Teasing and bullying: What can pediatricians do?

Teasing and bullying: What can pediatricians do? By James U. Scott, MD, Kathleen Hague-Armstrong, PhD, and Kathryne L. Downes Teasing and bullying harm both victim and perpetrator. Pediatricians are in a good position to address these destructive behaviors and reduce their toll. The number of children in the United States who suffer as a result of teasing and bullying is staggering. Roughly 20% of children in elementary and middle school5 million youngstershave reported being a victim of teasing or bullying.1 Forty percent of high school students reported that they either witnessed bullying or were the victim of it daily.2 More troubling than the numbers are the behavioral, health, and social consequences of teasing and bullying. Not only do these behaviors compromise healthy child development, but they may also lead to a tragic loss of lives through acts of violence or suicide. The heavy toll of teasing and bullying In response to the shootings at Columbine High School in Colorado and at other schools, the US Secret Service and US Department of Education conducted a study in 2002 to discover elements common to the shootings so that schools and communities can plan to take preventive action.3 Although no one common element was found, more than two thirds of the shooters reported that they had been victims of chronic bullying. Rejection and persecution by peers also has been linked to youth suicide, the third leading cause of death for adolescents.4,5 Although not all teasing and bullying incidents lead to a tragic outcome, both behaviors can cause significant and long-lasting health and mental health problems. The consequences may be especially damaging for children with an unstable family situation. School avoidance and failure, social problems, and somatic complaints have been linked to teasing and bullying among children as young as 5 years.6 Later problems related to teasing and bullying include substance abuse (smoking, alcohol, illegal drug use), gang affiliation, depression, and conduct disorder, often beginning by middle school, and poor academic performance that leads adolescents to drop out of high school.6,7,8 Whether a child is a victim of teasing and bullying, a bully, or a victim and a bully, peer relationships are affected. Peers tend to reject children whom they see as a victim.9 Bullies, especially those who are aggressive at an early age, remain at risk for poor relationships as adolescents and adults.10,11 Bullies who are themselves bullied are at highest risk for peer rejection, behavior and mental health problems, and school failure.7,8,12 The American Medical Association (AMA) has recognized teasing and bullying as both health and social issues and has called upon physicians to take the lead in prevention efforts.13 The AMA report recommended that physicians be vigilant for warning signs that a patient is being bullied, such as psychosomatic and behavioral symptoms, expressions of self-harm, or thoughts of suicide. It charged physicians to work with parents, teachers, and others in their communities to develop programs to treat both bullies and their victims. While both teasing and bullying can be painful experiences for children, severe bullying that involves physical aggression may cause the most trauma. (For more on the distinction between teasing and bullying, see "Teasing and bullying: What's the difference?".) When a power differential exists between bully and victim,14 children cannot escape unless adults intervene in a meaningful and proactive way.15,16 Recognizing and addressing the problem Teasing and bullying harm both the victim and the bully. Before those roles become entrenched, it is essential that children receive the support they need. The pediatrician may be the first to recognize clues to a child's distress (Table 1), such as unspecified somatic symptoms (stomachache, insomnia, enuresis)6 or sleep problems. Behavioral changes, including irritability, poor concentration, and school refusal, are other clues. Drug or alcohol abuse, school failure, self-mutilation, and violence are among the more serious presentations that may be related to being victimized. TABLE 1 Warning signs that a child is being bullied Somatic Stomachache Insomnia New-onset enuresis Behavior changes Irritability Poor concentration Refusal to attend school Serious problems School failure Drug and alcohol abuse Violence Self-mutilation Asking a few simple questions can help determine whether further assessment is needed. Useful strategies for interviewing children include descriptive comments ("Things seem to be tough for you at school"), reflection ("So you felt pretty angry when Josh called you that name"), encouragement ("I know that it's not easy to talk about this problem"), and clarification ("So tell me about a time when you were afraid to go to school"). Open-ended questions, such as "What is it like for you at school?," help children express