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Bullying: What the PNP Needs to Know
Article
Continuing Education
Bullying: What the PNP Needs to Know Gail Hornor, RNC, DNP, CPNP ABSTRACT Despite generations of doubt about the true impact of bullying, it is now clear that childhood bullying can have significant lifelong consequences for victims and bullies alike. Recent school shootings and suicides by students who have been victims of bullying have helped to solidify public awareness of the gravity of the problem of childhood bullying. Adults who were frequently bullied in childhood have an increased frequency of psychiatric disorders, including anxiety, depression, and suicidality, extending into middle age (Arseneault, 2017). In fact, frequent bullying in childhood may impact victims similar to experiencing multiple adverse childhood experiences (Takizawa, Maughan, & Arseneault, 2014). Bullying also has a detrimental effect on young perpetrators (Zuckerman, 2016). Bullying is clearly a pediatric health care problem. This continuing education article will explore bullying in terms of definitions, epidemiology, types, risk factors, resilience factors, consequences, and implications for practice. J Pediatr Health Care. (2018) 32, 399-408.
KEY WORDS Bullying, trauma, cyberbullying
Despite generations of doubt about the true impact of bullying, it is now clear that childhood bullying can have significant lifelong consequences for victims and bullies alike. Recent school shootings and suicides by students who have been victims of bullying has helped solidify public awareness of the gravity of the problem of childhood bullying. Adults who were frequently bullied in childhood have an increased frequency of psychiatric disorders, including anxiety, depression, and Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children’s Hospital, Center for Family Safety and Healing, Columbus, OH. Conflicts of interest: None to report. Correspondence: Gail Hornor, RNC, DNP, CPNP, Nationwide Children’s Hospital, Center for Family Safety and Healing, 655 East Livingston Ave, Columbus, OH 43205; e-mail: [email protected] 0891-5245/$36.00 Copyright © 2018 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2018.02.001
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suicidality, extending into middle age (Arseneault, 2017). Frequent bullying in childhood may have a similar effect on victims as multiple adverse childhood experiences (Takizawa, Maughan, & Arseneault, 2014). Bullying also has a detrimental effect on young perpetrators (Zuckerman, 2016). Bullying is clearly a pediatric health care problem. Pediatric nurse practitioners (PNPs) need to incorporate bullying prevention, identification, and intervention into their practice. This continuing education article will explore bullying in terms of definitions, epidemiology, types, risk factors, resilience factors, consequences, and implications for practice. DEFINITIONS There are many definitions of bullying, and they all tend to share three common criteria: intentionality, repetitiveness, and power imbalance (Olweus, 2012). Bullying is typically defined as the use of physical or emotional power to control or harm others and can include behaviors such as physical or verbal attacks, making threats, spreading rumors, name calling, or intentionally excluding someone from a group (Zuckerman, 2016). Bullying involves a pattern of repeated aggression, a deliberate intent to harm or disturb the victim despite the victim’s apparent distress, and a real or perceived imbalance of power (Cooper, Clements, & Holt, 2012). Bullying behavior in the traditional sense is typically perpetrated face to face, and the bully can observe the impact of his/her actions on the victim. Although any site where children and teens interact can be sites for bullying, certainly school, transportation to and from school, and after-school programs are common sites for bullying. Cyberbullying can be broadly defined as bullying that is carried out via electronic means such as text messages, e-mails, online chat rooms, or social networking sites (Wolke, Lee, & Guy, 2017). Cyberbullying, like traditional bullying, is an act of aggression characterized by a power imbalance and is often repeated (Kowalski, Giumetti, Schroeder, & Lattanner, 2014). Traditional physical bullying as opposed to cyberbullying occurs more frequently among males and decreases through the high school years (Messias, Kindrick, & Castro, 2014). Cyberbullying occurs more frequently July/August 2018
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among females and does not show a decreasing trend in high school (Messias et al., 2014). EPIDEMIOLOGY Bullying has often been trivialized and viewed as a universal childhood experience, one that everyone experiences. Because of this, bullying was not considered a health issue until the 1970s (Olweus & Limber, 2010). There was not a single piece of legislation in the United States addressing bullying until the Columbine High School mass shooting in 1999 (McClowry, Miller, & Mills, 2017). Within 3 years of the Columbine tragedy, 15 states had passed state laws mentioning bullying, and by 2015, every state and the District of Columbia had an anti-bullying law (Temkin, 2015). Despite this legislative effort, bullying continues to be a problem of epidemic proportions in the United States. According to the Centers for Disease Control and Prevention’s 2015 Youth Risk Behavior Surveillance System, 20.2% of high school students experience bullying (Kamn, McManus, & Harris, 2016). Bullying certainly does not typically begin in adolescence; bullying can begin very early. Jansen et al. (2012) state that about 10% to 14% of kindergarten students bully others and are bullied as well. Bullying often begins in early elementary school, increases steadily to a peak in early secondary school (ages 12-14 years), and tapers in late adolescence (Sapouna & Wolke, 2013). This increase in bullying in early adolescence is not due to bullying by previously unaggressive peers; rather, it is the result of heightened aggression by a small number of adolescents while most maintain rather low levels of bullying (Troop-Gordon, 2017). Approximately 30% of school children are bullies, victims, or bully– victims (Evans, Fraser, & Cotter, 2014). Females are bullied more often than males (24% vs. 16%, respectively). The most likely student to be bullied is a White female in ninth grade (Evans et al., 2014). Adolescents who perpetrate bullying tend to be thought of as popular, possessing a social status of leadership, influence, and respect (Cillessen & Rose, 2005). Other forms of aggression tend to decrease in adolescence, but relational aggression, such as spreading rumors or exclusion, increases (Rosen, Beron, & Underwood, 2016). Relational aggression can be seen in the preschool years; however, adolescents have increased mental and language skills to more effectively execute relational aggression. The prevalence rate for cyberbullying is reported to be as high as 52% of the adolescent population (Mishna, Khoury-Kassabri, Gadalla, & Daciuk, 2012). Studies suggest that there is considerable overlap between cyberbullying and traditional bullying. Cyberbullying on its own is very rare (Wolke et al., 2017). Two recent studies by Hase, Goldberg, Smith, and Stuck (2015) and Waasdorp and Bradshaw (2015) found the co-occurrence of traditional and cyberbullying 400
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to be as high as 88% to 93%. In other words, 9 out of 10 adolescents who report cyber-victimization also report experiencing traditional bullying (Wolke et al., 2017). Victims experiencing only cyberbullying had similar negative psychological outcomes to those experiencing only traditional bullying; however, those experiencing both are at highest risk of poor psychological outcomes (Wolke et al., 2017). TYPES OF BULLYING Cyberbullying Cyberbullying is unique Cyberbullying is in that it can take so unique in that it many different forms can take so many and can occur via many venues. Cyberspace different forms and gives bullies a new tool can occur via many to extend their bullyvenues. ing beyond school or other traditional faceto-face contact. Cyberbullies uses social media to mock, spread rumors, and harass their victims. They may be very technologically savvy and can remain anonymous and untraceable when posting messages, videos, photos, and fake profiles for wide distribution. An Internet post is essentially impossible to delete or stop once it is sent, especially if it has been passed around by others and distributed on multiple sites. Individuals often experience multiple types of cyberbullying. See Box 1 for types of cyberbullying. Cyberbullying and traditional bullying differ in accessibility. Traditional bullying typically occurs at school during the school day. Cyberbullying can be perpetrated from anywhere at any time 24 hours a day, 7 days a week. Also, cyberbullying, because of the nature of the venues through which it occurs, has a much greater BOX 1. Types of cyberbullying Flaming Harassment Outing and trickery
Exclusion Impersonation
Cyberstalking
Sexting
Online fight Repetitive, offensive messages sent to a target Discovering personal information about someone and then electronically sharing that information without the individual’s permission Blocking an individual from buddy lists or other electronic communications Pretending to be the victim and electronically communicating negatively or inappropriately with others as if the information is coming from the victim Using electronic communication to stalk someone by sending repeated threatening messages Sending nude/inappropriate photos of another person without that individual’s consent
Source: Kowalski, Giumetti, Schroeder, and Lattener (2014).
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potential audience than traditional bullying (Kowalski et al., 2014). For instance, thousands of people may view an online post or photo, whereas only a handful of people may view a bullying incident at school. Cyberbullying also differs from traditional bullying in relation to anonymity. Cyberbullies often perceive themselves as anonymous. This perception of anonymity makes cyberbullying attractive to individuals who would not be bullies in the traditional face-to-face style. An anonymous bully may not realize the impact of their cyberbullying; they cannot see the consequences of their actions, making them less likely to feel empathy or remorse (Zuckerman, 2016). Motivations for engaging in cyberbullying may differ from those for traditional bullying. In traditional faceto-face bullying, the rewards are instantaneous; the effect on the victim is immediately seen. Cyberbullying, on the other hand, results in delayed gratification. Any response of the victim is delayed, and the cyberbully cannot see the immediate effects on the victim. This suggests that the motivation for cyberbullying may be intrapersonal and more tied to performing the act rather than witnessing the consequences of that action (Kowalski et al., 2014). Conversely, the motivation for traditional face-to-face bullying may be interpersonal, tied to witnessing the effect of the bullying on the victim or to having others witness the bullying actions.
cal, or social harm on the targeted sibling. Sibling bullying can be physical, verbal, or relational in nature. Sibling bullying is a unique form of bullying that is repeated and harmful. Sibling bullying has been associated with increased risk of being involved in peer bullying, as well as concurrent and adult emotional problems such as distress, depression, and self-harm (Wolke et al., 2015). Wolke et al. explored familial factors associated with sibling bullying. The following factors were associated with sibling bullying: male siblings; siblings close in age; and a greater number of children in the family. Sibling bullying crosses economic barriers, with higher rates of sibling bullying being found in families of low socioeconomic status and also in families with higher parental education level (Tippett & Wolke, 2015). Child maltreatment, household domestic violence, lack of parental warmth, harsh parenting, and low parental supervision are also associated with sibling bullying (Tucker, Finkelhor, Turner, & Shattnuck, 2014). Singleparent or step-families were not associated with sibling bullying (Wolke et al., 2015). However, Kiselica and Morrill-Richards (2007) identified a link between differential parental treatment of siblings and sibling bullying, indicating that sibling bullying may be stimulated by inequality and a desire to improve status, similar to motivations underlying school bullying.
