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Bidirectional Association Between Bullying Perpetration and Internalizing Problems Among Youth
Journal of Adolescent Health xxx (2019) 1e8
www.jahonline.org Original article
Bidirectional Association Between Bullying Perpetration and Internalizing Problems Among Youth Marine Azevedo Da Silva, Ph.D. a, *, Jasmin C. Gonzalez b, Gregory L. Person c, and Silvia S. Martins, M.D., Ph.D. a a
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York School of Public Health, University of California, Berkeley, California c Department of Public Health Sciences, Xavier University of Louisiana, New Orleans, Louisiana b
Article history: Received May 23, 2019; Accepted September 18, 2019 Keywords: Bidirectional association; Bullying perpetration; Internalizing problems; Longitudinal cohort
A B S T R A C T
Purpose: Identification of the temporal pattern of associations between bullying perpetration and mental health problems among youth is needed for the optimal targeting of intervention and prevention. We examined the bidirectional association between bullying perpetration and internalizing problems among youth in the U.S. Methods: We used data from the prospective cohort study of the Population Assessment of Tobacco and Health waves 1 (September 12, 2013, to December 14, 2014) and 2 (October 23, 2014, to October 30, 2015), a nationally representative sample of youth. We analyzed the associations of bullying perpetration with internalizing problems using binary and multinomial logistic regressions. The 13,200 youths aged 12e17 years were included in the analytic sample. Results: There was a cross-sectional association between bullying perpetration and moderate/high lifetime internalizing problems (ORmoderate vs. no/low ¼ 3.13, 95% CI 2.67e3.65; and ORhigh vs. no/low ¼ 8.77, 95% CI 7.53e10.20). In the prospective analyses, bullying perpetration was associated with increased likelihood of moderate/high internalizing problems at follow-up (ORmoderate vs. no/low ¼ 1.49, 95% CI 1.15e1.94; and ORhigh vs. no/low ¼ 1.71, 95% CI 1.23e2.38), and youth with moderate/ high internalizing problems had higher odds of bullying perpetration at follow-up (ORmoderate ¼ 1.95, 95% CI 1.65e2.31; and ORhigh ¼ 3.21, 95% CI 2.74e3.76). Conclusions: The association between bullying perpetration and internalizing problems appears to be bidirectional. Bullying behaviors prevention and intervention strategies among youth should consider how to take into account and handle negative feelings and mental health problems. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Conflicts of interest: The authors have no conflicts of interest to disclose. Disclaimer: The views and opinions expressed in this article are those of the authors only and do not necessarily represent the views, official policy, or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies. * Address correspondence to: Marine Azevedo Da Silva, Ph.D., Mailman School of Public Health, Columbia University, 722 W 168th Street, Room R515, New York, NY 10032. E-mail address: [email protected] (M. Azevedo Da Silva). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.09.022
IMPLICATIONS AND CONTRIBUTION
This study aims to understand the temporal pattern of association between bullying perpetration and internalizing problems in youth. Findings identify a bidirectional prospective association between bullying perpetration and internalizing problems, suggesting that negative feelings and mental health problems are important targets in the bullying behaviors prevention/ intervention strategies among youth.
Bullying is defined as “any unwanted aggressive behavior(s) by another youth or group of youths, who are not siblings or current dating partners, involving an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated” [1]. A meta-analysis of 80 studies estimated that 36.0% (95% CI 35.8e36.2) and 34.5% (95% CI 34.3e34.8) of adolescents experienced bullying victimization and perpetration, respectively [2]. In the U.S., recent national surveys provide
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prevalence of bullying. The 2017 School Crime Supplement (SCS) of the National Crime Victimization Survey, a survey of students aged 12e18 years in public and private elementary, middle, and high schools as well as home-schooled youth, found that 20.2% (standard error of .71) of students reported being bullied during the school year [3]. The 2017 Youth Risk Behavior Surveillance, an epidemiologic surveillance system developed by the Centers for Disease Control and Prevention, showed that 19.0% (95% CI 17.6e 20.5) of high school students in grades 9e12 were bullied during the 12 months before the survey [4]. The most recent 2013e2014 Health Behaviour in School-Aged Children (HBSC) Survey, an international study conducted in collaboration with the World Health Organization Regional Office in Europe, found that 27.6% of children aged 11e15 years were bullied and that 25.3% bullied others during the past couple of months [5]. An extensive number of studies have focused on the causes and consequences of bullying victimization, a well-recognized global public health issue [1,6]. In particular, it is well documented that bullying victimization is associated with immediate and life-long mental health problems [6]. In contrast, prior research on the causes and consequences of bullying perpetration is more scattered. Previous studies have linked bullying perpetration to high risk for mental health problems such as depression [7e10], anxiety [9e11], psychological distress [12], psychosomatic symptoms [9], and suicidal behaviors [7,12,13]. However, other studies find no support for adverse outcomes [14e16]. Most of these studies were cross-sectional [7e10,12], making it difficult to determine the temporal sequence between bullying perpetration and mental health problems. Moreover, no studies have examined the hypothesis that the relationship between bullying perpetration and mental health problems may be bidirectional. Longitudinal studies with repeated measures on bullying perpetration and mental health problems are required to address these two causal directions. Therefore, in this study, we examined the bidirectional association between bullying perpetration and internalizing problems among youth in the U.S. using data from a nationally representative longitudinal study. Methods Study design and participants The Population Assessment of Tobacco and Health (PATH) study [17], conducted from September 12, 2013, to December 14, 2014 (wave 1), is a nationally representative longitudinal study on tobacco use behavior, attitudes and beliefs, and tobaccorelated health outcomes, supported by the U.S. National Institutes of Health and Food and Drug Administration. The PATH study recruited 32,320 adults (aged 18 years) and 13,651 youth (aged 12e17 years) via an address-based, area-probability sampling approach, using an in-person household screener. The study oversampled adult tobacco users, young adults (aged 18e24 years), and African-American adults. Generally, up to two youth were sampled per household. After obtaining consents from adults, parents, and emancipated youth and assent from youth, data were collected via Audio Computer-Assisted SelfInterviews in English or Spanish. The weighting procedures adjusted for oversampling and nonresponse, allowing estimates to be representative of the noninstitutionalized, civilian U.S. population aged 12 years. At wave 1, the weighted response rate for the household screener was 54.0%. Among screened
households, the overall weighted response rate at wave 1 was 74.0% for the adult interview, and 78.4% for the youth interview. Wave 2 interview was conducted as close as possible to the 1-year anniversary of each respondent's wave 1 interview (weighted response rate: adult interview, 83.2%; youth interview, 87.3%). More details about the study design and methods are presented elsewhere [17]. The Westat Institutional Review Board approved the study design and protocol to safeguard the rights, welfare, and well-being of all humans involved in this study; the Office of Management and Budget approved the data collection. For the purpose of this study, we used the PATH Study PublicUse Files from waves 1 (2013e2014) and 2 (2014e2015). Only youth participants with complete data at wave 1 on variables used for the associations examined were included (N ¼ 13,200; Figure 1). Compared with youth participants included in the analysis, those excluded (N ¼ 451) were younger and more likely to be in middle school; no major differences existed in sex and race/ethnicity. Of the 13,200 youths included, 11,615 were successfully screened at wave 2 (Figure 1). Compared with them, youth participants lost to follow-up (N ¼ 1,585) were older and more likely to be in other grade level; no major differences existed in sex and race/ethnicity. Measures Lifetime bullying perpetration. Bullying perpetration was assessed at waves 1 (2013e2014) and 2 (2014e2015) by asking youth participants “when was the last time that you were a bully or threatened other people two or more times?,” and response choices were as follows: never, over a year ago, 2e12 months ago, and past month. Bullying perpetration was dichotomized and defined as lifetime bullying perpetration (no vs. yes). Lifetime internalizing problems. Internalizing problems were assessed at waves 1 (2013e2014) and 2 (2014e2015) via the internalizing problems subscale of the Global Appraisal of Individual NeedseShort Screener (GAIN-SS), modified for the PATH study [18]. Items for the GAIN-SS were derived from the GAINInitial instrument that is a standardized biopsychosocial that integrates clinical and research assessment for people presenting to substance abuse or other behavioral health treatment [19]. The subscale included four items: (1) feeling very trapped/sad/ depressed, (2) trouble sleeping, (3) feeling nervous/anxious/ tense/scared, and (4) being distressed/upset about the past; across four periods: never, over a year ago, 2e12 months ago, and past month. The number of responses endorsed in the lifetime was summed for the internalizing problems subscale (complete data for the four components were required). The summary score ranged from 0 to 4. Based on the number of items endorsed, youth participants were categorized into three levels of severity: no/low (0 or 1 items), moderate (2 or 3 items), and high (4 items). These cut-points were informed by a previous study showing concurrent and predictive validity in other samples [18,20]. Individuals categorized as no/low severity are unlikely to have a diagnosis or need services, moderate severity identifies individuals who have a possible diagnosis and are likely to benefit from brief interventions, and high severity identifies individuals who have a high probability of diagnosis and need more formal assessment and intervention [19]. These cut-points were also used by a previous study on the same sample [21] and, based on Cronbach's alpha calculated for the current PATH study
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Figure 1. Flow diagram.
