Continuing Education Activity

Bullying is a severe and pervasive problem affecting children worldwide, with detrimental consequences for their physical and mental well-being. Bullying is a repeated and deliberate pattern of aggressive or hurtful behavior targeting individuals perceived as less powerful. Bullying manifests in various forms, such as physical, verbal, social/relational, and cyberbullying, each having unique characteristics. Vulnerable populations often at greater risk of being bullied are individuals who are perceived as "different" in various ways, including racial and ethnic minorities, immigrants, refugees, those with notable physical features or disabilities, and younger or more vulnerable children.

Healthcare professionals are uniquely positioned to identify bullying, provide targeted support, and assist with mitigating its mental and physical health consequences. This activity provides healthcare professionals with the knowledge and tools to increase their awareness of bullying, enabling early recognition and effective management of this complex issue. Bullying is a problem that affects both the victims and the perpetrators, and this course equips healthcare professionals with the knowledge and skills to positively impact the lives of those affected by bullying.

Objectives:

• Identify signs and symptoms of bullying behavior in individuals, recognizing both overt and subtle indications of victimization.

   

• Differentiate between various forms of bullying, including physical, verbal, social, and cyberbullying, to tailor appropriate intervention strategies.

• Assess the potential underlying causes of bullying behavior, including social and psychological factors, to inform intervention strategies.

   

• Collaborate with the interprofessional team to select appropriate therapeutic interventions and support resources for victims and perpetrators of bullying, considering individual needs and circumstances.

   

Introduction

Bullying is a severe and pervasive problem affecting children worldwide, with detrimental consequences for their physical and mental well-being. Bullying is a repeated and deliberate pattern of aggressive or hurtful behavior targeting individuals perceived as less powerful. Bullying manifests in various forms, such as physical, verbal, social/relational, and cyberbullying, each having unique characteristics. Vulnerable populations often at greater risk of being bullied are individuals who are perceived as "different" in various ways, including racial and ethnic minorities, immigrants, refugees, those with notable physical features or disabilities, and younger or more vulnerable children.

Healthcare professionals are uniquely positioned to identify bullying, provide targeted support, and assist with mitigating its mental and physical health consequences. This activity provides healthcare professionals with the knowledge and tools to increase their awareness of bullying, enabling early recognition and effective management of this complex issue. Bullying is a problem that affects both the victims and the perpetrators, and this course equips healthcare professionals with the knowledge and skills to positively impact the lives of those affected by bullying.

Bullying is an intentional, repetitive pattern of aggressive behavior whereby a person or group seeks to harm, intimidate, or control another person physically or emotionally; a perceived or actual imbalance of social power characterizes it. Bullies intend to hurt or make their victims uncomfortable.[1] The victims are generally likely to be regarded as "different" in some way, which puts racial and ethnic minorities, immigrants, refugees, those with notable physical features or disabilities, and children who are younger or more vulnerable at greater risk of being bullied. Bullying episodes are usually unprovoked and deliberate; often, bullies seek visibility and prestige through their actions. 

Bullying can happen anywhere, although it is more pervasive in schools. The harmful behavior often occurs in unstructured situations and less supervised areas such as playgrounds, cafeterias, hallways, bus stops, and buses. Both the victim and the perpetrator are at risk for harm and distress.

Different types of bullying, including physical, verbal, relational, and cyberbullying, exist. Verbal bullying, such as name-calling and taunting, is the most common. Recently, cyberbullying has received much attention, as children and teens have easy access to digital devices and social media sites. This type of bullying occurs via text messages, social media posts, emails, online forums, or other platforms, and the risk of cyberbullying increases with the duration of online activity.

Identifying cyberbullying is often challenging because it may be less repetitive than typical verbal or physical bullying.[2] Additionally, perpetrators can remain anonymous, allowing them to engage in behavior they might not when face to face with someone. Because online content is easily preserved and disseminated, cyberbullying can result in ongoing suffering for victims, especially when hurtful messages "go viral." Cyberbullying differs from traditional bullying as it does not rely on physical proximity or a specific location and can occur at any time of day or night. However, both may result in adverse psychological effects.