their thoughts and feelings about the problem. Crayons, puppets, and clay can help younger children tell their story. Adolescents who cannot articulate their feelings clearly and reflect on their experiences may be helped by a direct, explicit approach"Do you have friends at school? Any enemies? Tell me about them. What makes you see them as enemies?"17 Pediatricians need to know what resources are available to assist children who are bullies or victims of bullying, and they should help children connect to adults who can support them in their everyday lives, such as extended family members, school psychologists and counselors, and coaches. In more extreme casesin which a child expresses angry or rebellious behavior, thoughts about suicide, a wish to carry out vengeance, or signs of alcohol or drug abusethe pediatrician must notify the parents and refer the child and family for mental health counseling and crisis intervention. Parents need to be encouraged to reach out to their child through increased supervision and communication. Tables 2 and 3 summarize ways in which pediatricians can help victims and bullies, respectively. TABLE 2 How you can help victims of teasing and bullying Listen to both the parents' and child's perception of the problem. Listening to the parents empowers them to help the child. Ask children about teasing as early as 5 years of age because children in groups can make cruel remarks. Using open-ended questions can help children to speak in their own words. Using art materials can help when a child has difficulty communicating. At this young age, the parents' participation is crucial to reassure and protect the child . If parents choose to attempt conflict resolution between children, suggest that teaching the child about apologizing, asking forgiveness, shaking hands, and other culturally appropriate measures can help promote conflict resolution. Children older than about 8 years can be taught to cope with teasing by ignoring it. Introduce this technique for parent and child to practice in role play before using it in actual situations. Encourage parents to be proactive if the teasing is occurring outside the home. Suggest that they attempt to talk to witnesses to the teasing to obtain accurate firsthand information and that they seek to resolve conflicts by involving the parents of the teaser and other caregivers responsible for the teaser and victim, particularly when the teasing is repetitious, public, and obnoxious. Encourage the family to approach the school or, if appropriate, law enforcement authorities, to intervene if the bullying is occurring on school grounds or at school functions. Helpful people to talk to might include the school principal, guidance staff, and individual teachers, especially if bullying occurs consistently in the teacher's sphere of supervision. Consider encouraging school staff to arrange a meeting between parents to help solve the problem. Communicate by phone or letter with school personnel if cooperation does not occur. Offer to speak about teasing and bullying to school staff and students. If the child expresses thoughts about suicide or a wish to carry out vengeance, make an immediate referral for further mental health intervention and crisis management. Support the parents' involvement in seeking help for their child. TABLE 3 How you can help bullies stop Emphasize the seriousness of the problem. Express concern about bullying actions and make an effort to determine why the child acts in that manner. Assume an interested yet mildly confrontational style that reflects disapproval of the action but not the bully. Advise parents of bullies to express disappointment rather than anger. This approach often has more impact in dealing with the problem. Encourage disclosure of bullying acts by the child. Encourage accountability of the child to parents and teachers, guidance counselors, or other trusted adults with parental and child permission. Refer the child to a mental health counselor to explore ways to understand the bullying behavior, its origin, and ways to curb the behavior and express anger in a more appropriate, nonhurtful manner. Counseling parents The parents of both victims and bullies are often anxious or upset, and feel unable to help their child. Using active listening strategies such as reflection ("I hear that you are upset about children teasing Allie") and open-ended questions ("How well do you think your child is doing?"), the pediatrician can help parents gain a clearer understanding of the problem and often guide them toward a solution. The parents must be asked to describe the presenting problem, what happens before the behavior occurs, what happens after the behavior has occurred, and strategies they have used to deal with the problem.11,17 Enhancing parental knowledge of child rearing can help parents use more proactive strategies to solve problems. For example, if the problem occurs at school, encouraging parents to become