subsample cut-point, the reliability of the lifetime internalizing problems subscale was .81 at wave 1 and .82 at wave 2, suggesting that the items had relatively high internal consistency. Covariates. Baseline covariates (wave 1) were used as potential confounding variables. Sociodemographic characteristics included sex (male and female), age (12e14 years and 15e17 years), race/ethnicity (white non-Hispanic, black non-Hispanic, other non-Hispanic, and Hispanic), and education (middle school, high school, and other including not enrolled, homeschooled, school where students are not assigned to a particular grade, college, or vocational school). Statistical analysis Differences in baseline characteristics of youth participants as a function of lifetime bullying perpetration were assessed using chi-square test. To study the relationship between bullying perpetration and internalizing problems, we undertook different analyses. First, cross-sectional analysis aimed to assess the associations between lifetime bullying perpetration and lifetime internalizing problems at baseline (wave 1). Second, the prospective analysis, undertaken among participants with no/low internalizing problems at wave 1, examined the association between lifetime bullying perpetration at wave 1 and incidence
of internalizing problems at wave 2. Third, the prospective analysis examined the association between lifetime internalizing problems at wave 1 and subsequent bullying perpetration at wave 2 among participants who never declare bullying perpetration at wave 1. To explore these associations, we ran two types of logistic regressions: one multinomial (with internalizing problems as dependent variable) and one binary (with bullying perpetration as dependent variable). ORs were adjusted for sociodemographic characteristics: sex, age, race/ethnicity, and education. All estimates were weighted to represent the U.S. youth population; percentages (%), standard errors (SE), ORs, and confidence intervals (CIs) were estimated using the balanced repeated replication method [22], with Fay's adjustment set to .3 to increase estimate stability [23]. All analyses were conducted using Stata software, version 15 (StataCorp, 2017). Sensitivity analyses To test the robustness of our findings, we undertook several sensitivity analyses. We first conducted the same cross-sectional and longitudinal analyses to examine the associations between past-year bullying perpetration and lifetime internalizing problems. To do this, we created a three-category variable for “bullying perpetration” at baseline (wave 1) as follows: (1) never, (2) over a year ago, and (3) past year. Second, we examined the
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problems at wave 2 among participants with no/low internalizing problems at wave 1 and who participated in wave 2. Lifetime bullying perpetration at wave 1 was associated with incident moderate (ORmoderate vs. no/low ¼ 1.49, 95% CI 1.15e1.94) and high (ORhigh vs. no/low ¼ 1.71, 95% CI 1.23e2.38) internalizing problems, over the 1-year follow-up, in comparison to no/low internalizing problems.
association between past-month bullying perpetration and lifetime internalizing problems. For this step, we created a threecategory variable for “bullying perpetration” at baseline as follows: (1) never, (2) over a month ago, and (3) past month. Results Study population
Lifetime internalizing problems as a predictor of bullying perpetration
Among 13,651 youth (aged 12e17 years) of the PATH study, 13,200 had complete data on all variables at baseline and were included in the cross-sectional analysis (Figure 1). Table 1 shows the baseline characteristics of the participants overall and according to lifetime bullying perpetration at wave 1. In brief, 21.0% reported lifetime bullying perpetration, and 29.7% and 33.8% experienced moderate and high lifetime internalizing problems, respectively.
Table 2C shows adjusted ORs for the association between lifetime internalizing problems and incident bullying perpetration at wave 2 among participants who never declare bullying perpetration at wave 1 and participated in wave 2. Reporting moderate or high lifetime internalizing problems at wave 1 was associated with incident bullying perpetration (ORmoderate ¼ 1.95, 95% CI 1.65e2.31; ORhigh ¼ 3.21, 95% CI 2.74e 3.76), over the 1-year follow-up, compared with reporting no/ low lifetime internalizing problems.
Cross-sectional associations between lifetime bullying perpetration and lifetime internalizing problems Table 2A shows the adjusted ORs estimating the association of lifetime bullying perpetration and lifetime internalizing problems at baseline. Participants who reported perpetrating bullying were more likely to experience more severe lifetime internalizing problems (ORmoderate vs. no/low ¼ 3.13, 95% CI 2.67e3.65; and ORhigh vs. no/low ¼ 8.77, 95% CI 7.53e10.20) compared with participants who reported not perpetrating bullying.
Sensitivity analysis Among 13,200 participants, 79.0% reported they never bullied others, 10.9% reported having bullied others over a year ago, and 10.1% reported having bullied others in the past year (Table A1, Supplementary Data). When bullying perpetration was considered as a past month measure, 16.3% reported having bullied others over a month ago, and 4.7% reported having bullied others in the past month (Table A2, Supplementary Data).
Lifetime bullying perpetration as a predictor of internalizing problems
Cross-sectional associations between bullying perpetration and lifetime internalizing problems. The results with bullying perpetration considered as a past-year measure (Table A3-A,
Table 2B shows adjusted ORs for the association between lifetime bullying perpetration and incident internalizing
Table 1 Baseline participant's characteristics of the PATH study by lifetime bullying perpetration (wave 1, 2013e2014) Characteristics
Sex Male Female Age (years) 12e14 15e17 Race/ethnicity White, non-Hispanic Black, non-Hispanic Other, non-Hispanic Hispanic Education (grade in school) Middle school High school Other Lifetime internalizing problems severity No/low Moderate High
Overall N ¼ 13,200 (population size 24,050,521)
Lifetime bullying perpetration No (N ¼ 10,421; 79.0%)
n
%
SE
n
%
6,761 6,439
51.3 48.7
.08 .08
5,341 5,080
78.8 79.2
6,692 6,508
49.9 50.1
.09 .09
5,296 5,125
6,399 1,793 1,223 3,785
54.6 13.8 9.3 22.3
.09 .06 .06 .06
4,993 6,461 1,746
37.3 48.8 13.9
4,813 3,931 4,456
36.5 29.7 33.8
Yes (N ¼ 2,779; 21.0%) SE
P value
n
%
SE
.49 .58
1,420 1,359
21.2 20.8
.49 .58
79.2 78.8
.52 .57
1,396 1,383
20.8 21.2
.52 .57
4,959 1,428 940 3,094
77.6 79.1 80.3 81.9
.51 1.00 1.27 .82
1,440 365 283 691
22.4 20.9 19.7 18.1
.51 1.00 1.27 .82
.24 .26 .23
3,976 5,066 1,379
79.7 78.5 79.0
.63 .57 .98
1,017 1,395 367
20.3 21.5 21.0
.63 .57 .98
.53 .46 .57
4,472 3,195 2,754
92.8 81.2 62.1
.45 .63 .80
341 736 1,702
7.2 18.8 37.9
.45 .63 .80
.556
.674
<.001
.391
<.001
Represents unweighted sample size (n). Percentages (%) and standard errors (SE) are weighted to be representative of the U.S. youth population (N ¼ 24,050,521). Lifetime internalizing problems were assessed using the Global Appraisal of Individual NeedseShort Screener (GAIN-SS) and categorized as no/low (0e1 symptoms), moderate (2e3 symptoms), and high (4 symptoms) severity levels. P values are two sided. PATH ¼ Population Assessment of Tobacco and Health; SE ¼ standard error.