Sibling Bullying Sibling relationships have an important and lasting impact on an individual’s development. Sibling relationships are often the most enduring relationships of a lifetime: siblings are our companions, teachers, and our caregivers (Dunn & McGuire, 1992). However, up to 40% of individuals are exposed to sibling bullying every week (Wolke, Tippett, & Dantchev, 2015). Sibling rivalry and jealousy have existed since the beginning of time and have been depicted in literature throughout centuries, beginning with the biblical story of Cain and Abel. Cultural differences exist in the nature and dynamics of sibling relationships according to individualistic or collectivistic norms. Collectivistic societies place a greater focus on group versus individual goals; siblings tend to spend more time together and have more hierarchical relationships, older siblings have more responsibility caring for younger siblings, and older siblings garner more respect (Wolke et al., 2015). However, the United States is an individualistic society; the strength of the sibling relationship is often diluted by individual goals, and sibling companionship, support, and intimacy are lessened. Sibling bullying is defined by Wolke et al. (2015) any unwanted aggressive behavior(s) by a sibling that involves an observed or perceived power imbalance and is repeated multiple times or is very likely to be repeated; bullying may inflict physical, psychologi-
BULLIES The typical bully is not psychologically well adjusted, often has problems in his/her home life, cannot handle emotions, and has little empathy for others (Juvonen & Graham, 2014). Childhood bullies can be broadly divided into two types: those seeking status and those going after more vulnerable victims. Juvonen and Graham (2014) studied more than 16,000 American public and private school students in grades 6 through 10 and found that bullies motivated by social status tend to target their friends and other more popular students. However, the bullies who target vulnerable victims tend to be anxious or depressed and less popular themselves. Males typically engage in physically aggressive bullying; females tend to use verbal, social, and cyberbullying. Long-term consequences for bullies include alcohol and drug use later in adolescence and adulthood, early sexual activity, dropping out of school, criminal convictions as an adult, and being physically and/or emotionally abusive to romantic partners or their children as adults (Zuckerman, 2016). Both bullies and the bullied are more likely to commit suicide or engage in suicidal ideation (Zuckerman, 2016). Children involved in bullying, both victims and aggressors, are more likely to engage in frequent fighting, be injured in a fight, carry a weapon, and carry a weapon to school (Nansel, Overpeck, Haynie, Ruan, & Scheidt, 2003).
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Von Dijk, Poorthuis, and Malti (2016) explored the psychological processes in young kindergarten bullies versus bully victims. Generally speaking, bully victims and bullies differ in their social functioning. Young bullies tend to have as many friends as their noninvolved peers, and they are likely to affiliate with their noninvolved classmates. Young bullies have a dichotomous status among classmates: they are more likely to be popular yet also more likely to be rejected. However, young bully victims have fewer friends than noninvolved peers, are less likely to affiliate with noninvolved peers, and are more likely to be rejected by classmates. Therefore, young bully victims tend to be marginalized at an early age, and young bullies appear to be well integrated into their classes (Vlachur, Andreau, Botsoglou, & Didaskalou, 2011). Von Dijk et al. (2016) state that at an early age, bullies and bully victims share psychological processes that underlie their bullying behaviors. Both bullies and bully victims use aggressive strategies when interacting with peers. The difference in social status between bullies and bully victims can be explained by their success with their aggressive behavior. Bullies gain dominance by their aggressive behavior; bully victims evoke victimization by behaving aggressively. Therefore, bullies and bully victims are not different in their motivation for aggressive behavior at this young age; rather, they differ in the success of their aggression. BYSTANDERS Nearly every incident of Nearly every bullying, be it traditional incident of bullying, face-to-face bullying or be it traditional cyberbullying, involves not only the bully and face-to-face the victim but also bybullying or standers. Bystanders can cyberbullying, respond to the incident in a variety of ways, ininvolves not only cluding reinforcing or the bully and the assisting the bully, devictim but also fending the victim, or passively standing by bystanders. and acting as though nothing is happening (Pozzoli, Gini, & Thornberg, 2017). This varied response noted by bullying bystanders has been attributed to empathy or the lack thereof (Huitsing, Snijders, van Duijn, & Veenstra, 2014). A key element of empathy is the involvement of psychological processes that make a person have feelings that are more congruent with another’s situation than with his own situation (Hoffman, 2000). Bullies who target the same victims tend to support each other, as do victims who are bullied by the same bullies; they show empathy for one another (Huitsing et al., 2014). Bystanders who support bully victims exhibit empathy for the victim, often placing themselves at risk 402
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of retaliation, because the bullies may direct their aggression toward individuals who support their victims (Pozzoli et al., 2017). Victims with at least one defender have been found to have higher self-esteem and be more accepted and less rejected by their peers (Huitsing et al., 2014). Bully defenders and passive bystanders share a lack of feelings of empathy; they are unable to respond to victims with compassion and support, perhaps in part because of fear of retaliation (Pozzoli et al., 2017). RISK FACTORS There are characteristics that place children at increased risk of being bullied. Children who are different or perceived to be different from their peers are at risk for bullying (see Box 2). Characteristics that make individuals look different or behave differently from societal norms place them at risk of experiencing bullying. Children of racial and ethnic minorities, particularly African American (Albdour & Krouse, 2014) and Hispanic (Lai & Kao, 2017), are at increased bullying risk. Immigrant children are also at increased risk for bullying (Vitoroulis & Georgiades, 2017). Risk for racial, ethnic, and immigrant bullying can be reduced by making schools more diverse and having a higher representation of a student’s ethnic/racial/immigrant minority in that school (Vitoroulis & Georgiades, 2017). Religious affiliation can also be a cause of bullying. Arab American adolescents report experiencing bullying due BOX 2. Bullying risk factors Chronic illness Physical disability Obesity Underweight Different appearance Minority Racial Ethnic Religious Immigrant Learning disability Behavior problem LGBTQ Poverty Foster care Group home Poor family functioning Lack of close relationships Exposure to trauma Child maltreatment Physical abuse Sexual abuse Emotional abuse Neglect Familial interpersonal violence Parental drug/alcohol concerns Parental mental/health concerns Note. LGBTQ, lesbian, gay, bisexual, transgender, or queer. Adapted from McClowry et al. (2017).
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to their ethnic/racial background and also due to identifying as Muslim (Albdour, Lewin, Kavanaugh, Hong, & Wilson, 2017). Children with a chronic illness or physical disability are at increased bullying risk. Bullying can negatively affect the ability to manage a chronic illness and can result in decreased compliance with the health care plan (van Cleave & Davis, 2006). Learning disabilities and speech or cognitive delays place children at risk. Children who are socially different from their peers are also at increased risk: children living in foster care or group homes, poverty, family dysfunction, lack of close relationships, and poor family functioning. Trauma-exposed children are also at increased risk for bullying, such as those experiencing child maltreatment or exposure to domestic violence. Children who behave differently than their peers are vulnerable to bullying. Children and adolescents with internalizing problems are at increased risk for bullying. Depression and anxiety may communicate vulnerability to bullying peers (Troop-Gordon, 2017). Peer rejection or social isolation is also a risk factor; associating with a large group of peers is protective against victimization (Estell, Farmer, & Cairns, 2007). Children exhibiting externalizing behavior problems are also at increased risk. Aggressive and delinquent behaviors do not conform to peer norms and may elicit bullying from peers. For the most part, risk factors for peer victimization remain relatively constant across development. However, bullying for certain characteristics tends to peak in adolescence. Obese children are particularly vulnerable to bullying, and this phenomenon can have in a significant impact on these children’s emotional health. Weight-related bullying begins in childhood; however, rates of weight-related victimization escalate alarmingly in adolescence (Lampard, MacLehose, Eisenberg, Neumark-Sztainer, & Davison, 2014). Sexual attraction and gender role identity intensifies during adolescence. Youth who identify as gay, lesbian, or bisexual, as well as transgender and other gender nonconforming youth, are at high risk of experiencing bullying. Robinson, Espelage, and Rivers (2013) found that in a population of self-identifying adolescents, 52% of gay or bisexual boys and 57% of lesbian or bisexual girls reported experiencing extensive bullying. Bullying focused on the target’s real or perceived homosexual identity is just as prevalent as weightrelated bullying in adolescence (Troop-Gordon, 2017). Both the timing of and the physiologic changes associated with puberty can influence bullying; early or late pubertal changes in both boys and girls has been associated with increased risk for bullying. RESILIENCE TO BULLYING Resilience is defined the ability to manifest positive outcomes over time despite facing significant adversities (Luthar, Cicchetti, & Becker, 2000). There is disparity www.jpedhc.org
among the effects of bullying on child victims; some children who are victims of severe bullying function much better than others with similar bullying experiences. These children are resilient. Resilience is more than a personality trait; rather, it is a capacity that builds over time in the context of relationships with family and peers (Luthar, 2003). Sapouna and Wolke (2013) described individual, family, and peer factors associated with resilience in bully victims. Individual factors that were protective included having high self-esteem, feeling less socially alienated, and less negative emotionality. The way in which the adolescent cognitively interprets the bullying also affects resilience. Adolescents who do not perceive the bullying to be a significant threat to them either physically or socially tend to be more resilient. Adolescents who reported low or no levels of conflict with parents are more resilient. For these children, parents act as a buffer to the bullying. Positive sibling relationships were also found to be a protective factor for bullied adolescents, especially not having a sibling who bullied them. Therefore, adolescents bullied at school and also at home are less likely to be resilient. Sapouna and Wolke (2013) found that having a sibling who was not also a victim of bullying was a protective factor. Sapouna and Wolke also found the quality of peer relationships to be more important to bully resilience than the quantity of friends. Having friends who are not themselves bullied who exhibit higher levels of prosocial behavior was found to be protective. However, victims of bullying tend to have friends who are also victims of bullying, and these peer relationships may not be a source of resilience for bully victims (Sapouna & Wolke, 2013). Resilience to bullying is the result of a subtle interplay between many factors. CONSEQUENCES OF BULLYING Bullying of any type can result in significant consequence for victims. Bullying can result in mental and physical health consequences. Physical health consequences include deterioration of previously stable chronic medical conditions and nonadherence to medication regimens (McClowry et al., 2017). Bullying results in stress and can lead to a number of somatic complaints such as headaches, stomach aches, dizziness, irritable bowel syndrome, and other physical symptoms. It is intuitive that traditional face-to-face bullying is associated with increased school absenteeism: the victim is removing him-/herself from further trauma. Grinshteyn and Yang (2017) examined the relationship between cyberbullying and school absenteeism. In a sample of over 13,000 high school students, Grinshteyn and Yang (2017) found cyberbullying to be significantly associated with missing 1 to 4 or more days of school. These school absences were the result of being fearful of facing the perpetrators or other July/August 2018
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BOX 3. Consequences for bully victims and bullies Suicide/suicidal ideation (bullies and victims) Poor physical health/somatic complaints Deterioration of chronic health conditions Depression Low self-esteem School absenteeism Violence-related behaviors Substance use (bullies and victims) Academic failure (bullies and victims) Externalizing problems (bullies and victims) Internalizing problems Note. Adapted from Eisenberg and Aalsma (2005).