more involved with the school by collaborating with their child's teachers may strengthen the bullied child's sense of security. The pediatrician could also suggest that parents of a bully monitor the child's television time or restrict opportunities to play violent video games. Garrity and Baris's 1996 article in Contemporary Pediatrics includes a helpful guide for parents on how to deal with bullying.18 The parent guide is reproduced below. Working with school staff Because teasing and bullying often occur at school or on the way to school, the school staff is an essential partner in prevention. Schools have become more aware of their role in addressing the problems associated with teasing and bullying and may be open to collaborative problem solving with physicians and parents. The number 1 strategy known to deter teasing and bullying is increased supervision of students.11,14 Teachers, parent volunteers, and other students can help to safeguard children from mistreatment. Adult mentors in the schools and community have been successful in supporting children and adolescents, buffering the impact of teasing and bullying. Pediatricians can help schools develop programs that teach children appropriate social skills and peaceful methods so that they can resolve their conflicts by negotiation, mediation, problem solving, and alternatives to violence.11,19 A critical role Teasing and bullying are age-old problems that continue to shape child development. In today's world, they may lead to deadly consequences. The degree of damage to development may vary significantly from one child to the next, often depending on the severity, duration, and timing of the teasing or bullying and the effects of coexisting life influences. Children who lack effective coping skills and adult support may respond in ways that endanger their own safety and well-being or the safety of others.10 Social and behavioral problems, health problems, school failure, depression, suicide, and homicide are outcomes that might be avoided through the efforts of caring adults. Because pediatricians are often the first point of contact for children experiencing problems resulting from teasing and bullying, they can play a critical role in helping to find solutions. Perhaps more than anyone, they are aware of the painful experiences children encounter in growing up and the supports needed to protect children and ensure their healthy development. Moreover, pediatricians can use their influence as health-care providers to rally support for effective prevention and intervention efforts in schools and communities. The parent guide on teasing and bullying may be photocopied and distributed to families in your practice without permission of the publisher. REFERENCES 1. Pellegrini AD, Bartini M, Brooks F: School bullies, victims, and aggressive victims: Factors relating to group affiliation and victimization in early adolescence. Journal of Educational Psychology 1999;91:216 2. Hensen K, Massey O, Armstrong K: School Perceptions of School Safety: Results of the Omnibus Survey. Tampa, Fla, The Louis de La Parte Mental Health Institute, Department of Child and Family Studies, University of South Florida, 2002 3. Vossekuil B, Fein RA, Reddy M, et al: The Final Report and Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States. Washington, D.C., US Department of Education and US Secret Service, May 2002 4. Sandoval J, Brock SE: The school psychologist's role in suicide prevention. School Psychology Quarterly 1996;11(2):169 5. Carney AG, Merrel KW: Bullying in school: Perspectives on understanding and preventing an international problem. School Psychology International 2001;22(3):364 6. Karstadt L, Woods S: The school bullying problem. Nursing Standard 1999;14(11): 32 7. Haynie DL, Nansel TR, Eitel P, et al: Bullies, victims, and bully/victims: Distinct groups of at-risk youth. J Early Adolesc 2001;21(1):29 8. Nansel TR, Overpeck M, Pilla S, et al: Bullying behaviors among US youth: Prevalence and association with psychosocial adjustment. JAMA 2001;285(16): 2094 9. Crick NR, Bigbee MA: (Apr. 1998) Relational and overt forms of peer victimization: A multiinformant approach. J Consult Clin Psychol 1998;66(2):337 10. Sprague JR, Walker H: Early identification and intervention for youth with antisocial and violent behavior. Exceptional Children 2000;66(2):367 11. Canter AS, Carroll SA (eds): Helping Children at Home and School. Bethesda, Md., The National Association of School Psychologists, 1998, pp 359, 523524, 527529 12. Nagin D, Tremblay RE: Trajectories of boys' physical aggression, opposition, and hyperactivity on the path to physically violent and nonviolent juvenile delinquency. Child Dev 1999;70(5):1181 13. AMA calls on physicians to help reduce bullying. American Medical Association 2002 www.ama-assn.org/ama/pub 14. Batsche GM, Knoff HM: Bullies and their victims: Understanding a pervasive problem in the schools. School Psychology Review 1994;23(2):165 