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Table 2 Cross-sectional and prospective associations between bullying perpetration and internalizing problems OR (95% CI)
P value
A. Cross-sectional association between lifetime bullying perpetration at wave 1 and lifetime internalizing problems at wave 1a Lifetime bullying perpetration (wave 1) No Yes Lifetime bullying perpetration (wave 1) No Yes
Lifetime internalizing problems severity (wave 1), moderate versus no/low <.001 Reference 3.13 (2.67e3.65) Lifetime internalizing problems severity (wave 1), high versus no/low <.001 Reference 8.77 (7.53e10.20)
B. Prospective association between lifetime bullying perpetration at wave 1 and incident internalizing problems at wave 2b Internalizing problems severity, moderate versus no/low Lifetime bullying perpetration (wave 1) No Yes Lifetime bullying perpetration (wave 1) No Yes
.003 Reference 1.49 (1.15e1.94) Internalizing problems severity, high versus no/low .002 Reference 1.71 (1.23e2.38)
C. Prospective association between lifetime internalizing problems at wave 1 and incident bullying perpetration at wave 2c Bullying perpetration Lifetime internalizing problems severity (wave 1) No/low Moderate High
<.001d Reference 1.95 (1.65e2.31) 3.21 (2.74e3.76)
<.001 <.001
Odds ratio adjusted for sociodemographic characteristics (sex, age, race/ethnicity, and education). P values are two sided. CI ¼ confidence interval; OR ¼ odds ratio. a Results are of participants with complete data at baseline, N ¼ 13,200 (population size 24,050,521). b Results are of participants with no/low internalizing problems at wave 1 and participated at waves 1 and 2, N ¼ 4,104 (population size 8,474,953). c Results are of participants who never declare bullying perpetration at wave 1 and participated at waves 1 and 2, N ¼ 9,107 (population size 18,827,948). d Test for homogeneity among different lifetime internalizing problems severity classes.
Supplementary Data) show that participants who reported perpetrating bullying over a year ago (ORmoderate vs. no/low ¼ 3.15, 95% CI 2.53e3.91; and ORhigh vs. no/low ¼ 7.50, 95% CI 6.06e9.27) and in the past year (ORmoderate vs. no/low ¼ 3.09, 95% CI 2.50e3.84; and ORhigh vs. no/low ¼ 10.42, 95% CI 8.57e12.66) were more likely to experience more severe lifetime internalizing problems compared with participants who reported not perpetrating bullying. When bullying perpetration was considered as a pastmonth measure (Table A4-A, Supplementary Data), participants who reported perpetrating bullying over a month ago (ORmoderate vs. no/low ¼ 3.28, 95% CI 2.72e3.96; and ORhigh vs. no/low ¼ 8.69, 95% CI 7.32e10.33) and in the past month (ORmoderate vs. no/low ¼ 2.62, 95% CI 1.98e3.46; and ORhigh vs. no/low ¼ 9.07, 95% CI 7.07e11.64) were more likely to experience more severe lifetime internalizing problems compared with participants who reported not perpetrating bullying. Bullying perpetration as a predictor of internalizing problems. Table A3-B (Supplementary Data), where bullying perpetration was considered as a past-year measure, shows that bullying others in the past year was associated with new onset of moderate internalizing problems (ORmoderate vs. no/low ¼ 1.62, 95% CI 1.12e2.35). Bullying others over year ago was associated with new onset of high internalizing problems (ORhigh vs. no/low ¼ 1.80, 95% CI 1.11e2.91). Table A4-B (Supplementary Data), where bullying perpetration was considered as a past-month measure, shows that bullying others over a month ago was associated with new onset
of moderate (ORmoderate vs. no/low ¼ 1.48, 95% CI 1.08e2.04) and high (ORhigh vs. no/low ¼ 1.72, 95% CI 1.15e2.58) internalizing problems. Discussion Key findings We examined the bidirectional association of bullying perpetration with internalizing problems in a large cohort of youth. Cross-sectional analyses showed that bullying perpetration was associated with an increased probability of moderate/ high lifetime internalizing problems. In prospective analyses, we found that bullying perpetration was associated with incident moderate/high internalizing problems at wave 2. On the other hand, exposure to lifetime moderate/high internalizing problems was associated with incident bullying perpetration at wave 2. Sensitivity analysis found similar patterns of association as those reported in the main analyses for both cross-sectional and longitudinal analyses. Results in the context of previous studies Among U.S. youth aged 12e17 years, we found that 21.0% reported bullying perpetration in the lifetime, 10.1% in the past year, and 4.7% in the past month. Several other national surveys provided prevalence of bullying behaviors among youth in the U.S. These include the SCS to the National Crime Victimization
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Survey [3], the Youth Risk Behavior Survey [4], the National Survey of Children's Exposure to Violence [24], the HBSC [5,25], and the National Survey of Children's Health [26]. Neither the SCS, the Youth Risk Behavior Survey, nor the National Survey of Children's Exposure to Violence provides estimates of bullying perpetration. The most recent HBSC survey, in which the U.S. participated, is the 2009e2010. Students were asked “how often have you taken part in bullying another student(s) at school in the past couple of months?,” and findings showed that 28.4% of U.S. students (aged 11, 13, and 15 years) bullied others at school in the past couple of months [25]. Results from the 2016 National Survey of Children's Health showed that 6.4% of children and adolescents (aged 6e17 years) were reported by their parents to bully others (bullying perpetration was assessed using the question “How well does the following phrase describe this child? This child bullies others, picks on them, or excludes them.”) [26]. The methods of assessment (e.g., definitions, question wording with vs. without context of time, and selfreported vs. parent-reported), survey periods, and age range could explain the difference of bullying perpetration prevalence between these studies and our study. However, we believe that our findings provide an important extension to previous literature. Our cross-sectional results are consistent with previous studies showing similar associations of bullying perpetration with some components of internalizing problems (mainly depression and anxiety symptoms) [7e10]. The prospective finding of our study highlights a bidirectional association between bullying perpetration and internalizing problems. Bullying perpetration increases the risk of moderate/ high internalizing problems, and these problems are also likely to be associated with bullying perpetration. Previous longitudinal research was mainly focused on the association between bullying perpetration and the incidence of internalizing problems [11,14,15]. Our results are consistent with the findings from the study by Kretschmer et al. [11], showing that bullying perpetration was linked to later anxiety in a cohort study conducted among Dutch adolescents aged older than 10 years of follow-up. In contrast, Hemphill et al. [14] conducted a study among Australian students aged 12e14 years at baseline and found no association between bullying perpetration and later depressive symptoms. In the same vein, Copeland et al. [15] identified no association between bullying perpetration only and young adult psychiatric outcomes (depressive and anxiety disorders) in a community sample of children aged 9, 11, and 13 years from 11 counties in Western North Carolina. Discrepancies with these findings could result from the limited sample size, leading to insufficient power to detect a significant association or from the ability to take into account other bullying behavior, that is bullying victimization or from the consideration of disorders rather than symptoms as outcomes. Possible explanations Several hypotheses have been posited to explain the prospective association of bullying perpetration on mental health outcomes. Classmates tend to dislike youth who bully [27]. Youth who bully may become aware of their peer's dislike and rejection and might gradually feel negative about the future and developed symptoms of anxiety and depression. Moreover, bullying perpetration could result in a worldview that is perpetually competitive and threatened by rivals [28]. Youth
who engage in bullying might begin to view the world as aggressive and hostile and as a coercive space filled with conflict where one's status is mainly determined by power and control of others [29]. These might connect to a negative psychological cost as an ongoing struggle for dominance within a system where others dislike them. Other mechanisms have also been proposed to explain the prospective association of mental health problems on bullying perpetration. First, the association between internalizing problems and incident bullying perpetration seems to be in line with the acting-out hypothesis that negative emotional states are acted out in externalizing behavior [30]. Second, youth with internalizing problems could be often “marginalized,” have low self-esteem, feel insecure, and use bullying to fight a system that leaves them out. The social capital theory [31], which refers to the benefits gained from social relationship, suggests that using bullying tactics could be a means of acquiring social capital, improving youth's social status in the classroom or school to offset their marginalization. Third, similar to the idea of counterbalancing their “marginalization,” the dominance theory [32] suggests that bullying perpetration could be a means of obtaining and maintaining power and dominance to form an individual-based social hierarchy with one or a few dominant individuals at the top, whereas subordinate individuals are forced to the bottom. Finally, youth who present internalizing problems are more likely to have family hardships such as low socioeconomic status, family instability, conflictual family dynamics, and child maltreatment. Coercive cycles of family memberechild interaction could lead youth to expect that coercion is fundamental to interpersonal relationships [33], which leads them to bully peers [34]. However, we were not able to test these mechanistic hypotheses, and the precise mechanisms underlying the current observations remain to be further examined. Strengths and limitations To our knowledge, this is the first study to comprehensively examine the bidirectional association between bullying perpetration and internalizing problems in a nationally representative sample of U.S. youth. Our study design allowed us to show that the association is likely to be bidirectional between bullying perpetration and internalizing problem. However, these findings should be interpreted with some limitations. First, bullying is traditionally defined in the literature using three typical features: intentional harm, repetition over time, and real or perceived imbalance of power [1]. Although perpetration measure in this study addressed repeated behavior, the measure did not address the imbalance of power or the intentionality dimensions. It is difficult to define clearly, to young children, the notion of power imbalance. Moreover, it is challenging to make it understandable to them. When asked about bullying, most students tended to focus primarily on negative actions, such as being mean to or teased or threatened someone, regardless of whether or not it was repeated and whether or not it was in an unequal relationship [35]. Studies have found that students fail to recognize the power imbalance as a requirement for bullying and include other forms of peer aggression in their reports of bullying [36,37]. Moreover, in our study, bullying perpetration was measured based on a single-item question and did not define what bullying precisely entails or give examples thereof. Recent findings in the literature indicated that the use of a definition has no impact on