students, leading to fear-based absences. School absenteeism negatively affects not only academic development but also the social/relational development of the individual. Antila et al. (2017) examined the relationship between bullying victimization in adolescence and the subsequent development of personality disorders. The study sample was composed of 508 adolescents (300 girls, 208 boys) who received inpatient psychiatric care. Female bully victims had a fourfold greater likelihood of developing a personality disorder later in life; particularly borderline personality disorder. No association between bullying victimization and the development of a personality disorder later in adolescence or adulthood was found for males. Multiple studies have indicated that traditional bullying is a risk factor for suicide (Brunstein-Klomek, Sourander, & Gould, 2010; Klomek et al., 2008). Teens exclusively experiencing cyberbullying victimization are at a higher risk of suicide than those experiencing only traditional bullying (Messias et al., 2014). However, those experiencing both forms of bullying are at highest risk of suicide. A variety of negative consequences have been linked to bullying, for both the perpetrators and the victims (see Box 3). Bullies exhibit aggressive behaviors and are more likely to experience externalizing problems (Juvonen & Graham, 2014). Victims are characterized by a lack of confidence in social settings, shyness, introversion, and internalizing problems (Romero, Wiggs, Valencia, & Bauman, 2013). Children who are both bullies and victims (bully–victims) may fare the worst. Bully–victims are at greatest risk of conduct, academic, and peer relationship problems and lower selfesteem, greater anxiety, and more psychosomatic symptoms (Juvonen & Graham, 2014). Sangalang, Tran, Ayers, and Marsiglia (2016), in a study of 809 youths, found both bullies and bully–victims to be at significant risk for substance use compared with noninvolved peers. Bullies were more likely to use alcohol and tobacco; bully–victims disclosed alcohol, tobacco, and inhalant use. Radliff, Wheaton, Robinson, and Morris 404
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(2012) found that bullies and bully–victims both were more likely to engage in tobacco, marijuana, alcohol, and prescription drug use. The consequences The consequences of bullying can last a of bullying can last lifetime. Young adults a lifetime. who were victimized as children have higher rates of agoraphobia, depression, anxiety, panic disorder, and suicidal ideation compared with nonbullied peers (Arsenault, 2017). Young adults with a history of bullying are also at increased risk for psychiatric hospitalization and using psychotropic medications. Bullied individuals experience high levels of psychological distress throughout the lifespan. The consequences of bullying often extend into middle age and beyond (Takizawa et al., 2014). PREVENTION Recognizing both the widespread prevalence of bullying and its potential devastating consequences, states are actively engaged in addressing the problem by enacting laws and policies aimed at reducing bullying. Currently, 50 states have passed anti-bullying laws (Hatzenbuehler, Schwab-Reese, Ranapurwala, Hertz, & Ramirez, 2015). The U.S. Department of Education (DOE) has established a framework for anti-bullying laws and has disseminated this framework to schools across America. The U.S. Department of Education (2011) reviewed state anti-bullying laws and examined the extent to which state anti-bullying laws adhered to the framework recommended by the DOE in terms of definitions, policy development and reviews, and training and communication about policies (Stuart-Cassel, Bell, & Springer, 2011). Substantial diversity was found across state anti-bullying laws and policies. Limited research exists examining the effectiveness of anti-bullying laws and policies. An Australian study (Marsh, McGee, Hemphill, & Williams, 2011) found little change in bullying prevalence 4 years after passage of an anti-bullying law. However, a U.S. study, Hatzenbuehler and Keyes (2013) found that lesbian and gay students living in counties that had fewer schools with anti-bullying policies that included protection for lesbian, gay, bisexual, or transgender (LGBT) students were 2.5 times more likely to have attempted suicide in the past year compared with lesbian and gay students living in counties where school district anti-bullying policies included LGBT protections. Hatzenbuehler and Keyes (2013) examined the effectiveness of anti-bullying laws in reducing student risk of experiencing bullying and cyberbullying and found that students in states with at least one DOE legislative component (see Box 4) in their anti-bullying law had a 24% decreased chance of experiencing bullying and a 20% decreased chance of experiencing cyberbullying. Three individual aspects of anti-bullying Journal of Pediatric Health Care
BOX 4. Key characteristics of state anti-bullying laws Statement of purpose of the anti-bullying law Scope of school district for regulating bullies Specification of prohibited bullying conduct Enumerated groups that are protected under the law Development and implementation of LEA policies Components of LEA policies Definitions of bullying are consistent with state law Reporting procedures Procedures for investigation and responding to bullying Written records Sanctions for bullying Referral to mental health services Review of local policies Communication plan Training and preventive education Transparency and monitoring Statement of rights to other legal recourse Model policy Note. LEA, local educational agency. Modified from the U.S. Department of Health and Human Services (2014).
legislation were found to be associated with a decreased risk of experiencing both traditional bullying and cyberbullying: statement of scope, description of prohibited behaviors, and requirements for school districts to develop and implement local policies (Hatzenbuehler & Keyes, 2013). Resilience building is key to bullying prevention. Ideally, resilience building should begin at an early age. Promoting Alternative Thinking Strategies (i.e., PATHS) is one program that has shown success among elementary school students (Low, Smolkowski, & Cook, 2016). PATHS involves over 50 lessons designed to nurture social and emotional growth by promoting affect regulation, peer conflict, and problem solving via a multiyear program (Hinduja & Patchin, 2017). Other classroom-based programs, such as Steps to Respect and Second Step, for elementary and middle school students have been shown to cultivate some indicators of resilience through focus on social competence and social problem solving (Taub & Pearrow, 2005). Programs that focus on the whole child such as mentoring, forming positive connections and secure relationships, modeling of morals and values, and even faith-based messaging can help promote resilience to bullying (Hinduja & Patchin, 2017). Prevention efforts must involve school-wide efforts that provide positive behavior support, establish a common set of expectations for positive behavior across all school contexts, and involve all school staff (Flannery et al., 2016). IMPLICATIONS FOR PRACTICE Bullying is clearly a pediatric health care problem. Bullying can result in physical and mental health problems. PNPs must be able to promptly identify and appropriately intervene when bullying is affecting their www.jpedhc.org
BOX 5. Bullying questions Children How are things going at school? Do you feel safe at school? If no, explore Do you feel safe at home? If no, explore Does anyone at school make fun of, bother, or hurt you? Who? How often? What do they do? Does anyone at home make fun of, bother, or hurt you? Who? How often? What do they do? Does anyone online make fun of, bother, or hurt you? Who? How often? What do they do? Do you ever make fun of, bother, or hurt another student at school? How often? What do you do? Do you ever make fun of, bother, or hurt your brother or sister at home? How often? What do you do? Do you ever make fun of, bother, or hurt someone online? Who? How often? What do you do? Note. Adapted from McClowry et al. (2017).
patients. Screening for bullying should be a part of pediatric health care. The American Academy of Pediatrics (2009) recommends that bullying screening should occur at annual well-child visits beginning at age 6 years, typically when a child begins attending school. Screening can be as simple as establishing a rapport with the child and determining his/her understanding of what bullying is. PNPs can ask screening questions, such as How is school going? What is your favorite thing about school? and What don’t you like about school? PNPs can ask the child if anyone at school, at home, or online is bullying him/her. See Box 5 for examples of additional questions to explore a child’s bullying experience. Although universal bullying screening is recommended for yearly well-child visits, there are certain groups of patients that warrant more thorough and frequent screening: children with special health care needs, especially those who are suddenly noncompliant or nonresponsive to their treatment plan; children who are over- or underweight; and LGBT youth (McClowry et al., 2017). Patients exhibiting warning signs for bullying such as mood disorders, psychosomatic or behavioral symptoms, substance abuse, selfharm or suicidal ideation, school truancy, and decline in academic performance should also be thoroughly assessed for bullying. Other warning signs of bullying include unexplained physical injuries, sudden July/August 2018
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BOX 6. Dealing with bullying Ignore the bully and walk away Bullies thrive on your reaction Hold your anger Try humor Don’t get physical Practice confidence Practice your response Practice feeling good about yourself Take charge of your life You can’t control others Talk about it Parent Teacher Counselor Friend Find your true friends Note. Adapted from Nemours Foundation Kids Health.org (Nemours Foundation, 2017).
resistance to attending school, unusual need for more lunch money, and having aggressive outbursts (Anderson et al., 2001). PNPs should explore child’s bullying experience. See Box 6 for bullying strategies to discuss with the child, and see Box 7 for strategies for responding to cyberbullying. If the bullying screening result is positive and especially if bullying is chronic, bullying is happening in multiple sites (school, home, and/or online), and/or the child is symptomatic, the child should be linked with trauma-informed mental health services. Parents should be encouraged to have ongoing communication with their child’s school regarding bullying occurring at school. There are several online references available for parents, including the Children’s National Health System (2017). Anticipatory guidance is crucial in preventing bullying. Parents should be encouraged to talk with their children every day about school, friends, and academic performance. PNPs should discuss with parents the importance of being aware of their child’s Internet and social media use. Studies have shown that open communication between parents and children can decrease the incidence of bullying and cyberbullying (Hinduja & Patchin, 2013). BOX 7. Dealing with cyberbullying 1 2 3 4 5 6 7 8 9 10
Talk about it—to your parents, teacher, another trusted adult, or your best friend. Ignore the bullying. Never retaliate. If cyberbullying is repeated, tell them to stop. Laugh—try to laugh it off. Save the evidence. Block access. Report to content provider. Don’t electronically pass messages from cyberbullies. If safety is ever a concern, call the police.
Note. Adapted from Hinduja and Patchin (2012).