15. Hazler RJ, Carney JV: When victims turn aggressors: Factors in the development of deadly school violence. Professional School Counseling 2000;4(2):105 16. Landau, Milich R, Harris MJ, et al: "You really don't know how much it hurts": Children's and preservice teachers' reactions to childhood teasing. School Psychology Review 2001;30(3):329 17. Sattler JM: Clinical and Forensic Interviewing of Children and Families. San Diego, Jerome M. Sattler, Publisher, Inc., 1998, pp 106115, 134135 18. Garrity C, Baris MA: Bullies and victims: A guide for pediatricians. Contemporary Pediatrics 1996;139(2): 90 19. Shinn MR, Walker HM, Stoner G (eds): Interventions for Academic and Behavior Problems II: Preventative and Remedial Approaches. Bethesda, Md., National Association of School Psychologists, 2002, pp 143166, 303, 351372 DR. SCOTT is assistant professor of pediatrics and a developmental pediatrician, division of child development, University of South Florida College of Medicine, Tampa. DR. HAGUE-ARMSTRONG is a school psychologist and assistant professor in the departments of pediatrics and child and family studies, Louis De La Parte Florida Mental Health Institute, University of South Florida, Tampa. MS. DOWNES is an undergraduate research assistant at the University of South Florida, Tampa. The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article. Online resources about bullying American Academy of Pediatrics www.aap.org/advocacy/archives/aug01school.htm American Psychological Association Help Center www.helping.apa.org/warningsigns/recognizing.html National Association of School Psychologists www.nasponline.org/factsheets/bullying-fs.html National Resource Center for Safe Schools www.safetyzone.org US Department of Education www.ed.gov/pubs2002/crime2001/6.asp?nav=1 US Department of the Secret Service www.secretservice.gov/ntac.htm Teasing and bullying: What's the difference? Teasing and bullying are related but distinct behaviors that can be differentiated based on the intent of the perpetrator. Teasing is a provoking behavior that encourages reaction and interaction. It combines elements of hostility, humor, and ambiguity. Teasing is usually seen earlier than bullying, appearing first as expressions or gestures and later as words. It often occurs in the presence of peers, making embarrassment more public. Bullying has a more hostile intent than teasing and relies on intimidation of weaker children by stronger ones. Bullying includes three key elements: a power imbalance between bully and victim intent to harm the victim usually, repetition of the behavior toward a single victim, often in a chronic manner. In both teasing and bullying, the victim feels angry and embarrassed. Rarely, a victim may react with aggression towards the bully or self, at times with dire results such as homicide or suicide. GUIDE FOR PARENTS What to do about bullying? By Sarah Emerson Shea, MD It is both painful and frightening to suspect that your child is being bullied by another child at school or in the neighborhood. It is also painful and frightening to suspect that your child habitually bullies others. How do you know if there is a problem? It is normal for children to tease one another. Arguing is also common and should not be regarded as a problem, provided the balance between the children is relatively equal. Even physical roughness, while undesirable, is common enough in schoolyards that it should not by itself be interpreted as evidence of bullying behavior. Parents should be concerned if they learn that a child is repeatedly and deliberately victimizing other children. Examples include vicious and persistent teasing, poking or hitting, or taking advantage of another child by extorting money, food, toys, or assistance with school work. Children who come home with unexplained money or toys should be suspected of bullying or stealing. Schoolyard bullies usually engage in similar activity in other settings. At home they may defy authority figures, including parents, and engage in angry or destructive behavior. Sorting out whether your child is being bullied or simply getting his or her fair share of teasing can be more difficult. Children who are by nature shy or lacking in confidence are especially susceptible to bullying. Obviously, if a child regularly reports being taunted, hit, or having belongings damaged or stolen, you should be concerned. Watch too for the child who starts to demonstrate fearful behavior or refuses to attend school or participate in activities with other children. If you are not sure whether your child is being bullied, ask indirect questions about how he or she is spending lunch periods and about what it is like walking to school or taking the bus. Ask if there are children at the school or in the neighborhood who are bullies, without personalizing it to your child. Remember that children feel humiliated if they are victims. Often, they doubt the willingness or capacity of adults to help, and