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prevalence rates [38]. However, bullying rates seems to be highly sensitive to the structure of the survey questions: using a singleitem measure seems to yield lower prevalence rates of bullying than determining bullying based on a multiple-item approach [38,39]. Therefore, taking into account these issues related to the bullying measure, the prevalence estimates, as reported in this study, may overestimate or underestimate the true prevalence of bullying and, in return, influence the strength of association between bullying perpetration and internalizing problems. However, the importance of looking more broadly at peer difficulties has been emphasized previously in the literature [40]. Assessing the impact of bullying, characteristics of individuals involved, and the broader landscape of those individuals' strengths and well-being is important for intervention purposes. Second, data on bullying perpetration were based on self-reports, and because of the fact that bullying victimization was not assessed in the PATH study, we were neither able to study bullying victimization nor to disentangle those who were bullies-only from those who were bullies-victims (both being bullied and bullying others) among the perpetrator category. Cross-sectional studies show that these two groups have similar risk factors and outcomes, although bullies-victims tend to be exposed to more risk factors than bullies-only and to show the worst mental health outcomes. Future research, with available data on bullying victims and perpetrators, should examine combinations of victimizations and perpetration. Third, internalizing problems were assessed via the GAIN-SS that measures the severity of mental health symptomology rather than diagnosis. However, the high sensitivity and specificity between GAIN-SS items and diagnoses support the use of symptoms as good indicators of clinically significant mental health problems [19]. Fourth, although we were able to control for a large range of potential confounding variables, the possibility of residual confounding from unmeasured variables cannot be ruled out. Finally, studies with longer follow-up would be needed to assess the long-term bidirectional association of bullying perpetration and internalizing problems. Conclusion Despite these potential limitations, the results of this study suggest that the association between bullying perpetration and internalizing problems is likely to be bidirectional. Bullying perpetration increases the risk of developing internalizing problems, and having internalizing problems increases the probability of bullying others. These findings suggest that intervention and prevention strategies warrant increased focus for reducing bullying behaviors should consider including strategies of addressing how to handle/providing support for negative feelings and mental health problems. Acknowledgments Authors' contributions: M.A.D.S. conceptualized and designed the study, had access to all the data in the study, and carried out the data analysis and interpretation of the data. She drafted the initial manuscript and reviewed and revised the manuscript. S.S.M. conceptualized, designed, and supervised the study. She critically reviewed the manuscript for important intellectual content. J.C.G. and G.L.P. conducted the literature review, contributed to the analysis and interpretation of the data, and reviewed and revised the manuscript. All authors approved the
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final manuscript as submitted and are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding Sources This work was supported by a 2017 NIDA-Inserm Drug Abuse Research Fellowship from the National Institute on Drug Abuse and the French National Institute of Health and Medical Research. The funding sources had no role in the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jadohealth.2019.09.022. References [1] Gladden RM, Vivolo-Kantor AM, Hamburger ME, et al. 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 and U.S. Department of Education; 2014. [2] Modecki KL, Minchin J, Harbaugh AG, et al. Bullying prevalence across contexts: A meta-analysis measuring cyber and traditional bullying. J Adolesc Health 2014;55:602e11. [3] Musu L, Zhang A, Wang K, et al. Indicators of School Crime and Safety: 2018 (NCES 2019-047/NCJ 252571). Washington, DC: National Center for Education Statistics, U.S. Department of Education, and Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice; 2019. Available at: https://nces.ed.gov/pubs2019/2019047.pdf. [4] Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance d United States, 2017. MMWR Surveill Summ 2018;67:1e114. [5] Inchley J, Currie D, Young T, et al., eds. Growing up unequal: Gender and socioeconomic differences in young people's health and well-being: Health Behaviour in School-Aged Children (HBSC) Study: International report from the 2013/2014 survey. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2016. [6] Moore SE, Norman RE, Suetani S, et al. Consequences of bullying victimization in childhood and adolescence: A systematic review and metaanalysis. World J Psychiatry 2017;7:60e76. [7] Brunstein klomek A, Marrocco F, Kleinman M, et al. Bullying, depression, and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry 2007;46: 40e9. [8] Seals D, Young J. Bullying and victimization: Prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression. Adolescence 2003;38:735e47. [9] Kaltiala-Heino R, Rimpelä M, Rantanen P, et al. Bullying at schoolean indicator of adolescents at risk for mental disorders. J Adolesc 2000;23: 661e74. [10] Bouman T, van der Meulen M, Goossens FA, et al. Peer and self-reports of victimization and bullying: Their differential association with internalizing problems and social adjustment. J Sch Psychol 2012;50:759e74. [11] Kretschmer T, Veenstra R, Dekovi c M, et al. Bullying development across adolescence, its antecedents, outcomes, and gender-specific patterns. Dev Psychopathol 2017;29:941e55. [12] Thomas HJ, Connor JP, Lawrence DM, et al. Prevalence and correlates of bullying victimisation and perpetration in a nationally representative sample of Australian youth. Aust N Z J Psychiatry 2017;51:909e20. [13] Holt MK, Vivolo-Kantor AM, Polanin JR, et al. Bullying and suicidal ideation and behaviors: A meta-analysis. Pediatrics 2015;135:e496e509. [14] Hemphill SA, Kotevski A, Herrenkohl TI, et al. Longitudinal consequences of adolescent bullying perpetration and victimisation: A study of students in Victoria, Australia. Crim Behav Ment Health 2011;21:107e16. [15] Copeland WE, Wolke D, Angold A, et al. Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry 2013;70:419e26. [16] Lereya ST, Copeland WE, Zammit S, et al. Bully/victims: A longitudinal, population-based cohort study of their mental health. Eur Child Adolesc Psychiatry 2015;24:1461e71.
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[17] Hyland A, Ambrose BK, Conway KP, et al. Design and methods of the Population Assessment of Tobacco and Health (PATH) study. Tob Control 2017;26:371e8. [18] Dennis ML, Chan Y-F, Funk RR. Development and validation of the GAIN Short Screener (GSS) for internalizing, externalizing and substance use disorders and crime/violence problems among adolescents and adults. Am J Addict 2006;15 Suppl 1:80e91. [19] Dennis ML, White M, Titus JC, et al. Global Appraisal of Individual Needs (GAIN): Administration guide for the GAIN and related measures (version 5). Chestnut Health Systems; 2008. Available at: https://www.researchgate. net/profile/Michael_Dennis2/publication/267383950_GAIN_Global_Appraisal_ of_Individual_Needs_Administration_Guide_for_the_GAIN_and_Related_ Measures/links/54838a6f0cf25dbd59eb0ef0.pdf. [20] Garner BR, Belur VK, Dennis ML. The GAIN Short Screener (GSS) as a predictor of future arrest or incarceration among youth presenting to substance use disorder (SUD) treatment. Subst Abuse 2013;7:199e208. [21] Conway KP, Green VR, Kasza KA, et al. Co-occurrence of tobacco product use, substance use, and mental health problems among youth: Findings from wave 1 (2013-2014) of the population assessment of tobacco and health (PATH) study. Addict Behav 2018;76:208e17. [22] McCarthy PJ. Pseudoreplication: Further evaluation and applications of the balanced half-sample technique. Vital Health Stat 1969;2:1e24. [23] Judkins DR. Fay's method for variance estimation. J Official Stat 1990;6: 223e39. [24] Finkelhor D, Turner HA, Shattuck A, et al. Prevalence of childhood exposure to violence, crime, and abuse: Results from the national survey of Children's exposure to violence. JAMA Pediatr 2015;169:746e54. [25] Iannotti RJ. Health behavior in school-aged children (HBSC), 2009-2010: Version 1. Ann Arbor, MI: Inter-university Consortium for Political and Social Research; 2013, https://doi.org/10.3886/ICPSR34792.v1. [26] Lebrun-Harris LA, Sherman LJ, Limber SP, et al. Bullying victimization and perpetration among U.S. children and adolescents: 2016 National Survey of Children's Health. J Child Fam Stud 2019;28:2543e57. [27] de Bruyn EH, Cillessen AHN, Wissink IB. Associations of peer acceptance and perceived popularity with bullying and victimization in early adolescence. J Early Adolesc 2010;30:543e66.
