Adolescent health

Bullying
Michael Carr-Gregg Ramesh Manocha

Effects, prevalence and strategies for detection

Bullying is a form of aggression, characterised by repeated psychological or physical oppression, involving the abuse of power in relationships to cause distress or control another.1,2 It is a complex and serious problem, which expresses differently according to age, gender, culture and technology. Although bullying is traditionally understood as physical aggression, there are many other strategies that young people use to control and distress others (Table 1). More recently, the phenomenon of cyberbullying3 has become prevalent. It specifically involves communication technology, especially the internet, mobile telephones and text messaging, to cause distress to individuals. (For detailed information about cyberbullying see Resources.)

Background
The mental, physical, social and academic consequences of bullying have an enormous impact on human and social capital.

Objective
This article describes the effects and prevalence of bullying on young people and presents strategies for its detection. Strategies for the facilitation of a multidisciplinary approach to bullying in adolescents are also presented.

Discussion
Given the existing high rate of bullying, assessment should be incorporated into a standard psychosocial screening routine in the general practitioners clinic. Effective management is a multidisciplinary effort, involving parents, teachers and school officials, the GP, and mental health professionals. Given the variable effectiveness of schools in tackling bullying, GPs play an important role in identifying at risk patients, screening for psychiatric comorbidities, counselling families about the problem, and advocating for bullying prevention in their communities.

Bullying and young people

Normal adolescent development is characterised by a mismatch between fundamental drives and self regulatory skills which manifests as difficulty expressing thoughts and feelings, seeing anothers point of view and predicting the consequences of ones actions.4 This explains why bullying occurs most frequently in late primary school and early high school, when this mismatch peaks. It also makes it unlikely that bullying behaviour can ever be entirely eliminated, although it can certainly be minimised. Nevertheless, as outlined in the Kandersteg Declaration,5 every young person has the right to be respected and safe, and bullying is a violation of this basic human right. It is the responsibility of adults to ensure that these rights are defended and that healthy development and citizenship are promoted.

Keywords: adolescent; child, bullying

Prevalence
Although bullying has long been perceived an inevitable part of growing up, a recent American survey shows that children aged 815 years rate bullying as a greater problem than racism or peer pressure to have sex or use alcohol and other drugs.6 Australian data appears to reflect this trend; a 1996 study found 1 in 6 children reported being bullied weekly and being bothered by it.7 A recent Federal Government commissioned Australian study surveyed 7000 children from 124 schools nationally and found that bullying peaked in the final years of primary school, with 32% of students stating they

98 Reprinted from Australian Family Physician Vol. 40, No. 3, March 2011

Table 1. Types of bullying Physical bullying: hitting, poking, tripping, pushing or damaging someones belongings Verbal bullying: name calling, insults, homophobic or racist remarks and verbal abuse Social (covert) bullying: lying, spreading rumours, playing a nasty joke, mimicking and deliberately excluding someone Psychological bullying: threatening, manipulation and stalking Cyberbullying: using technology (eg. email, mobile telephones, chat rooms, social networking sites) to bully verbally, socially or psychologically Bullying is not: mutual arguments and disagreements single episodes of social rejection or dislike single episode acts of nastiness or spite random acts of aggression or intimidation. Source The National Centre Against Bullying www. ncab.org.au/Page.aspx?ID=206 were targeted.8 This data suggests that the prevalence of bullying is increasing and that Australia has one of the highest rates of bullying in the developed world. A recent review9 concluded that the effectiveness of school antibullying measures are modest at best,indicating that bullying is likely to be an ongoing problem.

Early detection
Given the high prevalence of bullying, GPs should incorporate an assessment for bullying into their standard psychosocial screening routine, ideally with every encounter with a young person.17 Young people are often reluctant to disclose that they are being bullied because they are ashamed, think it is their fault, may fear retaliation, or regard disclosure as dobbing. An Australian study18 of 415 high school students found that more than half (54%) would not report bullying to adults. Of those that would report, students more frequently said they would tell a parent, followed by a school friend, and then a teacher. Although young people are unlikely to spontaneously disclose the issue during a general practice consultation,17 parents/relatives or another third party may report it or a school may refer the victim to a GP. Many presentations should prompt consideration of bullying (Table 3). Interestingly, young people who perpetrate bullying are just as likely as the victims to report these types of symptoms, and young people who both bully and are victimised might be at greatest risk.19,20 Young people who bully are also more likely to report alcohol and substance use.21