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BOX 8. Familial psychosocial assessment Draw family tree Previous or current familial involvement with child protective services Previous or current parental involvement with law enforcement Parental employment/financial statements Parental drug/alcohol use Interpersonal violence Parental mental health concerns Intellectual disability/low functioning Anxiety Depression Other diagnosis Mental health/psychiatric medications Maternal/paternal Sexual abuse as a child Physical abuse as a child Child protective services involvement as a child Support systems
Because children experiencing bullying are at increased risk for experiencing other forms of trauma, it is important for PNPs to assess for additional trauma exposure. A thorough familial psychosocial assessment must be completed (see Box 8). PNPs should link families with appropriate interventions and monitor follow through. Children should be screened for sexual and physical abuse. The anogenital examination can be used to educate children about the concept of private parts and what to do if touched and to ask if their private parts have ever been touched. Children and parents should be screened regarding discipline methods, and PNPs should consistently encourage the use of nonphysical methods of discipline and other positive parenting concepts. If screening results lead to a suspicion of child maltreatment, a report to child protective services is indicated. Bullying is a significant pediatric health care problem. Advocating for local, state, and national policies and legislation addressing the bullying epidemic is an important role for all pediatric health care providers, including PNPs. PNPs must also endorse clinical practice behaviors that acknowledge the significance of bullying and other psychosocial traumas. By consistently screening pediatric patients for bullying and other psychosocial traumas and providing appropriate intervention, PNPs can make a difference in the lives of children. REFERENCES Albdour, M., & Krouse, A. (2014). Bullying and victimization among African American adolescents: A literature review. Journal of Child and Adolescent Psychiatric Nursing, 27, 68-82. Albdour, M., Lewin, L., Kavanaugh, K., Hong, J., & Wilson, F. (2017). Arab American adolescents’ perceived stress and bullying experiences: A qualitative study. Western Journal of Nursing Research, 39, 1567-1588. American Academy of Pediatrics. (2009). Committee on injury, violence, and poison prevention policy statement–Role of the
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pediatrician in youth violence prevention. Pediatrics, 124, 393402. Anderson, M., Kaufman, J., Simon, T., Barrios, L., Paulozzi, L., Ryan, G., et al. (2001). School-associated violent deaths in the Unites States, 1994-1999. JAMA: The Journal of the American Medical Association, 286, 2695-2702. Antila, H., Arola, R., Hakko, H., Riala, K., Riipinen, P., & Kantojarvi, L. (2017). Bullying involvement in relation to personality disorders a prospective follow-up of 508 inpatient adolescents. European Journal of Child and Adolescent Psychiatry, 87, 1-8. Arseneault, L. (2017). The long-term impact of bullying victimization on mental health. World Psychiatry, 16, 27-28. Brunstein-Klomek, A., Sourander, A., & Gould, M. (2010). The association of suicide and bullying in childhood to young adulthood: A review of cross-sectional and longitudinal research findings. Canadian Journal of Psychiatry, 55, 282-288. Children’s National Health System. (2017). Program for health care related to bullying. Washington, DC: Author. Retrieved from https://childrensnational.org/departments/bullying-related-healthrisks Cillessen, D., & Rose, A. (2005). Understanding popularity in the peer system. Current Directions in Psychological Science, 14, 102105. Cooper, G., Clements, P., & Holt, K. (2012). Examining childhood bullying and adolescent suicide: Implications for school nurses. Journal of School Nursing, 28, 275-283. Dunn, J., & McGuire, S. (1992). Sibling and peer relationships in childhood. Journal of Child Psychology and Psychiatry, 33, 67105. Eisenberg, M., & Aalsma, M. (2005). Bullying and peer victimization: Position paper of the Society for Adolescent Medicine. Journal of Adolescent Health, 36, 88-91. Estell, D., Farmer, T., & Cairns, B. (2007). Bullies and victims in rural African American youth: Behavioral characteristics and social network placement. Aggressive Behavior, 33, 145159. Evans, C., Fraser, M., & Cotter, K. (2014). The effectiveness of schoolbased bullying prevention programs: A systematic review. Aggression and Violent Behavior, 19, 532-544. Flannery, D., Todres, J., Bradshaw, C., Amar, A., Graham, S., Hatzenbuehler, M., … Rivara, F. (2016). Bullying prevention: A summary of the report of the national academies of sciences, engineering, and medicine. Prevention Science, 17, 10441053. Grinshteyn, E., & Yang, T. (2017). The association between electronic bullying and school absenteeism among high school students in the United States. Journal of School Health, 87, 142149. Hase, C., Goldberg, S., Smith, D., & Stuck, A. (2015). Impacts of traditional bullying and cyberbullying on the mental health of middle school and high school students. Psychology School, 52, 607-617. Hatzenbuehler, M., & Keyes, K. (2013). Inclusive anti-bullyng policies and reduced risk of suicide attempts in lesbian and gay youth. Journal of Adolescent Health, 53, 521-526. Hatzenbuehler, M., Schwab-Reese, L., Ranapurwala, S., Hertz, M., & Ramirez, M. (2015). Associations between antibullying policies and bullying in 25 states. JAMA, 169, 1-8. Hinduja, S., & Patchin, J. (2012). Responding to cyberbullying. Cyberbullying Research Center. Retrieved from https:// cyberbullying.org/Top-Ten-Tips-Teens-Response.pdf Hinduja, S., & Patchin, J. (2013). Social influences on cyberbullying behaviors among middle and high school students. Journal of Youth and Adolescents, 42, 711-722. Hinduja, S., & Patchin, J. (2017). Cultivating youth resilience to prevent bullying and cyberbullying victimization. Child Abuse & Neglect, 73, 51-62.
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Hoffman, M. (2000). Empathy and moral development: Implications for caring and justice. Cambridge, UK: Cambridge University Press. Huitsing, G., Snijders, T., van Duijn, M., & Veenstra, R. (2014). Victims, bullies, and their defenders: A longitudinal study of the coevolution of positive and negative networks. Development and Psychopathology, 26, 645-659. Jansen, P., Verlinden, M., Dommisse-van Berkel, A., Mieloo, C., van der Ende, J., Veenstra, R., & Tiemeier, H. (2012). Prevalence of bullying and victimization among children in early elementary school: Do family and school neighborhood socioeconomic status matter. BMC Public Health, 12, 490-494. Juvonen, J., & Graham, S. (2014). Bullying in schools: The power of bullies and the plight of victims. Annual Review Psychology, 65, 159-185. Kamn, L., McManus, T., & Harris, W. (2016). Youth risk behavior surveillance-United States, 2015. Pediatrics, 118, 1-174. Kiselica, M., & Morrill-Richards, M. (2007). Sibling maltreatment: The forgotten abuse. Journal of Developmental Counseling, 85, 148160. Klomek, A., Sourander, A., Kumpulainen, K., Piha, J., Tamminen, T., Moilanen, I., et al. (2008). Childhood bullying as a risk for later depression and suicidal ideation among Finnish males. Journal of Affective Disorders, 109, 47-55. Kowalski, R., Giumetti, G., Schroeder, A., & Lattanner, M. (2014). Bullying in the digital age: A critical review and meta-analysis of cyberbullying research among youth. Psychological Bulletin, 140, 1073-1137. Lai, T., & Kao, G. (2017). Hit, robbed, and put down (but not bullied): Underreporting of bullying by minority & male students. Journal of Youth & Adolescence, 19, 1-7. Lampard, A., MacLehose, R., Eisenberg, M., Neumark-Sztainer, D., & Davison, K. (2014). Weight-related teasing in the school environment. Journal of Youth and Adolescence, 43, 17701780. Low, S., Smolkowski, K., & Cook, C. (2016). What constitutes highquality implementation of SEL programs? A latent class analysis of second Step’ implementation. Prevention Science, 17, 981991. Luthar, S. (2003). Resilience and vulnerability. Adaptation in the context of childhood adversities. New York, NY: Cambridge Press. Luthar, S., Cicchetti, D., & Becker, B. (2000). A critical evaluation and guidelines for future work. Child Development, 71, 543-562. Marsh, L., McGee, R., Hemphill, S., & Williams, S. (2011). Content analysis of school anti-bullying policies: A comparison between New Zealand and Victoria, Australia. Health Promotion Journal Australia, 22, 172-177. McClowry, R., Miller, M., & Mills, G. (2017). What family physicians can do to combat bullying. Journal of Family Practice, 66, 8289. Messias, E., Kindrick, K., & Castro, J. (2014). School bullying, cyberbullying, or both: Correlates of teen suicidality in the 2011 CDC Youth risk Behavior Survey. Comprehensive Psychiatry, 55, 1063-1068. Mishna, P., Khoury-Kassabri, M., Gadalla, T., & Daciuk, J. (2012). Risk factors for involvement in cyberbullying victims, bullies, and bullyvictims. Children & Youth Services Review, 34, 63-70. Nansel, T., Overpeck, M., Haynie, O., Ruan, W., & Scheidt, P. (2003). Relationships between bullying and violence among US youth. Archives of Pediatric and Adolescent Medicine, 157, 348353. Nemours Foundation. (2017). Stop the bullying. Wilmington, DE. Retrieved from http://kidshealth.org/en/teens/bullies.html#. Author. Olweus, D. (2012). Cyberbullying: An overrated phenomenon? European Journal of Developmental Psychology, 9, 520-538. Olweus, D., & Limber, S. (2010). Bullying in school: Evaluation and dissemination of the Olweus Bullying Prevention Program. American Journal of Orthopsychiatry, 80, 124-134.
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Pozzoli, T., Gini, G., & Thornberg, R. (2017). Getting angry matters: Going beyond perspective taking and empathic concern to understand bystanders’ behavior in bullying. Journal of Adolescence, 61, 87-95. Radliff, K., Wheaton, J., Robinson, K., & Morris, J. (2012). Illuminating the relationship between bullying and substance use among middle and high school youth. Addictive Behaviors, 37, 569-572. Robinson, J., Espelage, D., & Rivers, T. (2013). Developmental trends in peer victimization and emotional distress in LGB and heterosexual youth. Pediatrics, 131, 423-430. Romero, A., Wiggs, C., Valencia, C., & Bauman, S. (2013). Latina suicide and bullying. Hispanic Journal of Behavioral Sciences, 35, 159-173. Rosen, L., Beron, K., & Underwood, M. (2016). Social victimization trajectories from middle childhood through late adolescence. Social Development, 26, 227-247. Sangalang, C., Tran, A., Ayers, S., & Marsiglia, F. (2016). Bullying among urban Mexican-heritage youth: Exploring risk for substance use by status as a bully, victim, and bully-victim. Children and Youth Services Review, 61, 216-221. Sapouna, M., & Wolke, D. (2013). Resilience to bullying victimization: The role of individual, family, and peer characteristics. Child Abuse & Neglect, 37, 997-1006. Stuart-Cassel, V., Bell, A., & Springer, F. (2011). Analysis of state bullying laws and policies. Washington, DC: U.S. Department of Education. Takizawa, R., Maughan, B., & Arseneault, L. (2014). Adult health outcomes of childhood bullying victimization: Evidence from a 5-decade longitudinal British birth cohort. American Journal of Psychiatry, 171, 777-784. Taub, J., & Pearrow, M. (2005). Resilience through violence prevention in schools. In S. Goldstein & R. B. Brooks (Eds.), Handbook of resilience in children (pp. 357-371). New York, NY: Springer. Temkin, D. (2015). All 50 states now have a bullying law. Now what? The Huffington Post. (April 27, 2015). Retrieved from http:// www.huffingtonpost.com/deborah-temkin/all-50-states-now -have-a_b_7153114.html
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Tippett, N., & Wolke, D. (2015). Aggression between siblings: Associations with the home environment and peer bullying. Aggressive Behavior, 41, 14-24. Troop-Gordon, W. (2017). Peer victimization in adolescence: The nature, progression, and consequences of being bullied within a developmental context. Journal of Adolescence, 55, 116-128. Tucker, C., Finkelhor, D., Turner, H., & Shattnuck, A. (2014). Family dynamics and young children’s sibling victimization. Journal of Family Psychology, 28, 625-633. U.S. Department of Education. (2011). Analysis of state bullying laws and policies. Washington, DC. Retrieved from https:// www2.ed.gov/rschstat/eval/bullying/state-bullying-laws/statebullying-laws.pdf. Author. U.S. Department of Health and Human Services. (2014). Washington, DC: Author. Key components in state anti-bullying laws. Retrieved from https://www.stopbullying.gov/laws/keycomponents/index.html van Cleave, J., & Davis, M. (2006). Bullying and peer victimization among children with special health care needs. Pediatrics, 118, e1212-e1219. Vitoroulis, I., & Georgiades, K. (2017). Bullying among immigrant and non-immigrant early adolescents: School- and student-level effects. Journal of Adolescence, 61, 141-151. Vlachur, M., Andreau, E., Botsoglou, K., & Didaskalou, E. (2011). Bully/ victim problems among preschool children: A review of current research evidence. Educational Psychology Review, 23, 329-358. Von Dijk, A., Poorthuis, A., & Malti, T. (2016). Psychological processes in young bullies versus bully-victims. Aggressive Behavior, 43, 1-10. Waasdorp, T., & Bradshaw, C. (2015). The overlap between cyberbullying and traditional bullying. Journal of Adolescent Health, 56, 483-488. Wolke, D., Lee, K., & Guy, A. (2017). Cyberbullying: A storm in a teacup? European Child and Adolescent Psychiatry, 26, 899908. Wolke, D., Tippett, N., & Dantchev, S. (2015). Bullying in the family: Sibling bullying. Lancet, 2, 917-929. Zuckerman, D. (2016). Bullying harms victims and perpetrators of all ages. Health Progress, 97(4), 63-66.
