Richard Lichenstein, MD

Although bullying was once thought of as a rite of passage into adulthood, it is now more appropriately considered a preventable health problem that not only has lasting impacts, but that the pediatrician can address in his or her office.

 This article will describe what bullying is, its impacts on the child, risk factors for bullying, and finally how the pediatrician can address bullying in the office.

The Centers for Disease Control and Prevention (CDC) defines bullying as “any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. Bullying may inflict harm or distress on the targeted youth including physical, psychological, social, or educational harm.”

Cyberbullying uses social media and other electronic means in order to hurt others. It is different from traditional bullying in that it can be done at any time, often anonymously, and spread to a greater audience quickly. Not surprisingly, young persons involved as both bullies and victims are frequent users of electronic media, and there is significant overlap in the characteristics of both traditional and cyberbullying.

Estimates of traditional bullying at school and cyberbullying range from 18% to 31% and 7% to 15%, respectively. The 2013 National Youth Risk Behavior Surveillance System (YRBSS) estimated that approximately 20% of high school students were bullied and 15% were cyberbullied.

Victims of bullying are at increased risk for a number of adverse consequences such as:

-       Suicidal ideation and attempts

Likewise, children who only bully are more likely to develop antisocial personality disorder and participate in criminality. Recent research has additionally identified another high-risk group-the “bully/victim.” These children not only bully other children but are also the victims of bullying. Observational research indicates that these children experience overall worse outcomes through adulthood.

-       Engages in more acts of bullying compared with a pure bully.

-       Experiences more thoughts of self-harm and suicidality.

-       Is more likely to have mental health issues in childhood and more intense anxiety and depression.

-       Is more likely to smoke and participate in other substance abuse.

-       Is less likely to graduate high school.

-       Experiences more intense anxiety and depression.

-       Is more likely to be socially isolated and may not have any friends at all.

Whereas there are a number of methodological issues with attempting to identify independent risk factors associated with bullying, the literature is able to identify many children impacted by bullying.

Boys are at greater risk of being physically bullied and girls are at greater risk of being emotionally or cyberbullied.

 Ethnic or religious minorities report small increases in being victims of bullying behaviors compared with other students.

Lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) adolescents report being victims of bullying more than twice as often as their heterosexual peers. These LGBTQ youth also are less likely to report it.

 This may be a factor in increased risk of suicide among this group. More supportive environments (schools with gay-straight alliances and antibullying policies specifically protecting LGBTQ adolescents) were associated with fewer suicide attempts.

Overweight children are more than twice as likely to be bullied than their normal-weight peers.

 Children with autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), and learning disabilities also report increased risk of being bullied.

 Finally, children with chronic conditions such as epilepsy or food allergy also report increased rates of being bullied.

A child’s relationship with peers impacts his/her risk of being bullied. Middle school children who make friends more easily are less likely to be bullied than those reporting more difficulty.

A number of parenting behaviors have relationships to bullying, although the effect size was small for youth involved as victims and moderate for those involved as bully/victims.

 Negative parenting behaviors increase risk of being involved as a victim and bully/victim whereas overprotection was only associated with being a victim.

 Low socioeconomic status is also associated with increased risk of being bullied.

A number of factors have been found to be protective of both becoming a bullying victim as well as on adverse effects of bullying. Parent connectedness or some form of caring adult is protective for young persons involved as bullies and victims whereas having caring friends further protected youth who are involved as victims.

 Positive parenting also has been noted to have small to moderate effects on bullying.

Although school climate is challenging to study due to a number of methodological issues, it can impact bullying. The Olweus Bullying Prevention Program significantly decreased bullying in Norwegian schools but has been difficult to replicate in US schools.

 Positive school climate has been found to have a small to moderate effect on decreasing bullying.

 Providing teachers engage, telling teachers is one coping strategy; others include ignoring the situation and taking steps to avoid a bullying situation altogether. Finally, empowering children with better skills to cope with their own feelings related to bullying behavior can be protective.

The pediatrician can incorporate a process both to screen for bullying as well as to provide support and resources for parents and caregivers.

As with many other issues impacting pediatrics, the pediatrician:

Systematically screening is one way to identify bullying across an entire practice. Bright Futures questionnaires include age-appropriate questions about bullying.

 is a framework to take comprehensive social history from an adolescent that can identify bullying. (For other published questionnaires that are available for pediatricians, see “Additional clinician resources.”)

The review of systems may reveal somatic complaints such as abdominal pain or headaches that may be associated with bullying. Additional warning signs that would prompt the pediatrician to examine bullying more closely include social withdrawal, school absenteeism, declining grades, behavioral problems, and suicidal ideation.

After identifying bullying, the next step is to understand the circumstances surrounding bullying. It is important for the pediatrician to identify when, where and how often bullying is occurring. Providers should determine context (eg, is the bullying direct [being hit, slapped, or pushed] or indirect [rumors or cyberbullying]). It also may be important to get information from teachers. If indicated, consider validated screens for anxieties and depression.

Additionally, the pediatrician needs to be aware that the behaviors may represent another type of hurtful behavior altogether such as peer conflict, dating violence, harassment, or hazing. Finally, the pediatrician needs to incorporate the previously mentioned risk factors and protective factors into their assessment and plans for the bullied child.