Relational or social bullying occurs when the aggressor manipulates social relationships to harm or control the victim. Unlike physical and verbal bullying, which involve direct acts of aggression, relational bullying is more subtle. The aggressors often rely on tactics such as spreading rumors, excluding victims from social groups, and manipulating social dynamics to damage reputations or relationships. In relational bullying, the bully aims to isolate, hurt, or control the victim emotionally, which can result in significant psychological and emotional sequelae.

Regardless of the type of bullying, the causes are complex. Those who engage in bullying may share certain backgrounds and qualities; likewise, targets of bullying often share similar experiences. Clinicians play a key role in identifying bullying and treating its physical and psychological impacts. Antibullying practices are also essential in helping to prevent and intervene in bullying situations. 

Etiology

Bullying Causes

Bullying results from a complex combination of individual, social, and environmental factors. Exposure to adverse childhood events increases the likelihood of becoming a perpetrator. Bullies have also been noted to exhibit more antisocial behaviors and more cannabis and alcohol use than their peers.[3] 

Some individuals who engage in bullying may have experienced bullying or forms of victimization themselves. Qualities that have been noted in bullies include:

• Aggression
• Frustration
• Low empathy
• Lack of impulse control
• Tendency to blame others for their problems
• Inability to accept responsibility for their actions
• High level of competitiveness
• Desire for power or dominance
• The perception that others have hostile intent toward them
• Having friends who are bullies

A bully doesn't necessarily need to be physically stronger than their victim. The power imbalance can be due to many factors, including popularity, socioeconomic status, or cognitive ability. Bullying behavior may also be used to gain increased social status.[4] Aggressive youth may not consciously consider their behavior bullying, especially those previously victimized. 

Factors Associated With Bullying

Family Dysfunction

Children from dysfunctional families are more vulnerable to bullying. Family violence is associated with bullying victimization, whereas family cohesion may be protective.[5] 

Socioeconomic Status

Higher socioeconomic status may not protect children from bullying, which affects all socioeconomic groups.[6] 

Race and Ethnicity

Racial and ethnic minorities are often disproportionately impacted by risk factors associated with bullying, such as adverse community and school environments. However, strong ethnic identity and positive cultural and family values may protect these groups against the hurtful effects of bullying.[7] 

Being "Different"

Children perceived as "different" from their peers are at greater risk of bullying.[8] Groups at higher risk of being victims include:

• Children whose behavior differs from their peers or who lack social confidence
• Racial and ethnic minorities
• Youth who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more (LGTBQIA+) 
• Immigrants and refugees
• Children with noticeable physical features, such as birthmarks, tall or short stature, or obesity
• Children with physical and intellectual disabilities or chronic medical conditions
• Children who are socially isolated, unpopular, or have few friends

Epidemiology

According to the National Center for Educational Statistics' School Crime Supplement (2019), 22% of students aged 12 to 18 reported being bullied at school. The type of bullying reported by these children and teenagers is below:

• Being the subject of rumors, 15% 
• Being made fun of, called names, or insulted, 14%
• Being excluded from activities on purpose,6%
• Being pushed, shoved, tripped, or spit on, 5%
• Being threatened with harm, 4%
• Forcibly being told to do things they did not want to do and others purposely destroyed their property, 2%

The CDC (Preventing Bullying, 2023) reports that 20% of high school students in the US report being bullied at school, with 17% reporting cyberbullying. Approximately 40% of high school students who identify as lesbian, gay, bisexual, or unsure of their sexual identity report being bullied, while 22% of bisexual high school students report being bullied. Female high school students experience a higher incidence of bullying, with 30% reporting such incidents, compared to 19% among their male counterparts. 

Teachers and school administrators report bullying as a frequent disciplinary problem, with 14% saying they deal with it daily or at least once weekly. 

This is a global problem, with reported rates ranging from 5% to 45%.[9] Most studies report that bullying is slightly more prevalent among boys than girls and occurs more frequently among middle school children. For boys, physical and verbal bullying is common; for girls, verbal and social bullying occurs more often.[10] 

Bullying peaks around age 12 and then gradually declines. However, recent research suggests that this is for the more obvious forms of verbal and physical bullying, whereas social and cyberbullying continue to increase during adolescence.[10][11] Racial and ethnic minority children and adolescents are disproportionately influenced by bullying, with Black teens experiencing bullying more than other adolescent populations.[12]

History and Physical

Children may not disclose they are bullied; however, clinicians should suspect a possible problem when the medical or social history reveals the following:

• Prior injuries or illnesses without a physical explanation
• Lost or damaged belongings, such as school books or clothing
• Frequent somatic symptoms, difficulty sleeping, nightmares, bedwetting, or appetite changes
• Avoidance of school or social situations; loss of friends
• Mood swings or feelings of helplessness and poor self-esteem
• Thoughts of self-injury or suicide
• Academic failure

Children who are bullied may present with psychosomatic symptoms or be diagnosed with anxiety or depression.[13][14] Physical examination is usually unremarkable, but weight changes may alert clinicians to appetite issues, and unexplained bruises or cuts may indicate physical altercations or self-inflicted injuries. 

