whom education programs may not succeed and for whom more intensive approaches are needed. Advocacy efforts can be directed at increasing community and family programs and services to eliminate risk factors and teach children social and cognitive skills. In addition, physicians can participate directly in community activities (schools, religious groups, youth groups) to increase awareness of bullying and its consequences, available community resources, and effective prevention and intervention strategies.

Physicians also can encourage participation of medical societies in national efforts to address this problem. The Health Resources and Services Administration’s Maternal and Child Health Bureau has begun work on a "Bullying Prevention Campaign" with the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, and the US Departments of Education and Justice. The effort seeks to engage families, schools, students, and communities to reduce the impact of bullying, teasing, and harassment by youth. A similar effort is being coordinated by the National Education Association. The AMA Alliance also has targeted bullying in schools as part of its national violence prevention and awareness campaign.

Comment

For many adults, bullying among children and adolescents is insidious and hidden from direct scrutiny. Children often remain silent about their bullying experiences, in part because they fear that bullies will intensify their abuse if the victims bring it to the attention of authorities. Children’s tendency to remain silent about bullying must be counteracted by efforts to educate them about the importance of reporting incidents to proper and responsive authorities. Children must be assured that bullies will not be allowed to continue (or increase) their abusive behavior after incidents are reported.

Because bullying is often unseen, adults may underestimate its prevalence and effects. Parents, teachers, and health care professionals should become more adept and sensitive at identifying possible victims and bullies and understand the severity of this problem. A growing body of research indicates that ignorance of the problem or failure to intervene can cause sadness, despair, and hopelessness in affected children. Unable to cope, with nowhere to turn, troubled youth may drop out of school or unleash their frustration, anguish, and rage on themselves or others. To prevent such occurrences, stronger commitment is needed to ensure that all children and adolescents have the opportunity to grow up in safe, secure environments where they are free from bullying, harassment, and intimidation.

Although studies of successful anti-bullying programs are scarce in the United States, evaluation data from other countries suggest that adopting a comprehensive approach in schools can change student behaviors and attitudes and increase adults’ willingness to intervene. While some programs may be more effective than others, no single program will meet the needs of all students. The best approach is to involve all community stakeholders in selecting a mix of violence prevention strategies based on local needs and resources. A comprehensive anti-bullying plan should involve the entire student body, while targeting some efforts to high-risk students. Programs must be tailored to a child’s age and developmental needs and capacities. Emphasis should be placed on primary prevention and early intervention. Early intervention should emphasize social and cognitive skills training and development, problem-solving techniques, and anger management. Effective prevention also should focus on helping families improve parenting skills. Parent training is essential to reinforce the need for adequate nurturance, supervision, appropriate discipline practices, and modeling of positive social behaviors. This includes developing a strong value system in the home and school that bullying is unacceptable and will not be tolerated. Expansion of school health and mental health services is needed to help troubled students and assist them before their problems become severe. Children who bully should have a comprehensive evaluation by a child psychiatrist or other qualified mental health professional.

Bullying is a serious form of abuse that may lead to more severe violence and delinquency later in life. Physicians should be vigilant for possible warning signs and intervene appropriately to minimize immediate and potential long-term effects in bullies and victims. Physicians should ask about bullying when children and adolescents present with unexplained psychosomatic and behavioral symptoms; when they experience problems at school or with friends; when they express thoughts of suicide or other deliberate acts of self-harm; or if they begin to use tobacco, alcohol, and other drugs. Physicians and other health care professionals can assist further through advocacy and technical support for system-wide change. This includes research, education and training, intervention, and public policy efforts.
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RECOMMENDATIONS (Adopted AMA Policy and Directives)

The following statements, recommended by theCouncil on Scientific Affairs, were adopted as AMA policy and directives at the 2002 AMA Annual Meeting:

1. The AMA recognizes bullying as a complex and abusive behavior with potentially serious social and mental health consequences for children and adolescents. Bullying is defined as a pattern of repeated aggression; with deliberate intent to harm or disturb a victim despite apparent victim distress; and a real or perceived imbalance of power (eg, due to age, strength, size), with the more powerful child or group attacking a physically or psychologically vulnerable victim. (Policy)
2. The AMA will work with appropriate federal agencies, medical societies, the Alliance, mental health organizations, education organizations, schools, youth organizations, and others in a national campaign to change societal attitudes toward and tolerance of bullying, and advocate for multifaceted age and developmentally appropriate interventions to address bullying in all its forms. (Directive)
3. The AMA advocates federal support of research (a) for the development and effectiveness testing of programs to prevent or reduce bullying behaviors, which should include rigorous program evaluation to determine long-term outcomes; (b) for the development of effective clinical tools and protocols for the identification, treatment, and referral of children and adolescents at risk for and traumatized by bullying; (c) to further elucidate biological, familial, and environmental underpinnings of aggressive and violent behaviors and the effects of such behaviors; and (d) to study the development of social and emotional competency and resiliency, and other factors that mitigate against violence and aggression in children and adolescents. (Policy)
4. The AMA urges physicians to (a) be vigilant for signs and symptoms of bullying and other psychosocial trauma and distress in children and adolescents; (b) enhance their awareness of the social and mental health consequences of bullying and other aggressive behaviors; (c) screen for psychiatric comorbidities in at-risk patients; (d) counsel affected patients and their families on effective intervention programs and coping strategies; and (e) advocate for family, school, and community programs and services for victims and perpetrators of bullying and other forms of violence and aggression. (Policy)
5. The AMA will advocate for federal, state, and local resources to increase the capacity of schools to provide safe and effective educational programs by which students can learn to reduce and prevent violence. This includes: (a) programs to teach, as early as possible, respect and tolerance, sensitivity to diversity, and interpersonal problem-solving; (b) violence reduction curricula as part of education and training for teachers, administrators, school staff, and students; (c) age and developmentally appropriate educational materials about the effects of violence and aggression; (d) proactive steps and policies to eliminate bullying and other aggressive behaviors; and (e) parental involvement. (Policy)
6. The AMA will advocate for expanded funding of comprehensive school-based programs to provide assessment, consultation, and intervention services for bullies and victimized students, as well as provide assistance to school staff, parents, and others with the development of programs and strategies to reduce bullying and other aggressive behaviors. (Policy)
7. The AMA urges parents and other caretakers of children and adolescents to (a) be actively involved in their child’s school and community activities; (b) teach children how to interact socially, resolve conflicts, deal with frustration, and cope with anger and stress; and (c) build supportive home environments that demonstrate respect, tolerance, and caring and that do not tolerate bullying, harassment, intimidation, social isolation, and exclusion. (Policy) Back to Top

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Table 1. Parent and Caregiver Tips for Reducing Bullying Among Children and Adolescents

Help children avoid being victimized by a bully

• Listen to them. Get them to admit there is a problem.
• Help them search for answers. Express confidence that the problem can be solved. Don’t expect them to work it out on their own.
• Make it clear that it is not their fault.
• Teach self-respect. Help them develop a sense of their own personal power and self-worth.
• Teach them when and how to be assertive and stand up for their own rights and show that they are not afraid of bullying behavior.
• If your child is harassed at school, encourage him or her to seek from help from a teacher, principal, or other adult.
• Emphasize that there is no shame in asking for help.
• Tell the child to try to ignore the bully, tell the bully to stop bothering them, defuse the situation with humor, or just walk way from insults and threats.
• Do not tell or teach them to fight back.
• Encourage friendships.
• Try to improve their self-esteem and self-confidence.
• Enroll them in classes or groups that develop social competencies.
• Intervene and show that bullying is not tolerated.
• Get involved at their school. See what programs are available to help prevent bullying.

Help prevent children from becoming bullies

• Look at your parenting practices. Model caring and empathetic relationships at home; model appropriate behavior, aggression control, and healthy temperament to your children.
• Supervise their activities; know their whereabouts.
• Find opportunities to help them channel aggression into sports or other organized group activities.
• Discuss and acknowledge the results of bullying behavior on themselves and others.
• Set clear and consistent behavioral expectations.
• Monitor television and video for violence messages.
• Recognize and reward positive attitudes, behaviors, and actions.
• Instill that "might does not make right."
• Set and enforce consistent rules and limits.
• Avoid use of physical punishment, harsh criticism, and violent emotional outbursts.
• Do not tolerate bullying and other aggressive behaviors. When witnessed, stop this behavior immediately.
• Teach them to respect themselves and others.
• Note any disturbing behaviors such as frequent angry outbursts, fighting, and teasing of other children; cruelty to animals; fire setting; frequent behavior problems at school and in the neighborhood; lack of friends; and use of alcohol and other drugs.
• Seek help from a physician, school counselor, or qualified mental health professional when children display bullying or aggressive behaviors.

Sources: References 3,7,30,41,90

Table 2. Sample Questions to Investigate Whether a Child is Being Bullied 

References

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Resolution 413 (A-01) 

Resolution 413, introduced by the American Academy of Child and Adolescent Psychiatry and the American College of Preventive Medicine, was amended and adopted at the 2001 Annual Meeting. It asks that our American Medical Association (AMA):

• Encourage appropriate public and private funding agencies to support research on bullying behavior and anti-bullying interventions;

• Through the Council on Scientific Affairs, review the available research on the efficacy of intervention programs designed to reduce bullying;

• Work with specialty societies, state and local medical associations, the Alliance, public health agencies, departments of education, and other interested parties in preparing and disseminating materials that will help schools, teachers, parents, and others to address bullying at the local level; and

• Evaluate survey instruments that can be used to measure the incidence of bullying.

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