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Continuing Education
Bullying: What the PNP Needs to Know Gail Hornor, RNC, DNP, CPNP ABSTRACT Despite generations of doubt about the true impact of bullying, it is now clear that childhood bullying can have significant lifelong consequences for victims and bullies alike. Recent school shootings and suicides by students who have been victims of bullying have helped to solidify public awareness of the gravity of the problem of childhood bullying. Adults who were frequently bullied in childhood have an increased frequency of psychiatric disorders, including anxiety, depression, and suicidality, extending into middle age (Arseneault, 2017). In fact, frequent bullying in childhood may impact victims similar to experiencing multiple adverse childhood experiences (Takizawa, Maughan, & Arseneault, 2014). Bullying also has a detrimental effect on young perpetrators (Zuckerman, 2016). Bullying is clearly a pediatric health care problem. This continuing education article will explore bullying in terms of definitions, epidemiology, types, risk factors, resilience factors, consequences, and implications for practice. J Pediatr Health Care. (2018) 32, 399-408.
KEY WORDS Bullying, trauma, cyberbullying
Despite generations of doubt about the true impact of bullying, it is now clear that childhood bullying can have significant lifelong consequences for victims and bullies alike. Recent school shootings and suicides by students who have been victims of bullying has helped solidify public awareness of the gravity of the problem of childhood bullying. Adults who were frequently bullied in childhood have an increased frequency of psychiatric disorders, including anxiety, depression, and Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children’s Hospital, Center for Family Safety and Healing, Columbus, OH. Conflicts of interest: None to report. Correspondence: Gail Hornor, RNC, DNP, CPNP, Nationwide Children’s Hospital, Center for Family Safety and Healing, 655 East Livingston Ave, Columbus, OH 43205; e-mail: [email protected] 0891-5245/$36.00 Copyright © 2018 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2018.02.001
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suicidality, extending into middle age (Arseneault, 2017). Frequent bullying in childhood may have a similar effect on victims as multiple adverse childhood experiences (Takizawa, Maughan, & Arseneault, 2014). Bullying also has a detrimental effect on young perpetrators (Zuckerman, 2016). Bullying is clearly a pediatric health care problem. Pediatric nurse practitioners (PNPs) need to incorporate bullying prevention, identification, and intervention into their practice. This continuing education article will explore bullying in terms of definitions, epidemiology, types, risk factors, resilience factors, consequences, and implications for practice. DEFINITIONS There are many definitions of bullying, and they all tend to share three common criteria: intentionality, repetitiveness, and power imbalance (Olweus, 2012). Bullying is typically defined as the use of physical or emotional power to control or harm others and can include behaviors such as physical or verbal attacks, making threats, spreading rumors, name calling, or intentionally excluding someone from a group (Zuckerman, 2016). Bullying involves a pattern of repeated aggression, a deliberate intent to harm or disturb the victim despite the victim’s apparent distress, and a real or perceived imbalance of power (Cooper, Clements, & Holt, 2012). Bullying behavior in the traditional sense is typically perpetrated face to face, and the bully can observe the impact of his/her actions on the victim. Although any site where children and teens interact can be sites for bullying, certainly school, transportation to and from school, and after-school programs are common sites for bullying. Cyberbullying can be broadly defined as bullying that is carried out via electronic means such as text messages, e-mails, online chat rooms, or social networking sites (Wolke, Lee, & Guy, 2017). Cyberbullying, like traditional bullying, is an act of aggression characterized by a power imbalance and is often repeated (Kowalski, Giumetti, Schroeder, & Lattanner, 2014). Traditional physical bullying as opposed to cyberbullying occurs more frequently among males and decreases through the high school years (Messias, Kindrick, & Castro, 2014). Cyberbullying occurs more frequently July/August 2018
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among females and does not show a decreasing trend in high school (Messias et al., 2014). EPIDEMIOLOGY Bullying has often been trivialized and viewed as a universal childhood experience, one that everyone experiences. Because of this, bullying was not considered a health issue until the 1970s (Olweus & Limber, 2010). There was not a single piece of legislation in the United States addressing bullying until the Columbine High School mass shooting in 1999 (McClowry, Miller, & Mills, 2017). Within 3 years of the Columbine tragedy, 15 states had passed state laws mentioning bullying, and by 2015, every state and the District of Columbia had an anti-bullying law (Temkin, 2015). Despite this legislative effort, bullying continues to be a problem of epidemic proportions in the United States. According to the Centers for Disease Control and Prevention’s 2015 Youth Risk Behavior Surveillance System, 20.2% of high school students experience bullying (Kamn, McManus, & Harris, 2016). Bullying certainly does not typically begin in adolescence; bullying can begin very early. Jansen et al. (2012) state that about 10% to 14% of kindergarten students bully others and are bullied as well. Bullying often begins in early elementary school, increases steadily to a peak in early secondary school (ages 12-14 years), and tapers in late adolescence (Sapouna & Wolke, 2013). This increase in bullying in early adolescence is not due to bullying by previously unaggressive peers; rather, it is the result of heightened aggression by a small number of adolescents while most maintain rather low levels of bullying (Troop-Gordon, 2017). Approximately 30% of school children are bullies, victims, or bully– victims (Evans, Fraser, & Cotter, 2014). Females are bullied more often than males (24% vs. 16%, respectively). The most likely student to be bullied is a White female in ninth grade (Evans et al., 2014). Adolescents who perpetrate bullying tend to be thought of as popular, possessing a social status of leadership, influence, and respect (Cillessen & Rose, 2005). Other forms of aggression tend to decrease in adolescence, but relational aggression, such as spreading rumors or exclusion, increases (Rosen, Beron, & Underwood, 2016). Relational aggression can be seen in the preschool years; however, adolescents have increased mental and language skills to more effectively execute relational aggression. The prevalence rate for cyberbullying is reported to be as high as 52% of the adolescent population (Mishna, Khoury-Kassabri, Gadalla, & Daciuk, 2012). Studies suggest that there is considerable overlap between cyberbullying and traditional bullying. Cyberbullying on its own is very rare (Wolke et al., 2017). Two recent studies by Hase, Goldberg, Smith, and Stuck (2015) and Waasdorp and Bradshaw (2015) found the co-occurrence of traditional and cyberbullying 400
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to be as high as 88% to 93%. In other words, 9 out of 10 adolescents who report cyber-victimization also report experiencing traditional bullying (Wolke et al., 2017). Victims experiencing only cyberbullying had similar negative psychological outcomes to those experiencing only traditional bullying; however, those experiencing both are at highest risk of poor psychological outcomes (Wolke et al., 2017). TYPES OF BULLYING Cyberbullying Cyberbullying is unique Cyberbullying is in that it can take so unique in that it many different forms can take so many and can occur via many venues. Cyberspace different forms and gives bullies a new tool can occur via many to extend their bullyvenues. ing beyond school or other traditional faceto-face contact. Cyberbullies uses social media to mock, spread rumors, and harass their victims. They may be very technologically savvy and can remain anonymous and untraceable when posting messages, videos, photos, and fake profiles for wide distribution. An Internet post is essentially impossible to delete or stop once it is sent, especially if it has been passed around by others and distributed on multiple sites. Individuals often experience multiple types of cyberbullying. See Box 1 for types of cyberbullying. Cyberbullying and traditional bullying differ in accessibility. Traditional bullying typically occurs at school during the school day. Cyberbullying can be perpetrated from anywhere at any time 24 hours a day, 7 days a week. Also, cyberbullying, because of the nature of the venues through which it occurs, has a much greater BOX 1. Types of cyberbullying Flaming Harassment Outing and trickery
Exclusion Impersonation
Cyberstalking
Sexting
Online fight Repetitive, offensive messages sent to a target Discovering personal information about someone and then electronically sharing that information without the individual’s permission Blocking an individual from buddy lists or other electronic communications Pretending to be the victim and electronically communicating negatively or inappropriately with others as if the information is coming from the victim Using electronic communication to stalk someone by sending repeated threatening messages Sending nude/inappropriate photos of another person without that individual’s consent
Source: Kowalski, Giumetti, Schroeder, and Lattener (2014).
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potential audience than traditional bullying (Kowalski et al., 2014). For instance, thousands of people may view an online post or photo, whereas only a handful of people may view a bullying incident at school. Cyberbullying also differs from traditional bullying in relation to anonymity. Cyberbullies often perceive themselves as anonymous. This perception of anonymity makes cyberbullying attractive to individuals who would not be bullies in the traditional face-to-face style. An anonymous bully may not realize the impact of their cyberbullying; they cannot see the consequences of their actions, making them less likely to feel empathy or remorse (Zuckerman, 2016). Motivations for engaging in cyberbullying may differ from those for traditional bullying. In traditional faceto-face bullying, the rewards are instantaneous; the effect on the victim is immediately seen. Cyberbullying, on the other hand, results in delayed gratification. Any response of the victim is delayed, and the cyberbully cannot see the immediate effects on the victim. This suggests that the motivation for cyberbullying may be intrapersonal and more tied to performing the act rather than witnessing the consequences of that action (Kowalski et al., 2014). Conversely, the motivation for traditional face-to-face bullying may be interpersonal, tied to witnessing the effect of the bullying on the victim or to having others witness the bullying actions.
cal, or social harm on the targeted sibling. Sibling bullying can be physical, verbal, or relational in nature. Sibling bullying is a unique form of bullying that is repeated and harmful. Sibling bullying has been associated with increased risk of being involved in peer bullying, as well as concurrent and adult emotional problems such as distress, depression, and self-harm (Wolke et al., 2015). Wolke et al. explored familial factors associated with sibling bullying. The following factors were associated with sibling bullying: male siblings; siblings close in age; and a greater number of children in the family. Sibling bullying crosses economic barriers, with higher rates of sibling bullying being found in families of low socioeconomic status and also in families with higher parental education level (Tippett & Wolke, 2015). Child maltreatment, household domestic violence, lack of parental warmth, harsh parenting, and low parental supervision are also associated with sibling bullying (Tucker, Finkelhor, Turner, & Shattnuck, 2014). Singleparent or step-families were not associated with sibling bullying (Wolke et al., 2015). However, Kiselica and Morrill-Richards (2007) identified a link between differential parental treatment of siblings and sibling bullying, indicating that sibling bullying may be stimulated by inequality and a desire to improve status, similar to motivations underlying school bullying.