[28] Pornari CD, Wood J. Peer and cyber aggression in secondary school students: The role of moral disengagement, hostile attribution bias, and outcome expectancies. Aggress Behav 2010;36:81e94. [29] Hawley PH. Prosocial and coercive configurations of resource control in early adolescence: A case for the well-adapted Machiavellian. MerrillPalmer Q 2003;49:279e309. [30] Overbeek G, Vollebergh W, Meeus W, et al. Course, co-occurrence, and longitudinal associations of emotional disturbance and delinquency from adolescence to young adulthood: A six-year three-wave study. J Youth Adolesc 2001;30:401e26. [31] Coleman JS. Social capital in the creation of human capital. Am J Sociol 1988;94:S95e120. [32] Long JD, Pellegrini AD. Studying change in dominance and bullying with linear mixed models. Sch Psychol Rev 2003;32:401e17. [33] Rudolph KD, Lansford JE, Rodkin PC. Interpersonal theories of developmental psychopathology. Dev Psychopathol 2016;1:1e69. [34] Espelage DL, Low S, Rao MA, et al. Family violence, bullying, fighting, and substance use among adolescents: A longitudinal mediational model. J Res Adolesc 2014;24:337e49. [35] Vaillancourt T, McDougall P, Hymel S, et al. Bullying: Are researchers and children/youth talking about the same thing? Int J Behav Dev 2008;32: 486e95. [36] Baly MW, Cornell DG. Effects of an educational video on the measurement of bullying by self-report. J Sch Violence 2011;10:221e38. [37] Green JG, Felix ED, Sharkey JD, et al. Identifying bully victims: Definitional versus behavioral approaches. Psychol Assess 2013;25: 651e7. [38] Huang FL, Cornell DG. The impact of definition and question order on the prevalence of bullying victimization using student self-reports. Psychol Assess 2015;27:1484e93. [39] Jetelina KK, Reingle Gonzalez JM, Cuccaro PM, et al. Self-reporting discrepancies of bullying victimization and perpetration measures. Ann Epidemiol 2019;32:58e63. [40] Williams LCA, Stelko-Pereira AC. Let's prevent school violence, not just bullying and peer victimization: A commentary on Finkelhor, Turner, and Hamby (2012). Child Abuse Neglect 2013;37:235e6.
www.jahonline.org Original article
Bidirectional Association Between Bullying Perpetration and Internalizing Problems Among Youth Marine Azevedo Da Silva, Ph.D. a, *, Jasmin C. Gonzalez b, Gregory L. Person c, and Silvia S. Martins, M.D., Ph.D. a a
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York School of Public Health, University of California, Berkeley, California c Department of Public Health Sciences, Xavier University of Louisiana, New Orleans, Louisiana b
Article history: Received May 23, 2019; Accepted September 18, 2019 Keywords: Bidirectional association; Bullying perpetration; Internalizing problems; Longitudinal cohort
A B S T R A C T
Purpose: Identification of the temporal pattern of associations between bullying perpetration and mental health problems among youth is needed for the optimal targeting of intervention and prevention. We examined the bidirectional association between bullying perpetration and internalizing problems among youth in the U.S. Methods: We used data from the prospective cohort study of the Population Assessment of Tobacco and Health waves 1 (September 12, 2013, to December 14, 2014) and 2 (October 23, 2014, to October 30, 2015), a nationally representative sample of youth. We analyzed the associations of bullying perpetration with internalizing problems using binary and multinomial logistic regressions. The 13,200 youths aged 12e17 years were included in the analytic sample. Results: There was a cross-sectional association between bullying perpetration and moderate/high lifetime internalizing problems (ORmoderate vs. no/low ¼ 3.13, 95% CI 2.67e3.65; and ORhigh vs. no/low ¼ 8.77, 95% CI 7.53e10.20). In the prospective analyses, bullying perpetration was associated with increased likelihood of moderate/high internalizing problems at follow-up (ORmoderate vs. no/low ¼ 1.49, 95% CI 1.15e1.94; and ORhigh vs. no/low ¼ 1.71, 95% CI 1.23e2.38), and youth with moderate/ high internalizing problems had higher odds of bullying perpetration at follow-up (ORmoderate ¼ 1.95, 95% CI 1.65e2.31; and ORhigh ¼ 3.21, 95% CI 2.74e3.76). Conclusions: The association between bullying perpetration and internalizing problems appears to be bidirectional. Bullying behaviors prevention and intervention strategies among youth should consider how to take into account and handle negative feelings and mental health problems. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Conflicts of interest: The authors have no conflicts of interest to disclose. Disclaimer: The views and opinions expressed in this article are those of the authors only and do not necessarily represent the views, official policy, or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies. * Address correspondence to: Marine Azevedo Da Silva, Ph.D., Mailman School of Public Health, Columbia University, 722 W 168th Street, Room R515, New York, NY 10032. E-mail address: [email protected] (M. Azevedo Da Silva). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.09.022
IMPLICATIONS AND CONTRIBUTION
This study aims to understand the temporal pattern of association between bullying perpetration and internalizing problems in youth. Findings identify a bidirectional prospective association between bullying perpetration and internalizing problems, suggesting that negative feelings and mental health problems are important targets in the bullying behaviors prevention/ intervention strategies among youth.
Bullying is defined as “any unwanted aggressive behavior(s) by another youth or group of youths, who are not siblings or current dating partners, involving an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated” [1]. A meta-analysis of 80 studies estimated that 36.0% (95% CI 35.8e36.2) and 34.5% (95% CI 34.3e34.8) of adolescents experienced bullying victimization and perpetration, respectively [2]. In the U.S., recent national surveys provide
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prevalence of bullying. The 2017 School Crime Supplement (SCS) of the National Crime Victimization Survey, a survey of students aged 12e18 years in public and private elementary, middle, and high schools as well as home-schooled youth, found that 20.2% (standard error of .71) of students reported being bullied during the school year [3]. The 2017 Youth Risk Behavior Surveillance, an epidemiologic surveillance system developed by the Centers for Disease Control and Prevention, showed that 19.0% (95% CI 17.6e 20.5) of high school students in grades 9e12 were bullied during the 12 months before the survey [4]. The most recent 2013e2014 Health Behaviour in School-Aged Children (HBSC) Survey, an international study conducted in collaboration with the World Health Organization Regional Office in Europe, found that 27.6% of children aged 11e15 years were bullied and that 25.3% bullied others during the past couple of months [5]. An extensive number of studies have focused on the causes and consequences of bullying victimization, a well-recognized global public health issue [1,6]. In particular, it is well documented that bullying victimization is associated with immediate and life-long mental health problems [6]. In contrast, prior research on the causes and consequences of bullying perpetration is more scattered. Previous studies have linked bullying perpetration to high risk for mental health problems such as depression [7e10], anxiety [9e11], psychological distress [12], psychosomatic symptoms [9], and suicidal behaviors [7,12,13]. However, other studies find no support for adverse outcomes [14e16]. Most of these studies were cross-sectional [7e10,12], making it difficult to determine the temporal sequence between bullying perpetration and mental health problems. Moreover, no studies have examined the hypothesis that the relationship between bullying perpetration and mental health problems may be bidirectional. Longitudinal studies with repeated measures on bullying perpetration and mental health problems are required to address these two causal directions. Therefore, in this study, we examined the bidirectional association between bullying perpetration and internalizing problems among youth in the U.S. using data from a nationally representative longitudinal study. Methods Study design and participants The Population Assessment of Tobacco and Health (PATH) study [17], conducted from September 12, 2013, to December 14, 2014 (wave 1), is a nationally representative longitudinal study on tobacco use behavior, attitudes and beliefs, and tobaccorelated health outcomes, supported by the U.S. National Institutes of Health and Food and Drug Administration. The PATH study recruited 32,320 adults (aged 18 years) and 13,651 youth (aged 12e17 years) via an address-based, area-probability sampling approach, using an in-person household screener. The study oversampled adult tobacco users, young adults (aged 18e24 years), and African-American adults. Generally, up to two youth were sampled per household. After obtaining consents from adults, parents, and emancipated youth and assent from youth, data were collected via Audio Computer-Assisted SelfInterviews in English or Spanish. The weighting procedures adjusted for oversampling and nonresponse, allowing estimates to be representative of the noninstitutionalized, civilian U.S. population aged 12 years. At wave 1, the weighted response rate for the household screener was 54.0%. Among screened