Interventions can range from individual to programmatic. The following suggestions focus on what the pediatrician can do in his/her office.

Although most cases can be handled in the office setting, it is important for the pediatrician to identify if a child is in imminent danger or has been the victim of physical or sexual abuse. When necessary, the pediatrician must contact the appropriate law enforcement authorities and school. Likewise, if the pediatrician is concerned about suicidality, he/she must contact an appropriate mental health professional or transport the patient to the emergency department.

Through role playing in the office and encouraging caregivers to model at home, children can learn how to respond to bullying.

One possible method of interaction with a bully that can be modeled is as follows:

- Look directly at the bully and confidently speak to him/her in a firm, loud voice. Examples might include:

- Immediately walk away with confidence (do not run) and with your head held high.

Children may need to be told to tell a different adult if they have previously reported bullying and nothing was done. As many children do not report bullying, it is also important to explain to them that discussing with an adult will not only provide support but will also help develop a plan to stop bullying.

If the child is a victim of cyberbullying, the pediatrician can recommend:

·      Don’t forward, respond, or “like” online content that is harmful to others.

·      Keep evidence of cyberbullying such as dates, times, descriptions, screen shots, e-mails, and texts.

·      Report bullying to school and law enforcement as appropriate.

At a more general level, the pediatrician should incorporate being a good digital citizen into age-appropriate education. Parents should be encouraged to be aware of what their kids are doing online and to talk with their children about how text and other online content can be perceived and the very real-world consequences of it. Parents need to remind children that digital content can spread quickly online and discuss what to do if they or someone else is being victimized by a cyberbully.

Invariably, the school should be involved. The pediatrician should advise parents and caregivers to meet with teachers or counselors to discuss concerns and work up the school administrative ladder if needed. Additionally, the pediatrician can consider calling or writing to a teacher/counselor to discuss concerns.

Provide parents and youth with recognized resources, such as 

Just as with any other medical problem, the pediatrician should offer a follow-up visit. If initial interventions are not successful or have worsened, consider referral to a mental health professional.

Outside the care of individual patients, the pediatrician can advocate locally, regionally, and nationally to prevent and provide programs surrounding bullying. Most states have laws to prevent bullying in schools, but there is significant variation in the strengths of these laws.

Consider working with schools and local policymakers to strengthen antibullying laws, provide education, and improve services.

When parents or teachers see bullying in progress, they should step in and stop it. However, because most bullying takes place outside the presence of adults, can interventions empower students to stop bullying? Hawkins demonstrated that when student bystanders intervened, 57% of episodes ceased within 10 seconds.

 The problem is that children intervene only 15% to 20% of the time.

A school-based antibullying program in Finland-KiVa-takes a multipronged approach to try to decrease bullying and its impacts. Its goals are to:

·      Increase awareness that groups play in maintaining bullying.

·      Promote empathy toward victims.

·      Promote children’s skills in supporting the victim and increase their self-efficacy to do so.

·      Increase coping skills for the victimized.

In intervention schools, peers both defended victims more commonly and had greater antibullying attitudes as well as empathy toward victims of bullying. Self-reported victimization and bullying decreased in intervention sites by 30% and 17%, respectively.

Garandeau looked at the intentions of youth who bully to change behavior as part of a school-based intervention wherein schools were randomized to a confrontational versus nonconfrontational method of dealing with a bullying incident.

 Those who bullied were anonymously surveyed following the incident.

Condemning the behavior and making those who bullied feel empathy for the victim were significantly associated with more intentions to stop bullying compared with those treated with the confrontational approach.

Screen bullies for psychiatric or behavioral problems

 found that large numbers of youth involved as pure bullies and bully/victims demonstrated symptoms that may indicate a psychiatric problem. Advocating for more mental health services to get children the help they need rather than asking school systems to handle these problems is another area of potential advocacy.

Bullying is a significant problem impacting young persons today. Pediatricians need to be aware of risk factors and impacts, and develop office-based systems to screen for and address this problem. Further, the pediatrician needs to be aware of and advocate for more antibullying resources in his/her community.

1.  Flannery DJ, Todres J, Bradshaw CP, et al. Bullying prevention: a summary of the report of the National Academies of Sciences, Engineering, and Medicine: Committee on the Biological and Psychosocial Effects of Peer Victimization: lessons for bullying prevention. 

2. Gladden RM, Vivolo-Kantor AM, Hamburger ME, Lumpkin CD. 

Bullying Surveillance among Youths: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0

. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, US Department of Education; 2014.

3. Kowalski RM, Limber SP. Psychological, physical, and academic correlates of cyberbullying and traditional bullying. 

4. Kann L, Kinchen S, Shanklin SL, et al; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance--United States, 2013. 

5. Copeland WE, Wolke D, Angold A, Costello EJ. Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. 

6. Wolke D, Copeland WE, Angold A, Costello EJ. Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. 

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Bullying is a preventable health problem that has lasting impacts. Pediatricians need to screen patients for risk factors, empower families with coping skills, and advocate for antibullying resources in their communities.

Richard Lichenstein, MD

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