Sibling Bullying Sibling relationships have an important and lasting impact on an individual’s development. Sibling relationships are often the most enduring relationships of a lifetime: siblings are our companions, teachers, and our caregivers (Dunn & McGuire, 1992). However, up to 40% of individuals are exposed to sibling bullying every week (Wolke, Tippett, & Dantchev, 2015). Sibling rivalry and jealousy have existed since the beginning of time and have been depicted in literature throughout centuries, beginning with the biblical story of Cain and Abel. Cultural differences exist in the nature and dynamics of sibling relationships according to individualistic or collectivistic norms. Collectivistic societies place a greater focus on group versus individual goals; siblings tend to spend more time together and have more hierarchical relationships, older siblings have more responsibility caring for younger siblings, and older siblings garner more respect (Wolke et al., 2015). However, the United States is an individualistic society; the strength of the sibling relationship is often diluted by individual goals, and sibling companionship, support, and intimacy are lessened. Sibling bullying is defined by Wolke et al. (2015) any unwanted aggressive behavior(s) by a sibling that involves an observed or perceived power imbalance and is repeated multiple times or is very likely to be repeated; bullying may inflict physical, psychologi-
BULLIES The typical bully is not psychologically well adjusted, often has problems in his/her home life, cannot handle emotions, and has little empathy for others (Juvonen & Graham, 2014). Childhood bullies can be broadly divided into two types: those seeking status and those going after more vulnerable victims. Juvonen and Graham (2014) studied more than 16,000 American public and private school students in grades 6 through 10 and found that bullies motivated by social status tend to target their friends and other more popular students. However, the bullies who target vulnerable victims tend to be anxious or depressed and less popular themselves. Males typically engage in physically aggressive bullying; females tend to use verbal, social, and cyberbullying. Long-term consequences for bullies include alcohol and drug use later in adolescence and adulthood, early sexual activity, dropping out of school, criminal convictions as an adult, and being physically and/or emotionally abusive to romantic partners or their children as adults (Zuckerman, 2016). Both bullies and the bullied are more likely to commit suicide or engage in suicidal ideation (Zuckerman, 2016). Children involved in bullying, both victims and aggressors, are more likely to engage in frequent fighting, be injured in a fight, carry a weapon, and carry a weapon to school (Nansel, Overpeck, Haynie, Ruan, & Scheidt, 2003).
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Von Dijk, Poorthuis, and Malti (2016) explored the psychological processes in young kindergarten bullies versus bully victims. Generally speaking, bully victims and bullies differ in their social functioning. Young bullies tend to have as many friends as their noninvolved peers, and they are likely to affiliate with their noninvolved classmates. Young bullies have a dichotomous status among classmates: they are more likely to be popular yet also more likely to be rejected. However, young bully victims have fewer friends than noninvolved peers, are less likely to affiliate with noninvolved peers, and are more likely to be rejected by classmates. Therefore, young bully victims tend to be marginalized at an early age, and young bullies appear to be well integrated into their classes (Vlachur, Andreau, Botsoglou, & Didaskalou, 2011). Von Dijk et al. (2016) state that at an early age, bullies and bully victims share psychological processes that underlie their bullying behaviors. Both bullies and bully victims use aggressive strategies when interacting with peers. The difference in social status between bullies and bully victims can be explained by their success with their aggressive behavior. Bullies gain dominance by their aggressive behavior; bully victims evoke victimization by behaving aggressively. Therefore, bullies and bully victims are not different in their motivation for aggressive behavior at this young age; rather, they differ in the success of their aggression. BYSTANDERS Nearly every incident of Nearly every bullying, be it traditional incident of bullying, face-to-face bullying or be it traditional cyberbullying, involves not only the bully and face-to-face the victim but also bybullying or standers. Bystanders can cyberbullying, respond to the incident in a variety of ways, ininvolves not only cluding reinforcing or the bully and the assisting the bully, devictim but also fending the victim, or passively standing by bystanders. and acting as though nothing is happening (Pozzoli, Gini, & Thornberg, 2017). This varied response noted by bullying bystanders has been attributed to empathy or the lack thereof (Huitsing, Snijders, van Duijn, & Veenstra, 2014). A key element of empathy is the involvement of psychological processes that make a person have feelings that are more congruent with another’s situation than with his own situation (Hoffman, 2000). Bullies who target the same victims tend to support each other, as do victims who are bullied by the same bullies; they show empathy for one another (Huitsing et al., 2014). Bystanders who support bully victims exhibit empathy for the victim, often placing themselves at risk 402
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of retaliation, because the bullies may direct their aggression toward individuals who support their victims (Pozzoli et al., 2017). Victims with at least one defender have been found to have higher self-esteem and be more accepted and less rejected by their peers (Huitsing et al., 2014). Bully defenders and passive bystanders share a lack of feelings of empathy; they are unable to respond to victims with compassion and support, perhaps in part because of fear of retaliation (Pozzoli et al., 2017). RISK FACTORS There are characteristics that place children at increased risk of being bullied. Children who are different or perceived to be different from their peers are at risk for bullying (see Box 2). Characteristics that make individuals look different or behave differently from societal norms place them at risk of experiencing bullying. Children of racial and ethnic minorities, particularly African American (Albdour & Krouse, 2014) and Hispanic (Lai & Kao, 2017), are at increased bullying risk. Immigrant children are also at increased risk for bullying (Vitoroulis & Georgiades, 2017). Risk for racial, ethnic, and immigrant bullying can be reduced by making schools more diverse and having a higher representation of a student’s ethnic/racial/immigrant minority in that school (Vitoroulis & Georgiades, 2017). Religious affiliation can also be a cause of bullying. Arab American adolescents report experiencing bullying due BOX 2. Bullying risk factors Chronic illness Physical disability Obesity Underweight Different appearance Minority Racial Ethnic Religious Immigrant Learning disability Behavior problem LGBTQ Poverty Foster care Group home Poor family functioning Lack of close relationships Exposure to trauma Child maltreatment Physical abuse Sexual abuse Emotional abuse Neglect Familial interpersonal violence Parental drug/alcohol concerns Parental mental/health concerns Note. LGBTQ, lesbian, gay, bisexual, transgender, or queer. Adapted from McClowry et al. (2017).
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to their ethnic/racial background and also due to identifying as Muslim (Albdour, Lewin, Kavanaugh, Hong, & Wilson, 2017). Children with a chronic illness or physical disability are at increased bullying risk. Bullying can negatively affect the ability to manage a chronic illness and can result in decreased compliance with the health care plan (van Cleave & Davis, 2006). Learning disabilities and speech or cognitive delays place children at risk. Children who are socially different from their peers are also at increased risk: children living in foster care or group homes, poverty, family dysfunction, lack of close relationships, and poor family functioning. Trauma-exposed children are also at increased risk for bullying, such as those experiencing child maltreatment or exposure to domestic violence. Children who behave differently than their peers are vulnerable to bullying. Children and adolescents with internalizing problems are at increased risk for bullying. Depression and anxiety may communicate vulnerability to bullying peers (Troop-Gordon, 2017). Peer rejection or social isolation is also a risk factor; associating with a large group of peers is protective against victimization (Estell, Farmer, & Cairns, 2007). Children exhibiting externalizing behavior problems are also at increased risk. Aggressive and delinquent behaviors do not conform to peer norms and may elicit bullying from peers. For the most part, risk factors for peer victimization remain relatively constant across development. However, bullying for certain characteristics tends to peak in adolescence. Obese children are particularly vulnerable to bullying, and this phenomenon can have in a significant impact on these children’s emotional health. Weight-related bullying begins in childhood; however, rates of weight-related victimization escalate alarmingly in adolescence (Lampard, MacLehose, Eisenberg, Neumark-Sztainer, & Davison, 2014). Sexual attraction and gender role identity intensifies during adolescence. Youth who identify as gay, lesbian, or bisexual, as well as transgender and other gender nonconforming youth, are at high risk of experiencing bullying. Robinson, Espelage, and Rivers (2013) found that in a population of self-identifying adolescents, 52% of gay or bisexual boys and 57% of lesbian or bisexual girls reported experiencing extensive bullying. Bullying focused on the target’s real or perceived homosexual identity is just as prevalent as weightrelated bullying in adolescence (Troop-Gordon, 2017). Both the timing of and the physiologic changes associated with puberty can influence bullying; early or late pubertal changes in both boys and girls has been associated with increased risk for bullying. RESILIENCE TO BULLYING Resilience is defined the ability to manifest positive outcomes over time despite facing significant adversities (Luthar, Cicchetti, & Becker, 2000). There is disparity www.jpedhc.org
among the effects of bullying on child victims; some children who are victims of severe bullying function much better than others with similar bullying experiences. These children are resilient. Resilience is more than a personality trait; rather, it is a capacity that builds over time in the context of relationships with family and peers (Luthar, 2003). Sapouna and Wolke (2013) described individual, family, and peer factors associated with resilience in bully victims. Individual factors that were protective included having high self-esteem, feeling less socially alienated, and less negative emotionality. The way in which the adolescent cognitively interprets the bullying also affects resilience. Adolescents who do not perceive the bullying to be a significant threat to them either physically or socially tend to be more resilient. Adolescents who reported low or no levels of conflict with parents are more resilient. For these children, parents act as a buffer to the bullying. Positive sibling relationships were also found to be a protective factor for bullied adolescents, especially not having a sibling who bullied them. Therefore, adolescents bullied at school and also at home are less likely to be resilient. Sapouna and Wolke (2013) found that having a sibling who was not also a victim of bullying was a protective factor. Sapouna and Wolke also found the quality of peer relationships to be more important to bully resilience than the quantity of friends. Having friends who are not themselves bullied who exhibit higher levels of prosocial behavior was found to be protective. However, victims of bullying tend to have friends who are also victims of bullying, and these peer relationships may not be a source of resilience for bully victims (Sapouna & Wolke, 2013). Resilience to bullying is the result of a subtle interplay between many factors. CONSEQUENCES OF BULLYING Bullying of any type can result in significant consequence for victims. Bullying can result in mental and physical health consequences. Physical health consequences include deterioration of previously stable chronic medical conditions and nonadherence to medication regimens (McClowry et al., 2017). Bullying results in stress and can lead to a number of somatic complaints such as headaches, stomach aches, dizziness, irritable bowel syndrome, and other physical symptoms. It is intuitive that traditional face-to-face bullying is associated with increased school absenteeism: the victim is removing him-/herself from further trauma. Grinshteyn and Yang (2017) examined the relationship between cyberbullying and school absenteeism. In a sample of over 13,000 high school students, Grinshteyn and Yang (2017) found cyberbullying to be significantly associated with missing 1 to 4 or more days of school. These school absences were the result of being fearful of facing the perpetrators or other July/August 2018
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BOX 3. Consequences for bully victims and bullies Suicide/suicidal ideation (bullies and victims) Poor physical health/somatic complaints Deterioration of chronic health conditions Depression Low self-esteem School absenteeism Violence-related behaviors Substance use (bullies and victims) Academic failure (bullies and victims) Externalizing problems (bullies and victims) Internalizing problems Note. Adapted from Eisenberg and Aalsma (2005).