households, the overall weighted response rate at wave 1 was 74.0% for the adult interview, and 78.4% for the youth interview. Wave 2 interview was conducted as close as possible to the 1-year anniversary of each respondent's wave 1 interview (weighted response rate: adult interview, 83.2%; youth interview, 87.3%). More details about the study design and methods are presented elsewhere [17]. The Westat Institutional Review Board approved the study design and protocol to safeguard the rights, welfare, and well-being of all humans involved in this study; the Office of Management and Budget approved the data collection. For the purpose of this study, we used the PATH Study PublicUse Files from waves 1 (2013e2014) and 2 (2014e2015). Only youth participants with complete data at wave 1 on variables used for the associations examined were included (N ¼ 13,200; Figure 1). Compared with youth participants included in the analysis, those excluded (N ¼ 451) were younger and more likely to be in middle school; no major differences existed in sex and race/ethnicity. Of the 13,200 youths included, 11,615 were successfully screened at wave 2 (Figure 1). Compared with them, youth participants lost to follow-up (N ¼ 1,585) were older and more likely to be in other grade level; no major differences existed in sex and race/ethnicity. Measures Lifetime bullying perpetration. Bullying perpetration was assessed at waves 1 (2013e2014) and 2 (2014e2015) by asking youth participants “when was the last time that you were a bully or threatened other people two or more times?,” and response choices were as follows: never, over a year ago, 2e12 months ago, and past month. Bullying perpetration was dichotomized and defined as lifetime bullying perpetration (no vs. yes). Lifetime internalizing problems. Internalizing problems were assessed at waves 1 (2013e2014) and 2 (2014e2015) via the internalizing problems subscale of the Global Appraisal of Individual NeedseShort Screener (GAIN-SS), modified for the PATH study [18]. Items for the GAIN-SS were derived from the GAINInitial instrument that is a standardized biopsychosocial that integrates clinical and research assessment for people presenting to substance abuse or other behavioral health treatment [19]. The subscale included four items: (1) feeling very trapped/sad/ depressed, (2) trouble sleeping, (3) feeling nervous/anxious/ tense/scared, and (4) being distressed/upset about the past; across four periods: never, over a year ago, 2e12 months ago, and past month. The number of responses endorsed in the lifetime was summed for the internalizing problems subscale (complete data for the four components were required). The summary score ranged from 0 to 4. Based on the number of items endorsed, youth participants were categorized into three levels of severity: no/low (0 or 1 items), moderate (2 or 3 items), and high (4 items). These cut-points were informed by a previous study showing concurrent and predictive validity in other samples [18,20]. Individuals categorized as no/low severity are unlikely to have a diagnosis or need services, moderate severity identifies individuals who have a possible diagnosis and are likely to benefit from brief interventions, and high severity identifies individuals who have a high probability of diagnosis and need more formal assessment and intervention [19]. These cut-points were also used by a previous study on the same sample [21] and, based on Cronbach's alpha calculated for the current PATH study
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Figure 1. Flow diagram.
subsample cut-point, the reliability of the lifetime internalizing problems subscale was .81 at wave 1 and .82 at wave 2, suggesting that the items had relatively high internal consistency. Covariates. Baseline covariates (wave 1) were used as potential confounding variables. Sociodemographic characteristics included sex (male and female), age (12e14 years and 15e17 years), race/ethnicity (white non-Hispanic, black non-Hispanic, other non-Hispanic, and Hispanic), and education (middle school, high school, and other including not enrolled, homeschooled, school where students are not assigned to a particular grade, college, or vocational school). Statistical analysis Differences in baseline characteristics of youth participants as a function of lifetime bullying perpetration were assessed using chi-square test. To study the relationship between bullying perpetration and internalizing problems, we undertook different analyses. First, cross-sectional analysis aimed to assess the associations between lifetime bullying perpetration and lifetime internalizing problems at baseline (wave 1). Second, the prospective analysis, undertaken among participants with no/low internalizing problems at wave 1, examined the association between lifetime bullying perpetration at wave 1 and incidence
of internalizing problems at wave 2. Third, the prospective analysis examined the association between lifetime internalizing problems at wave 1 and subsequent bullying perpetration at wave 2 among participants who never declare bullying perpetration at wave 1. To explore these associations, we ran two types of logistic regressions: one multinomial (with internalizing problems as dependent variable) and one binary (with bullying perpetration as dependent variable). ORs were adjusted for sociodemographic characteristics: sex, age, race/ethnicity, and education. All estimates were weighted to represent the U.S. youth population; percentages (%), standard errors (SE), ORs, and confidence intervals (CIs) were estimated using the balanced repeated replication method [22], with Fay's adjustment set to .3 to increase estimate stability [23]. All analyses were conducted using Stata software, version 15 (StataCorp, 2017). Sensitivity analyses To test the robustness of our findings, we undertook several sensitivity analyses. We first conducted the same cross-sectional and longitudinal analyses to examine the associations between past-year bullying perpetration and lifetime internalizing problems. To do this, we created a three-category variable for “bullying perpetration” at baseline (wave 1) as follows: (1) never, (2) over a year ago, and (3) past year. Second, we examined the
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problems at wave 2 among participants with no/low internalizing problems at wave 1 and who participated in wave 2. Lifetime bullying perpetration at wave 1 was associated with incident moderate (ORmoderate vs. no/low ¼ 1.49, 95% CI 1.15e1.94) and high (ORhigh vs. no/low ¼ 1.71, 95% CI 1.23e2.38) internalizing problems, over the 1-year follow-up, in comparison to no/low internalizing problems.
association between past-month bullying perpetration and lifetime internalizing problems. For this step, we created a threecategory variable for “bullying perpetration” at baseline as follows: (1) never, (2) over a month ago, and (3) past month. Results Study population
Lifetime internalizing problems as a predictor of bullying perpetration
Among 13,651 youth (aged 12e17 years) of the PATH study, 13,200 had complete data on all variables at baseline and were included in the cross-sectional analysis (Figure 1). Table 1 shows the baseline characteristics of the participants overall and according to lifetime bullying perpetration at wave 1. In brief, 21.0% reported lifetime bullying perpetration, and 29.7% and 33.8% experienced moderate and high lifetime internalizing problems, respectively.
Table 2C shows adjusted ORs for the association between lifetime internalizing problems and incident bullying perpetration at wave 2 among participants who never declare bullying perpetration at wave 1 and participated in wave 2. Reporting moderate or high lifetime internalizing problems at wave 1 was associated with incident bullying perpetration (ORmoderate ¼ 1.95, 95% CI 1.65e2.31; ORhigh ¼ 3.21, 95% CI 2.74e 3.76), over the 1-year follow-up, compared with reporting no/ low lifetime internalizing problems.
Cross-sectional associations between lifetime bullying perpetration and lifetime internalizing problems Table 2A shows the adjusted ORs estimating the association of lifetime bullying perpetration and lifetime internalizing problems at baseline. Participants who reported perpetrating bullying were more likely to experience more severe lifetime internalizing problems (ORmoderate vs. no/low ¼ 3.13, 95% CI 2.67e3.65; and ORhigh vs. no/low ¼ 8.77, 95% CI 7.53e10.20) compared with participants who reported not perpetrating bullying.
Sensitivity analysis Among 13,200 participants, 79.0% reported they never bullied others, 10.9% reported having bullied others over a year ago, and 10.1% reported having bullied others in the past year (Table A1, Supplementary Data). When bullying perpetration was considered as a past month measure, 16.3% reported having bullied others over a month ago, and 4.7% reported having bullied others in the past month (Table A2, Supplementary Data).