Evaluation

When bullying is suspected, the clinician should first speak with the child directly to assess the severity of the problem. Because this may be the first time a child shares such sensitive information with a trusted adult, the clinicians should create a safe space for the child to feel comfortable talking, using open-ended questions, active listening, and empathy, and ensuring confidentiality unless a situation mandates reporting it to authorities. 

A simple approach is to ask these 3 questions:[15]

• Are you being bullied?
• How often are you bullied?
• How long have you been bullied?

Understanding the nature and severity of bullying is essential for developing effective strategies to combat it. It's important to differentiate between physical, verbal, social, and cyberbullying, as each type may require a unique approach to prevention and intervention. Additionally, assessing the severity of bullying incidents helps prioritize support and resources for those who need it most. The clinician must then decide whether it is appropriate to notify the parent, school, or child protective services if a child's welfare is threatened. As part of taking a thorough history, the clinician should inquire about other forms of victimization, such as child maltreatment and domestic violence. 

Treatment / Management

Bullying is a learned behavior that may be preventable; recognizing children at high risk for bullying may help prevent long-term consequences. Although there is no quick fix for bullying, early identification is the first step in prevention and intervention. To this end, all states in the US require schools to develop antibullying policies and procedures; similar initiatives exist in many countries worldwide.[9] Clear step-by-step procedures to investigate reports and knowledge of local antibullying statutes are also helpful.[16] 

Many researchers believe bullying is a group process; therefore, interventions should target the peer group rather than individual bullies and victims. Research shows that the most successful programs use multidisciplinary interventions and that a multitiered approach involving families, schools, and the community is helpful.[17][18] However, the impact of antibullying programs remains smaller than desired.[19] A meta-analysis reported a mean decrease of only approximately 20% in bullying rates with such initiatives.[20] 

There is no universal protocol that works for every situation or school. Effective interventions share certain features, including parent and teacher education, strict classroom rules and procedures, and a schoolwide antibullying culture.[21] Unfortunately, such multifaceted programs are often expensive to implement. 

Valuable AntiBullying Practices 

Bullying prevention

• Teach children not to bully and actively discourage bullying.
• Mobilize bystanders to make bullying unacceptable and hold the bullies accountable for their actions.
• Engage in classroom discussions emphasizing that bullying is not tolerated (which helps deprive the bully of an appreciable audience). 
• Improve supervision in less-structured areas such as the playground, cafeteria, hallway, and on the bus.
• Educate children about the consequences of bullying and let them know that bullying is hurtful and never permitted.
• Recognize that isolated curriculum interventions are less effective than multidisciplinary antibullying programs that include teachers and all school ancillary staff, such as cafeteria workers, administrators, custodians, and bus drivers.[22]
• Consider focus groups, which can guide prevention program content and strategy to understand children's perspectives.[23]

Bullying intervention

• Provide a safe environment for the victim.
• Encourage activities that promote self-esteem, such as sports and hobbies. 
• Educate parents about the signs and effects of bullying and invite them to collaborate with the school. 
• Assure children that being bullied is not their fault.
• Teach children skills to use when confronted by bullies (eg, tell the bully to stop, walk away, and notify a trusted adult). 
• Work with school and other agencies as applicable to protect the victim.
• Recommend that parents and guardians monitor children's online activity. 
• Offer counseling support to the perpetrator and the victim when appropriate. 
• Apply consistent disciplinary consequences such as removal of privileges or reparations.   
• Enforce penalties such as mandated community service for unacceptable behavior.

Punishment-based strategies (suspension and expulsion) should be reserved for severe disruptive and aggressive behavior. Overly harsh policies usually ignore underlying social and behavioral issues contributing to bullying and may lead to students abandoning formal education early.