students, leading to fear-based absences. School absenteeism negatively affects not only academic development but also the social/relational development of the individual. Antila et al. (2017) examined the relationship between bullying victimization in adolescence and the subsequent development of personality disorders. The study sample was composed of 508 adolescents (300 girls, 208 boys) who received inpatient psychiatric care. Female bully victims had a fourfold greater likelihood of developing a personality disorder later in life; particularly borderline personality disorder. No association between bullying victimization and the development of a personality disorder later in adolescence or adulthood was found for males. Multiple studies have indicated that traditional bullying is a risk factor for suicide (Brunstein-Klomek, Sourander, & Gould, 2010; Klomek et al., 2008). Teens exclusively experiencing cyberbullying victimization are at a higher risk of suicide than those experiencing only traditional bullying (Messias et al., 2014). However, those experiencing both forms of bullying are at highest risk of suicide. A variety of negative consequences have been linked to bullying, for both the perpetrators and the victims (see Box 3). Bullies exhibit aggressive behaviors and are more likely to experience externalizing problems (Juvonen & Graham, 2014). Victims are characterized by a lack of confidence in social settings, shyness, introversion, and internalizing problems (Romero, Wiggs, Valencia, & Bauman, 2013). Children who are both bullies and victims (bully–victims) may fare the worst. Bully–victims are at greatest risk of conduct, academic, and peer relationship problems and lower selfesteem, greater anxiety, and more psychosomatic symptoms (Juvonen & Graham, 2014). Sangalang, Tran, Ayers, and Marsiglia (2016), in a study of 809 youths, found both bullies and bully–victims to be at significant risk for substance use compared with noninvolved peers. Bullies were more likely to use alcohol and tobacco; bully–victims disclosed alcohol, tobacco, and inhalant use. Radliff, Wheaton, Robinson, and Morris 404
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(2012) found that bullies and bully–victims both were more likely to engage in tobacco, marijuana, alcohol, and prescription drug use. The consequences The consequences of bullying can last a of bullying can last lifetime. Young adults a lifetime. who were victimized as children have higher rates of agoraphobia, depression, anxiety, panic disorder, and suicidal ideation compared with nonbullied peers (Arsenault, 2017). Young adults with a history of bullying are also at increased risk for psychiatric hospitalization and using psychotropic medications. Bullied individuals experience high levels of psychological distress throughout the lifespan. The consequences of bullying often extend into middle age and beyond (Takizawa et al., 2014). PREVENTION Recognizing both the widespread prevalence of bullying and its potential devastating consequences, states are actively engaged in addressing the problem by enacting laws and policies aimed at reducing bullying. Currently, 50 states have passed anti-bullying laws (Hatzenbuehler, Schwab-Reese, Ranapurwala, Hertz, & Ramirez, 2015). The U.S. Department of Education (DOE) has established a framework for anti-bullying laws and has disseminated this framework to schools across America. The U.S. Department of Education (2011) reviewed state anti-bullying laws and examined the extent to which state anti-bullying laws adhered to the framework recommended by the DOE in terms of definitions, policy development and reviews, and training and communication about policies (Stuart-Cassel, Bell, & Springer, 2011). Substantial diversity was found across state anti-bullying laws and policies. Limited research exists examining the effectiveness of anti-bullying laws and policies. An Australian study (Marsh, McGee, Hemphill, & Williams, 2011) found little change in bullying prevalence 4 years after passage of an anti-bullying law. However, a U.S. study, Hatzenbuehler and Keyes (2013) found that lesbian and gay students living in counties that had fewer schools with anti-bullying policies that included protection for lesbian, gay, bisexual, or transgender (LGBT) students were 2.5 times more likely to have attempted suicide in the past year compared with lesbian and gay students living in counties where school district anti-bullying policies included LGBT protections. Hatzenbuehler and Keyes (2013) examined the effectiveness of anti-bullying laws in reducing student risk of experiencing bullying and cyberbullying and found that students in states with at least one DOE legislative component (see Box 4) in their anti-bullying law had a 24% decreased chance of experiencing bullying and a 20% decreased chance of experiencing cyberbullying. Three individual aspects of anti-bullying Journal of Pediatric Health Care
BOX 4. Key characteristics of state anti-bullying laws Statement of purpose of the anti-bullying law Scope of school district for regulating bullies Specification of prohibited bullying conduct Enumerated groups that are protected under the law Development and implementation of LEA policies Components of LEA policies Definitions of bullying are consistent with state law Reporting procedures Procedures for investigation and responding to bullying Written records Sanctions for bullying Referral to mental health services Review of local policies Communication plan Training and preventive education Transparency and monitoring Statement of rights to other legal recourse Model policy Note. LEA, local educational agency. Modified from the U.S. Department of Health and Human Services (2014).
legislation were found to be associated with a decreased risk of experiencing both traditional bullying and cyberbullying: statement of scope, description of prohibited behaviors, and requirements for school districts to develop and implement local policies (Hatzenbuehler & Keyes, 2013). Resilience building is key to bullying prevention. Ideally, resilience building should begin at an early age. Promoting Alternative Thinking Strategies (i.e., PATHS) is one program that has shown success among elementary school students (Low, Smolkowski, & Cook, 2016). PATHS involves over 50 lessons designed to nurture social and emotional growth by promoting affect regulation, peer conflict, and problem solving via a multiyear program (Hinduja & Patchin, 2017). Other classroom-based programs, such as Steps to Respect and Second Step, for elementary and middle school students have been shown to cultivate some indicators of resilience through focus on social competence and social problem solving (Taub & Pearrow, 2005). Programs that focus on the whole child such as mentoring, forming positive connections and secure relationships, modeling of morals and values, and even faith-based messaging can help promote resilience to bullying (Hinduja & Patchin, 2017). Prevention efforts must involve school-wide efforts that provide positive behavior support, establish a common set of expectations for positive behavior across all school contexts, and involve all school staff (Flannery et al., 2016). IMPLICATIONS FOR PRACTICE Bullying is clearly a pediatric health care problem. Bullying can result in physical and mental health problems. PNPs must be able to promptly identify and appropriately intervene when bullying is affecting their www.jpedhc.org
BOX 5. Bullying questions Children How are things going at school? Do you feel safe at school? If no, explore Do you feel safe at home? If no, explore Does anyone at school make fun of, bother, or hurt you? Who? How often? What do they do? Does anyone at home make fun of, bother, or hurt you? Who? How often? What do they do? Does anyone online make fun of, bother, or hurt you? Who? How often? What do they do? Do you ever make fun of, bother, or hurt another student at school? How often? What do you do? Do you ever make fun of, bother, or hurt your brother or sister at home? How often? What do you do? Do you ever make fun of, bother, or hurt someone online? Who? How often? What do you do? Note. Adapted from McClowry et al. (2017).
patients. Screening for bullying should be a part of pediatric health care. The American Academy of Pediatrics (2009) recommends that bullying screening should occur at annual well-child visits beginning at age 6 years, typically when a child begins attending school. Screening can be as simple as establishing a rapport with the child and determining his/her understanding of what bullying is. PNPs can ask screening questions, such as How is school going? What is your favorite thing about school? and What don’t you like about school? PNPs can ask the child if anyone at school, at home, or online is bullying him/her. See Box 5 for examples of additional questions to explore a child’s bullying experience. Although universal bullying screening is recommended for yearly well-child visits, there are certain groups of patients that warrant more thorough and frequent screening: children with special health care needs, especially those who are suddenly noncompliant or nonresponsive to their treatment plan; children who are over- or underweight; and LGBT youth (McClowry et al., 2017). Patients exhibiting warning signs for bullying such as mood disorders, psychosomatic or behavioral symptoms, substance abuse, selfharm or suicidal ideation, school truancy, and decline in academic performance should also be thoroughly assessed for bullying. Other warning signs of bullying include unexplained physical injuries, sudden July/August 2018
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BOX 6. Dealing with bullying Ignore the bully and walk away Bullies thrive on your reaction Hold your anger Try humor Don’t get physical Practice confidence Practice your response Practice feeling good about yourself Take charge of your life You can’t control others Talk about it Parent Teacher Counselor Friend Find your true friends Note. Adapted from Nemours Foundation Kids Health.org (Nemours Foundation, 2017).
resistance to attending school, unusual need for more lunch money, and having aggressive outbursts (Anderson et al., 2001). PNPs should explore child’s bullying experience. See Box 6 for bullying strategies to discuss with the child, and see Box 7 for strategies for responding to cyberbullying. If the bullying screening result is positive and especially if bullying is chronic, bullying is happening in multiple sites (school, home, and/or online), and/or the child is symptomatic, the child should be linked with trauma-informed mental health services. Parents should be encouraged to have ongoing communication with their child’s school regarding bullying occurring at school. There are several online references available for parents, including the Children’s National Health System (2017). Anticipatory guidance is crucial in preventing bullying. Parents should be encouraged to talk with their children every day about school, friends, and academic performance. PNPs should discuss with parents the importance of being aware of their child’s Internet and social media use. Studies have shown that open communication between parents and children can decrease the incidence of bullying and cyberbullying (Hinduja & Patchin, 2013). BOX 7. Dealing with cyberbullying 1 2 3 4 5 6 7 8 9 10
Talk about it—to your parents, teacher, another trusted adult, or your best friend. Ignore the bullying. Never retaliate. If cyberbullying is repeated, tell them to stop. Laugh—try to laugh it off. Save the evidence. Block access. Report to content provider. Don’t electronically pass messages from cyberbullies. If safety is ever a concern, call the police.
Note. Adapted from Hinduja and Patchin (2012).