Lifetime bullying perpetration as a predictor of internalizing problems
Cross-sectional associations between bullying perpetration and lifetime internalizing problems. The results with bullying perpetration considered as a past-year measure (Table A3-A,
Table 2B shows adjusted ORs for the association between lifetime bullying perpetration and incident internalizing
Table 1 Baseline participant's characteristics of the PATH study by lifetime bullying perpetration (wave 1, 2013e2014) Characteristics
Sex Male Female Age (years) 12e14 15e17 Race/ethnicity White, non-Hispanic Black, non-Hispanic Other, non-Hispanic Hispanic Education (grade in school) Middle school High school Other Lifetime internalizing problems severity No/low Moderate High
Overall N ¼ 13,200 (population size 24,050,521)
Lifetime bullying perpetration No (N ¼ 10,421; 79.0%)
n
%
SE
n
%
6,761 6,439
51.3 48.7
.08 .08
5,341 5,080
78.8 79.2
6,692 6,508
49.9 50.1
.09 .09
5,296 5,125
6,399 1,793 1,223 3,785
54.6 13.8 9.3 22.3
.09 .06 .06 .06
4,993 6,461 1,746
37.3 48.8 13.9
4,813 3,931 4,456
36.5 29.7 33.8
Yes (N ¼ 2,779; 21.0%) SE
P value
n
%
SE
.49 .58
1,420 1,359
21.2 20.8
.49 .58
79.2 78.8
.52 .57
1,396 1,383
20.8 21.2
.52 .57
4,959 1,428 940 3,094
77.6 79.1 80.3 81.9
.51 1.00 1.27 .82
1,440 365 283 691
22.4 20.9 19.7 18.1
.51 1.00 1.27 .82
.24 .26 .23
3,976 5,066 1,379
79.7 78.5 79.0
.63 .57 .98
1,017 1,395 367
20.3 21.5 21.0
.63 .57 .98
.53 .46 .57
4,472 3,195 2,754
92.8 81.2 62.1
.45 .63 .80
341 736 1,702
7.2 18.8 37.9
.45 .63 .80
.556
.674
<.001
.391
<.001
Represents unweighted sample size (n). Percentages (%) and standard errors (SE) are weighted to be representative of the U.S. youth population (N ¼ 24,050,521). Lifetime internalizing problems were assessed using the Global Appraisal of Individual NeedseShort Screener (GAIN-SS) and categorized as no/low (0e1 symptoms), moderate (2e3 symptoms), and high (4 symptoms) severity levels. P values are two sided. PATH ¼ Population Assessment of Tobacco and Health; SE ¼ standard error.
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Table 2 Cross-sectional and prospective associations between bullying perpetration and internalizing problems OR (95% CI)
P value
A. Cross-sectional association between lifetime bullying perpetration at wave 1 and lifetime internalizing problems at wave 1a Lifetime bullying perpetration (wave 1) No Yes Lifetime bullying perpetration (wave 1) No Yes
Lifetime internalizing problems severity (wave 1), moderate versus no/low <.001 Reference 3.13 (2.67e3.65) Lifetime internalizing problems severity (wave 1), high versus no/low <.001 Reference 8.77 (7.53e10.20)
B. Prospective association between lifetime bullying perpetration at wave 1 and incident internalizing problems at wave 2b Internalizing problems severity, moderate versus no/low Lifetime bullying perpetration (wave 1) No Yes Lifetime bullying perpetration (wave 1) No Yes
.003 Reference 1.49 (1.15e1.94) Internalizing problems severity, high versus no/low .002 Reference 1.71 (1.23e2.38)
C. Prospective association between lifetime internalizing problems at wave 1 and incident bullying perpetration at wave 2c Bullying perpetration Lifetime internalizing problems severity (wave 1) No/low Moderate High
<.001d Reference 1.95 (1.65e2.31) 3.21 (2.74e3.76)
<.001 <.001
Odds ratio adjusted for sociodemographic characteristics (sex, age, race/ethnicity, and education). P values are two sided. CI ¼ confidence interval; OR ¼ odds ratio. a Results are of participants with complete data at baseline, N ¼ 13,200 (population size 24,050,521). b Results are of participants with no/low internalizing problems at wave 1 and participated at waves 1 and 2, N ¼ 4,104 (population size 8,474,953). c Results are of participants who never declare bullying perpetration at wave 1 and participated at waves 1 and 2, N ¼ 9,107 (population size 18,827,948). d Test for homogeneity among different lifetime internalizing problems severity classes.
Supplementary Data) show that participants who reported perpetrating bullying over a year ago (ORmoderate vs. no/low ¼ 3.15, 95% CI 2.53e3.91; and ORhigh vs. no/low ¼ 7.50, 95% CI 6.06e9.27) and in the past year (ORmoderate vs. no/low ¼ 3.09, 95% CI 2.50e3.84; and ORhigh vs. no/low ¼ 10.42, 95% CI 8.57e12.66) were more likely to experience more severe lifetime internalizing problems compared with participants who reported not perpetrating bullying. When bullying perpetration was considered as a pastmonth measure (Table A4-A, Supplementary Data), participants who reported perpetrating bullying over a month ago (ORmoderate vs. no/low ¼ 3.28, 95% CI 2.72e3.96; and ORhigh vs. no/low ¼ 8.69, 95% CI 7.32e10.33) and in the past month (ORmoderate vs. no/low ¼ 2.62, 95% CI 1.98e3.46; and ORhigh vs. no/low ¼ 9.07, 95% CI 7.07e11.64) were more likely to experience more severe lifetime internalizing problems compared with participants who reported not perpetrating bullying. Bullying perpetration as a predictor of internalizing problems. Table A3-B (Supplementary Data), where bullying perpetration was considered as a past-year measure, shows that bullying others in the past year was associated with new onset of moderate internalizing problems (ORmoderate vs. no/low ¼ 1.62, 95% CI 1.12e2.35). Bullying others over year ago was associated with new onset of high internalizing problems (ORhigh vs. no/low ¼ 1.80, 95% CI 1.11e2.91). Table A4-B (Supplementary Data), where bullying perpetration was considered as a past-month measure, shows that bullying others over a month ago was associated with new onset
of moderate (ORmoderate vs. no/low ¼ 1.48, 95% CI 1.08e2.04) and high (ORhigh vs. no/low ¼ 1.72, 95% CI 1.15e2.58) internalizing problems. Discussion Key findings We examined the bidirectional association of bullying perpetration with internalizing problems in a large cohort of youth. Cross-sectional analyses showed that bullying perpetration was associated with an increased probability of moderate/ high lifetime internalizing problems. In prospective analyses, we found that bullying perpetration was associated with incident moderate/high internalizing problems at wave 2. On the other hand, exposure to lifetime moderate/high internalizing problems was associated with incident bullying perpetration at wave 2. Sensitivity analysis found similar patterns of association as those reported in the main analyses for both cross-sectional and longitudinal analyses. Results in the context of previous studies Among U.S. youth aged 12e17 years, we found that 21.0% reported bullying perpetration in the lifetime, 10.1% in the past year, and 4.7% in the past month. Several other national surveys provided prevalence of bullying behaviors among youth in the U.S. These include the SCS to the National Crime Victimization
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Survey [3], the Youth Risk Behavior Survey [4], the National Survey of Children's Exposure to Violence [24], the HBSC [5,25], and the National Survey of Children's Health [26]. Neither the SCS, the Youth Risk Behavior Survey, nor the National Survey of Children's Exposure to Violence provides estimates of bullying perpetration. The most recent HBSC survey, in which the U.S. participated, is the 2009e2010. Students were asked “how often have you taken part in bullying another student(s) at school in the past couple of months?,” and findings showed that 28.4% of U.S. students (aged 11, 13, and 15 years) bullied others at school in the past couple of months [25]. Results from the 2016 National Survey of Children's Health showed that 6.4% of children and adolescents (aged 6e17 years) were reported by their parents to bully others (bullying perpetration was assessed using the question “How well does the following phrase describe this child? This child bullies others, picks on them, or excludes them.”) [26]. The methods of assessment (e.g., definitions, question wording with vs. without context of time, and selfreported vs. parent-reported), survey periods, and age range could explain the difference of bullying perpetration prevalence between these studies and our study. However, we believe that our findings provide an important extension to previous literature. Our cross-sectional results are consistent with previous studies showing similar associations of bullying perpetration with some components of internalizing problems (mainly depression and anxiety symptoms) [7e10]. The prospective finding of our study highlights a bidirectional association between bullying perpetration and internalizing problems. Bullying perpetration increases the risk of moderate/ high internalizing problems, and these problems are also likely to be associated with bullying perpetration. Previous longitudinal research was mainly focused on the association between bullying perpetration and the incidence of internalizing problems [11,14,15]. Our results are consistent with the findings from the study by Kretschmer et al. [11], showing that bullying perpetration was linked to later anxiety in a cohort study conducted among Dutch adolescents aged older than 10 years of follow-up. In contrast, Hemphill et al. [14] conducted a study among Australian students aged 12e14 years at baseline and found no association between bullying perpetration and later depressive symptoms. In the same vein, Copeland et al. [15] identified no association between bullying perpetration only and young adult psychiatric outcomes (depressive and anxiety disorders) in a community sample of children aged 9, 11, and 13 years from 11 counties in Western North Carolina. Discrepancies with these findings could result from the limited sample size, leading to insufficient power to detect a significant association or from the ability to take into account other bullying behavior, that is bullying victimization or from the consideration of disorders rather than symptoms as outcomes. Possible explanations Several hypotheses have been posited to explain the prospective association of bullying perpetration on mental health outcomes. Classmates tend to dislike youth who bully [27]. Youth who bully may become aware of their peer's dislike and rejection and might gradually feel negative about the future and developed symptoms of anxiety and depression. Moreover, bullying perpetration could result in a worldview that is perpetually competitive and threatened by rivals [28]. Youth