they fear that complaining to the authorities will provoke further retaliation from the bullies. If your child is a bully Take the problem seriously. Children who are aggressive and bullying when young are at high risk for social problems later on in life. Look for underlying problems that may be causing your child to feel angry or frustrated. Is your child experiencing bullying from someone else, then passing it on to the next victim? This "food chain" phenomenon can be observed in children who are themselves exposed to verbal or physical abuse from parents, siblings, or other children. Supervise your child's behavior more closely. Arrange to increase his or her participation in supervised, organized activities such as sports or scouting. Stay in the vicinity as much as possible when your child is playing with others. Make sure your child understands that you won't tolerate behavior that hurts other people. Talk about the rights and feelings of others. For example, if you hear that someone has been hurt physically or emotionally, share the story with your child and ask, "How do you think he is feeling now? How would you be feeling if that happened to you? What might help him feel better?" Talk about TV shows or films: "How do you think Forrest Gump felt when everybody teased him? How can you tell?" Respond to incidents of bullying behavior with negative consequences. A particularly good consequence is withdrawal of time with others. Most bullying children do not like being alone. Teach alternative approaches. Bullies may be in the habit of coercing others rather than negotiating. Teach and practice negotiating skills. Many schools now offer programs or have materials on nonviolent problem solving. Talk to your principal or parent-teacher group to find out about these. Notice and reward good play and good negotiation. Your praise and attention along with tangible rewards such as special outings can encourage your child to stick with nonbullying behavior. If your child is bullied Do not overreact. Take a deep breath while you look at your options. Depending on the severity of the problem, you will need to decide whether to notify school authorities and other parents. Listen to your child. Remember that your child has been victimized. Do not add to his or her burden with an angry, blaming, or anxious response. Avoid questions such as "Why don't you just stand up to him?" Let your child tell you how he or she feels. The act of unburdening can be very helpful to your child. Talk to your child about what makes people act like bullies. Help your child understand that he or she is not to blame in any way and that the bully is the one with the problem. Explain that children who bully are usually confused or unhappy. Review options with your child. It is not a good idea to tell the victim of bullying to respond in kind. Remember that children who are bullied are often shy and nonaggressive and it is unrealistic to expect them to change. Responding in kind, especially to physical aggression, also places your child at risk. The other extreme, going along with whatever the bully says, is equally unacceptable. Offer your child the option of maintaining some dignity while trying to get out of the situation. Suggest that he or she look the bully in the eye, say, "I don't like your teasing. Stop," and then walk away from the situation, ignoring any further taunt. Suggest that your child seek the company of others. Discuss whether your child can avoid, within reason, situations that place him or her at risk of being bullied. Encourage other friendships. Some children get stuck in relationships with bullies, especially within neighborhoods, for lack of other social options. Create other options by encouraging your child to join clubs or teams. Invite other children over to play on a regular basis. Remember that your child's self-confidence needs boosting. Praise him or her for facing up to fears. Remember that the simple act of going to school knowing that one may be bullied is an act of bravery. Make sure your child participates in activities he or she enjoys and can excel at or develop expertise in. Community approaches Rather than accepting the bully/victim phenomenon as part of childhood, families, schools, and the larger community should work to eliminate these behaviors. Talk to neighborhood parents and school parent/teacher associations about your concerns regarding aggression and bullying. If the problem is widespread, it may be an indication for action at a broader level, such as development of social skills programs, better supervision of play, richer community recreation options, and support from mental health services. This material is adapted from Contemporary Pediatrics/Canada, June 1994, p 14, and used with permission. This guide may be photocopied and distributed without permission to give to your patients and their parents. Reproduction for any other purpose requires express permission of the publisher.