Bully engagement 

• Listen to their story, remain nonconfrontational, and express concern for the victim.
• Ask them to suggest ways to improve their actions (it is essential to describe the specific behavior that needs to be changed).
• Explore the basis for their behavior; be objective and state the facts.
• Set the boundaries between acceptable and unacceptable behavior; communicate that bullying is inappropriate and will not be tolerated.

Some children may cease bullying when they become aware of the hurt they have caused and learn alternative coping methods.

Differential Diagnosis

When bullying is identified, clinicians should evaluate victims for mental health consequences, including posttraumatic stress disorder, anxiety, depression, and suicidal ideation. 

Prognosis

Bullying is a common, modifiable risk factor for poor mental health outcomes.[24] Victims often experience difficulties in school, such as decreased academic performance, absenteeism, and problems with concentration. The adverse psychological effects of severe bullying may continue into adulthood for perpetrators and victims, leading to posttraumatic stress disorder symptoms and suicidal ideation and attempts. Cyberbullying, in particular, has been linked to physical and mental health problems, including anxiety, depression, stress, sleep disturbances, self-harm, and suicidal ideation.

Complications

Bullying is associated with short- and long-term health and psychosocial consequences.[25] Even when adequately treated, physical injuries may cause lingering disabilities. In recent years, adverse outcomes have been increasingly recognized for both victims and bullies, including social isolation, anxiety, depression, suicidality, and illicit substance use.[26][27] These sequelae can continue into adulthood. 

Victims of severe bullying may feel threatened and depressed and are at risk of developing post-traumatic stress disorder. As adults, they are more likely to carry weapons and have higher rates of suicide attempts and poor psychosocial adjustment.[28][29]

Perpetrators often exhibit a negative attitude towards school and may leave before graduation. Long-term associated consequences include criminal activities, intimate partner violence, delinquency, and antisocial behavior.[30]

Consultations

Several school and community bullying prevention centers provide resources and specialized support to counter bullying. In addition, bullying and cyberbullying helplines are available in many countries.

These resources are confidential, free, and available 24/7:

Stop Bullying Now Hotline

• 1-800-273-8255 or www.stopbullying.gov 
• Established by the US Department of Health and Human Services
• Available to adults and children

Childline 

• 0800 1111 (United Kingdom)
• Available to children under 18 years
• Offers advice and counseling to young people in distress or abusive situations

Kids Helpline

• 1-800-55-1800 (Australia)
• Provides children, parents, and schools with advice

Pearls and Other Issues

Bullying is not primarily a law enforcement issue, but all 50 states in the US have enacted school antibullying legislation or policies. Bullying may also appear in the criminal code related to other crimes, such as aggravated harassment or stalking, and may apply to juveniles, depending upon the locale. Clinicians should be informed about the laws in their communities. 

Enhancing Healthcare Team Outcomes

A team approach is most effective in preventing and treating bullying. Pediatricians and other primary care clinicians should routinely screen youth for bullying exposure and identify subtle indicators when patients do not readily disclose they are victims. The American Academy of Pediatrics recommends violence prevention counseling for school-age children and screening at well-child visits beginning at age 6.[31] The interprofessional healthcare team includes nurses, counselors, social workers, and clinicians who must work together to assess and care for children involved in bullying, both victims and perpetrators. Parents, teachers, school officials, and adults who care for children in the community also need to participate for optimal outcomes. 

Teaching parenting skills such as good communication, positive discipline, and nurturing may strengthen families and make children more resistant to bullying and less likely to become perpetrators. Family therapy with trained mental health specialists effectively reduces anger and improves interpersonal relationships in dysfunctional families. Schools should establish antibullying policies in the student code of conduct and promote a culture that condemns bullying. School programs can teach children who are bystanders to intervene and potentially dissuade bullies, who may feel pressure to conform to the behavior of the majority. On the other hand, bystanders who actively support or encourage bullies can empower them to continue their aggressive behavior.[32][33][34] 

Schools that foster a culture of empathy and support and encourage reporting of bullying may be more successful in reducing the prevalence and effects of the problem. Teachers, administrators, and school nurses often are firsthand witnesses who can communicate their concerns to primary care clinicians, who assess children for medical and mental health consequences of bullying. Including parents and schools on the interprofessional team strengthens prevention efforts and supports treatment for all children involved in bullying.[32]