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BOX 8. Familial psychosocial assessment Draw family tree Previous or current familial involvement with child protective services Previous or current parental involvement with law enforcement Parental employment/financial statements Parental drug/alcohol use Interpersonal violence Parental mental health concerns Intellectual disability/low functioning Anxiety Depression Other diagnosis Mental health/psychiatric medications Maternal/paternal Sexual abuse as a child Physical abuse as a child Child protective services involvement as a child Support systems
Because children experiencing bullying are at increased risk for experiencing other forms of trauma, it is important for PNPs to assess for additional trauma exposure. A thorough familial psychosocial assessment must be completed (see Box 8). PNPs should link families with appropriate interventions and monitor follow through. Children should be screened for sexual and physical abuse. The anogenital examination can be used to educate children about the concept of private parts and what to do if touched and to ask if their private parts have ever been touched. Children and parents should be screened regarding discipline methods, and PNPs should consistently encourage the use of nonphysical methods of discipline and other positive parenting concepts. If screening results lead to a suspicion of child maltreatment, a report to child protective services is indicated. Bullying is a significant pediatric health care problem. Advocating for local, state, and national policies and legislation addressing the bullying epidemic is an important role for all pediatric health care providers, including PNPs. PNPs must also endorse clinical practice behaviors that acknowledge the significance of bullying and other psychosocial traumas. By consistently screening pediatric patients for bullying and other psychosocial traumas and providing appropriate intervention, PNPs can make a difference in the lives of children. REFERENCES Albdour, M., & Krouse, A. (2014). Bullying and victimization among African American adolescents: A literature review. Journal of Child and Adolescent Psychiatric Nursing, 27, 68-82. Albdour, M., Lewin, L., Kavanaugh, K., Hong, J., & Wilson, F. (2017). Arab American adolescents’ perceived stress and bullying experiences: A qualitative study. Western Journal of Nursing Research, 39, 1567-1588. American Academy of Pediatrics. (2009). Committee on injury, violence, and poison prevention policy statement–Role of the
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pediatrician in youth violence prevention. Pediatrics, 124, 393402. Anderson, M., Kaufman, J., Simon, T., Barrios, L., Paulozzi, L., Ryan, G., et al. (2001). School-associated violent deaths in the Unites States, 1994-1999. JAMA: The Journal of the American Medical Association, 286, 2695-2702. Antila, H., Arola, R., Hakko, H., Riala, K., Riipinen, P., & Kantojarvi, L. (2017). Bullying involvement in relation to personality disorders a prospective follow-up of 508 inpatient adolescents. European Journal of Child and Adolescent Psychiatry, 87, 1-8. Arseneault, L. (2017). The long-term impact of bullying victimization on mental health. World Psychiatry, 16, 27-28. Brunstein-Klomek, A., Sourander, A., & Gould, M. (2010). The association of suicide and bullying in childhood to young adulthood: A review of cross-sectional and longitudinal research findings. Canadian Journal of Psychiatry, 55, 282-288. Children’s National Health System. (2017). Program for health care related to bullying. Washington, DC: Author. Retrieved from https://childrensnational.org/departments/bullying-related-healthrisks Cillessen, D., & Rose, A. (2005). Understanding popularity in the peer system. Current Directions in Psychological Science, 14, 102105. Cooper, G., Clements, P., & Holt, K. (2012). Examining childhood bullying and adolescent suicide: Implications for school nurses. Journal of School Nursing, 28, 275-283. Dunn, J., & McGuire, S. (1992). Sibling and peer relationships in childhood. Journal of Child Psychology and Psychiatry, 33, 67105. Eisenberg, M., & Aalsma, M. (2005). Bullying and peer victimization: Position paper of the Society for Adolescent Medicine. Journal of Adolescent Health, 36, 88-91. Estell, D., Farmer, T., & Cairns, B. (2007). Bullies and victims in rural African American youth: Behavioral characteristics and social network placement. Aggressive Behavior, 33, 145159. Evans, C., Fraser, M., & Cotter, K. (2014). The effectiveness of schoolbased bullying prevention programs: A systematic review. Aggression and Violent Behavior, 19, 532-544. Flannery, D., Todres, J., Bradshaw, C., Amar, A., Graham, S., Hatzenbuehler, M., … Rivara, F. (2016). Bullying prevention: A summary of the report of the national academies of sciences, engineering, and medicine. Prevention Science, 17, 10441053. Grinshteyn, E., & Yang, T. (2017). The association between electronic bullying and school absenteeism among high school students in the United States. Journal of School Health, 87, 142149. Hase, C., Goldberg, S., Smith, D., & Stuck, A. (2015). Impacts of traditional bullying and cyberbullying on the mental health of middle school and high school students. Psychology School, 52, 607-617. Hatzenbuehler, M., & Keyes, K. (2013). Inclusive anti-bullyng policies and reduced risk of suicide attempts in lesbian and gay youth. Journal of Adolescent Health, 53, 521-526. Hatzenbuehler, M., Schwab-Reese, L., Ranapurwala, S., Hertz, M., & Ramirez, M. (2015). Associations between antibullying policies and bullying in 25 states. JAMA, 169, 1-8. Hinduja, S., & Patchin, J. (2012). Responding to cyberbullying. Cyberbullying Research Center. Retrieved from https:// cyberbullying.org/Top-Ten-Tips-Teens-Response.pdf Hinduja, S., & Patchin, J. (2013). Social influences on cyberbullying behaviors among middle and high school students. Journal of Youth and Adolescents, 42, 711-722. Hinduja, S., & Patchin, J. (2017). Cultivating youth resilience to prevent bullying and cyberbullying victimization. Child Abuse & Neglect, 73, 51-62.
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Hoffman, M. (2000). Empathy and moral development: Implications for caring and justice. Cambridge, UK: Cambridge University Press. Huitsing, G., Snijders, T., van Duijn, M., & Veenstra, R. (2014). Victims, bullies, and their defenders: A longitudinal study of the coevolution of positive and negative networks. Development and Psychopathology, 26, 645-659. Jansen, P., Verlinden, M., Dommisse-van Berkel, A., Mieloo, C., van der Ende, J., Veenstra, R., & Tiemeier, H. (2012). Prevalence of bullying and victimization among children in early elementary school: Do family and school neighborhood socioeconomic status matter. BMC Public Health, 12, 490-494. Juvonen, J., & Graham, S. (2014). Bullying in schools: The power of bullies and the plight of victims. Annual Review Psychology, 65, 159-185. Kamn, L., McManus, T., & Harris, W. (2016). Youth risk behavior surveillance-United States, 2015. Pediatrics, 118, 1-174. Kiselica, M., & Morrill-Richards, M. (2007). Sibling maltreatment: The forgotten abuse. Journal of Developmental Counseling, 85, 148160. Klomek, A., Sourander, A., Kumpulainen, K., Piha, J., Tamminen, T., Moilanen, I., et al. (2008). Childhood bullying as a risk for later depression and suicidal ideation among Finnish males. Journal of Affective Disorders, 109, 47-55. Kowalski, R., Giumetti, G., Schroeder, A., & Lattanner, M. (2014). Bullying in the digital age: A critical review and meta-analysis of cyberbullying research among youth. Psychological Bulletin, 140, 1073-1137. Lai, T., & Kao, G. (2017). Hit, robbed, and put down (but not bullied): Underreporting of bullying by minority & male students. Journal of Youth & Adolescence, 19, 1-7. Lampard, A., MacLehose, R., Eisenberg, M., Neumark-Sztainer, D., & Davison, K. (2014). Weight-related teasing in the school environment. Journal of Youth and Adolescence, 43, 17701780. Low, S., Smolkowski, K., & Cook, C. (2016). What constitutes highquality implementation of SEL programs? A latent class analysis of second Step’ implementation. Prevention Science, 17, 981991. Luthar, S. (2003). Resilience and vulnerability. Adaptation in the context of childhood adversities. New York, NY: Cambridge Press. Luthar, S., Cicchetti, D., & Becker, B. (2000). A critical evaluation and guidelines for future work. Child Development, 71, 543-562. Marsh, L., McGee, R., Hemphill, S., & Williams, S. (2011). Content analysis of school anti-bullying policies: A comparison between New Zealand and Victoria, Australia. Health Promotion Journal Australia, 22, 172-177. McClowry, R., Miller, M., & Mills, G. (2017). What family physicians can do to combat bullying. Journal of Family Practice, 66, 8289. Messias, E., Kindrick, K., & Castro, J. (2014). School bullying, cyberbullying, or both: Correlates of teen suicidality in the 2011 CDC Youth risk Behavior Survey. Comprehensive Psychiatry, 55, 1063-1068. Mishna, P., Khoury-Kassabri, M., Gadalla, T., & Daciuk, J. (2012). Risk factors for involvement in cyberbullying victims, bullies, and bullyvictims. Children & Youth Services Review, 34, 63-70. Nansel, T., Overpeck, M., Haynie, O., Ruan, W., & Scheidt, P. (2003). Relationships between bullying and violence among US youth. Archives of Pediatric and Adolescent Medicine, 157, 348353. Nemours Foundation. (2017). Stop the bullying. Wilmington, DE. Retrieved from http://kidshealth.org/en/teens/bullies.html#. Author. Olweus, D. (2012). Cyberbullying: An overrated phenomenon? European Journal of Developmental Psychology, 9, 520-538. Olweus, D., & Limber, S. (2010). Bullying in school: Evaluation and dissemination of the Olweus Bullying Prevention Program. American Journal of Orthopsychiatry, 80, 124-134.
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Pozzoli, T., Gini, G., & Thornberg, R. (2017). Getting angry matters: Going beyond perspective taking and empathic concern to understand bystanders’ behavior in bullying. Journal of Adolescence, 61, 87-95. Radliff, K., Wheaton, J., Robinson, K., & Morris, J. (2012). Illuminating the relationship between bullying and substance use among middle and high school youth. Addictive Behaviors, 37, 569-572. Robinson, J., Espelage, D., & Rivers, T. (2013). Developmental trends in peer victimization and emotional distress in LGB and heterosexual youth. Pediatrics, 131, 423-430. Romero, A., Wiggs, C., Valencia, C., & Bauman, S. (2013). Latina suicide and bullying. Hispanic Journal of Behavioral Sciences, 35, 159-173. Rosen, L., Beron, K., & Underwood, M. (2016). Social victimization trajectories from middle childhood through late adolescence. Social Development, 26, 227-247. Sangalang, C., Tran, A., Ayers, S., & Marsiglia, F. (2016). Bullying among urban Mexican-heritage youth: Exploring risk for substance use by status as a bully, victim, and bully-victim. Children and Youth Services Review, 61, 216-221. Sapouna, M., & Wolke, D. (2013). Resilience to bullying victimization: The role of individual, family, and peer characteristics. Child Abuse & Neglect, 37, 997-1006. Stuart-Cassel, V., Bell, A., & Springer, F. (2011). Analysis of state bullying laws and policies. Washington, DC: U.S. Department of Education. Takizawa, R., Maughan, B., & Arseneault, L. (2014). Adult health outcomes of childhood bullying victimization: Evidence from a 5-decade longitudinal British birth cohort. American Journal of Psychiatry, 171, 777-784. Taub, J., & Pearrow, M. (2005). Resilience through violence prevention in schools. In S. Goldstein & R. B. Brooks (Eds.), Handbook of resilience in children (pp. 357-371). New York, NY: Springer. Temkin, D. (2015). All 50 states now have a bullying law. Now what? The Huffington Post. (April 27, 2015). Retrieved from http:// www.huffingtonpost.com/deborah-temkin/all-50-states-now -have-a_b_7153114.html
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Tippett, N., & Wolke, D. (2015). Aggression between siblings: Associations with the home environment and peer bullying. Aggressive Behavior, 41, 14-24. Troop-Gordon, W. (2017). Peer victimization in adolescence: The nature, progression, and consequences of being bullied within a developmental context. Journal of Adolescence, 55, 116-128. Tucker, C., Finkelhor, D., Turner, H., & Shattnuck, A. (2014). Family dynamics and young children’s sibling victimization. Journal of Family Psychology, 28, 625-633. U.S. Department of Education. (2011). Analysis of state bullying laws and policies. Washington, DC. Retrieved from https:// www2.ed.gov/rschstat/eval/bullying/state-bullying-laws/statebullying-laws.pdf. Author. U.S. Department of Health and Human Services. (2014). Washington, DC: Author. Key components in state anti-bullying laws. Retrieved from https://www.stopbullying.gov/laws/keycomponents/index.html van Cleave, J., & Davis, M. (2006). Bullying and peer victimization among children with special health care needs. Pediatrics, 118, e1212-e1219. Vitoroulis, I., & Georgiades, K. (2017). Bullying among immigrant and non-immigrant early adolescents: School- and student-level effects. Journal of Adolescence, 61, 141-151. Vlachur, M., Andreau, E., Botsoglou, K., & Didaskalou, E. (2011). Bully/ victim problems among preschool children: A review of current research evidence. Educational Psychology Review, 23, 329-358. Von Dijk, A., Poorthuis, A., & Malti, T. (2016). Psychological processes in young bullies versus bully-victims. Aggressive Behavior, 43, 1-10. Waasdorp, T., & Bradshaw, C. (2015). The overlap between cyberbullying and traditional bullying. Journal of Adolescent Health, 56, 483-488. Wolke, D., Lee, K., & Guy, A. (2017). Cyberbullying: A storm in a teacup? European Child and Adolescent Psychiatry, 26, 899908. Wolke, D., Tippett, N., & Dantchev, S. (2015). Bullying in the family: Sibling bullying. Lancet, 2, 917-929. Zuckerman, D. (2016). Bullying harms victims and perpetrators of all ages. Health Progress, 97(4), 63-66.
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