who engage in bullying might begin to view the world as aggressive and hostile and as a coercive space filled with conflict where one's status is mainly determined by power and control of others [29]. These might connect to a negative psychological cost as an ongoing struggle for dominance within a system where others dislike them. Other mechanisms have also been proposed to explain the prospective association of mental health problems on bullying perpetration. First, the association between internalizing problems and incident bullying perpetration seems to be in line with the acting-out hypothesis that negative emotional states are acted out in externalizing behavior [30]. Second, youth with internalizing problems could be often “marginalized,” have low self-esteem, feel insecure, and use bullying to fight a system that leaves them out. The social capital theory [31], which refers to the benefits gained from social relationship, suggests that using bullying tactics could be a means of acquiring social capital, improving youth's social status in the classroom or school to offset their marginalization. Third, similar to the idea of counterbalancing their “marginalization,” the dominance theory [32] suggests that bullying perpetration could be a means of obtaining and maintaining power and dominance to form an individual-based social hierarchy with one or a few dominant individuals at the top, whereas subordinate individuals are forced to the bottom. Finally, youth who present internalizing problems are more likely to have family hardships such as low socioeconomic status, family instability, conflictual family dynamics, and child maltreatment. Coercive cycles of family memberechild interaction could lead youth to expect that coercion is fundamental to interpersonal relationships [33], which leads them to bully peers [34]. However, we were not able to test these mechanistic hypotheses, and the precise mechanisms underlying the current observations remain to be further examined. Strengths and limitations To our knowledge, this is the first study to comprehensively examine the bidirectional association between bullying perpetration and internalizing problems in a nationally representative sample of U.S. youth. Our study design allowed us to show that the association is likely to be bidirectional between bullying perpetration and internalizing problem. However, these findings should be interpreted with some limitations. First, bullying is traditionally defined in the literature using three typical features: intentional harm, repetition over time, and real or perceived imbalance of power [1]. Although perpetration measure in this study addressed repeated behavior, the measure did not address the imbalance of power or the intentionality dimensions. It is difficult to define clearly, to young children, the notion of power imbalance. Moreover, it is challenging to make it understandable to them. When asked about bullying, most students tended to focus primarily on negative actions, such as being mean to or teased or threatened someone, regardless of whether or not it was repeated and whether or not it was in an unequal relationship [35]. Studies have found that students fail to recognize the power imbalance as a requirement for bullying and include other forms of peer aggression in their reports of bullying [36,37]. Moreover, in our study, bullying perpetration was measured based on a single-item question and did not define what bullying precisely entails or give examples thereof. Recent findings in the literature indicated that the use of a definition has no impact on
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prevalence rates [38]. However, bullying rates seems to be highly sensitive to the structure of the survey questions: using a singleitem measure seems to yield lower prevalence rates of bullying than determining bullying based on a multiple-item approach [38,39]. Therefore, taking into account these issues related to the bullying measure, the prevalence estimates, as reported in this study, may overestimate or underestimate the true prevalence of bullying and, in return, influence the strength of association between bullying perpetration and internalizing problems. However, the importance of looking more broadly at peer difficulties has been emphasized previously in the literature [40]. Assessing the impact of bullying, characteristics of individuals involved, and the broader landscape of those individuals' strengths and well-being is important for intervention purposes. Second, data on bullying perpetration were based on self-reports, and because of the fact that bullying victimization was not assessed in the PATH study, we were neither able to study bullying victimization nor to disentangle those who were bullies-only from those who were bullies-victims (both being bullied and bullying others) among the perpetrator category. Cross-sectional studies show that these two groups have similar risk factors and outcomes, although bullies-victims tend to be exposed to more risk factors than bullies-only and to show the worst mental health outcomes. Future research, with available data on bullying victims and perpetrators, should examine combinations of victimizations and perpetration. Third, internalizing problems were assessed via the GAIN-SS that measures the severity of mental health symptomology rather than diagnosis. However, the high sensitivity and specificity between GAIN-SS items and diagnoses support the use of symptoms as good indicators of clinically significant mental health problems [19]. Fourth, although we were able to control for a large range of potential confounding variables, the possibility of residual confounding from unmeasured variables cannot be ruled out. Finally, studies with longer follow-up would be needed to assess the long-term bidirectional association of bullying perpetration and internalizing problems. Conclusion Despite these potential limitations, the results of this study suggest that the association between bullying perpetration and internalizing problems is likely to be bidirectional. Bullying perpetration increases the risk of developing internalizing problems, and having internalizing problems increases the probability of bullying others. These findings suggest that intervention and prevention strategies warrant increased focus for reducing bullying behaviors should consider including strategies of addressing how to handle/providing support for negative feelings and mental health problems. Acknowledgments Authors' contributions: M.A.D.S. conceptualized and designed the study, had access to all the data in the study, and carried out the data analysis and interpretation of the data. She drafted the initial manuscript and reviewed and revised the manuscript. S.S.M. conceptualized, designed, and supervised the study. She critically reviewed the manuscript for important intellectual content. J.C.G. and G.L.P. conducted the literature review, contributed to the analysis and interpretation of the data, and reviewed and revised the manuscript. All authors approved the
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final manuscript as submitted and are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding Sources This work was supported by a 2017 NIDA-Inserm Drug Abuse Research Fellowship from the National Institute on Drug Abuse and the French National Institute of Health and Medical Research. The funding sources had no role in the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jadohealth.2019.09.022. References [1] Gladden RM, Vivolo-Kantor AM, Hamburger ME, et al. 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 and U.S. Department of Education; 2014. [2] Modecki KL, Minchin J, Harbaugh AG, et al. Bullying prevalence across contexts: A meta-analysis measuring cyber and traditional bullying. J Adolesc Health 2014;55:602e11. [3] Musu L, Zhang A, Wang K, et al. Indicators of School Crime and Safety: 2018 (NCES 2019-047/NCJ 252571). Washington, DC: National Center for Education Statistics, U.S. Department of Education, and Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice; 2019. Available at: https://nces.ed.gov/pubs2019/2019047.pdf. [4] Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance d United States, 2017. MMWR Surveill Summ 2018;67:1e114. [5] Inchley J, Currie D, Young T, et al., eds. Growing up unequal: Gender and socioeconomic differences in young people's health and well-being: Health Behaviour in School-Aged Children (HBSC) Study: International report from the 2013/2014 survey. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2016. [6] Moore SE, Norman RE, Suetani S, et al. Consequences of bullying victimization in childhood and adolescence: A systematic review and metaanalysis. World J Psychiatry 2017;7:60e76. [7] Brunstein klomek A, Marrocco F, Kleinman M, et al. Bullying, depression, and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry 2007;46: 40e9. [8] Seals D, Young J. Bullying and victimization: Prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression. Adolescence 2003;38:735e47. [9] Kaltiala-Heino R, Rimpelä M, Rantanen P, et al. Bullying at schoolean indicator of adolescents at risk for mental disorders. J Adolesc 2000;23: 661e74. [10] Bouman T, van der Meulen M, Goossens FA, et al. Peer and self-reports of victimization and bullying: Their differential association with internalizing problems and social adjustment. J Sch Psychol 2012;50:759e74. [11] Kretschmer T, Veenstra R, Dekovi c M, et al. Bullying development across adolescence, its antecedents, outcomes, and gender-specific patterns. Dev Psychopathol 2017;29:941e55. [12] Thomas HJ, Connor JP, Lawrence DM, et al. Prevalence and correlates of bullying victimisation and perpetration in a nationally representative sample of Australian youth. Aust N Z J Psychiatry 2017;51:909e20. [13] Holt MK, Vivolo-Kantor AM, Polanin JR, et al. Bullying and suicidal ideation and behaviors: A meta-analysis. Pediatrics 2015;135:e496e509. [14] Hemphill SA, Kotevski A, Herrenkohl TI, et al. Longitudinal consequences of adolescent bullying perpetration and victimisation: A study of students in Victoria, Australia. Crim Behav Ment Health 2011;21:107e16. [15] Copeland WE, Wolke D, Angold A, et al. Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry 2013;70:419e26. [16] Lereya ST, Copeland WE, Zammit S, et al. Bully/victims: A longitudinal, population-based cohort study of their mental health. Eur Child Adolesc Psychiatry 2015;24:1461e71.
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