Assessment
Many adolescents are willing to discuss health concerns with their GP if engaged in an adolescent friendly way. General practitioners are legally and ethically bound to keep information that is disclosed by patients confidential. Concerns about confidentiality are a major barrier for young people,22 so it is important to reassure them that the information they disclose will be kept confidential except in extreme circumstances. (Where, for example, the patients life may be in danger, public interest or mandatory reporting obligations occur.) So, once the young persons mental competence is established, it is important to ensure that at least part of each consultation is conducted without the presence of the parent. Removing the parent from the consultation room can be presented as usual protocol with a statement such as, Well Mrs Jones, before you leave, and I talk to Amy alone, do you have any more questions? Table 2. Tasks for the GP in managing young people affected by bullying Early detection Assessment of the severity and impacts Counselling and support Encouraging the young person to disclose the bullying to parents Developing an action plan with the family Appropriate referral Broader roles as required such as: advocating on behalf of the young person to school officials or other community agencies encouraging parents to engage their children in positive school and community activities helping other adults to recognise the physical and psychological symptoms associated with bullying

Social and emotional impact

Although bullying among young people can occur in any setting, it typically occurs at school or on the way to and from school. Young people involved in bullying are at risk of poor school functioning, as measured by attitudes toward school, academic performance and absenteeism.10 They may suffer significant psychological distress,11,12 and in rare instances take their own life.13 Young people with serious psychosocial problems might experience problems associated with attention, behaviour, and emotional regulation, which interfere with their ability to learn.10 The evidence base demonstrating a link between the experience of being bullied with mental health problems in later life is growing.14 Therefore, although bullying and victimisation might occur early in life, longitudinal studies indicate that its effects can be long lasting. Longitudinal studies also indicate that the tendency to bully at school significantly predicts subsequent antisocial and violent behaviour.15 A study from the United States of America also found that the attackers in more than two-thirds of 37 mass school shootings felt persecuted, bullied, threatened, attacked, or injured by others, and that revenge was an underlying motive.16

The role of the GP

General practitioners have a critical role to play in the assessment and management of young people affected by bullying. The key aspects of this role are outlined in Table 2.

Reprinted from Australian Family Physician Vol. 40, No. 3, march 2011 99

FOCUS Bullying effects, prevalence and strategies for detection

The HEADSS (Home, Education and Employment, Activities, Drugs, Sexuality, Suicide/depression) psychosocial assessment strategy17 is a common method of establishing a meaningful rapport between the GP and the young person. It is a useful clinical tool, can usually be completed within the scope of most consultations, and provides a framework for GPs to effectively assess for bullying (see Resources). The GP should ascertain the type of bullying, ie. physical, verbal, psychological (social exclusion, rumours, putdowns), sexual (which can be physical or verbal) or cyber, and determine if mandatory reporting is necessary. If there are concerns about online behaviour that involves sexual exploitation of a child this should be reported to the Australian Federal Police Child Protection Operations team (see Resources). Further practical strategies to facilitate disclosure are described in Table 4 and 5.

Table 3. Common clinical indicators of bullying29,30 School refusal or excuses for school avoidance (eg. feeling sick) Wanting to go to school a different way (eg. changing the route, or being driven instead of catching a bus) Being tense, tearful and unhappy before or after school Talking about hating school or other children Suspicious bruises or scratches Damage to, or loss of, personal belongings Sleeping difficulties including nightmares and enuresis Social withdrawal Refusing to discuss what happens at school Somatic symptoms such as headache or abdominal pain

Counselling and supporting the young person

Ongoing review and support of the young person and their family is very important. Although counselling skills are beyond the scope of this article, some cognitive behaviour therapy-style techniques that can be useful to teach young people include: fogging when other people make hurtful remarks, dont argue and try not to become upset. Imagine that you are inside a huge, white fog bank: the insults are swallowed up by the fog long before they reach you staying in the neutral zone reply to taunts with something short and bland: thats what you think or maybe, then walk away. Interactive websites such as MoodGYM23 and Reach Out Central24 offer cognitive behavioural strategies to help reframe negative thinking patterns (see Resources). There are five key messages that the GP should convey to the young victim of bullying. 1. That they have shown great courage coming forward and the good news is that they dont have to face it on their own 2. Its not their fault but is most likely a reflection of the insecurities of the bully 3. All students have a legal right to learn in a safe environment 4. They should not try to tackle the bully by themselves 5. That bullies thrive on secrecy and the best option is to tell someone in authority.

Table 4. Useful questions about school1 What do you like about school? What are you good/not good at? How do you get along with teachers and other students? Is there an adult you can talk to at school about how you feel? Have your marks changed recently? Many young people experience bullying at school or at home via the net or mobile telephone, have you ever had to put up with this?

Table 5. Example of a bullying history The many young people technique allows sensitive questions to be asked in a nonthreatening way I have heard that many young people your age, experience bullying at school or at home online or by phone have any of your friends ever had to put up with this? Remembering what we said about confidentiality, that this was just between the two of us, can you tell me whether you have ever experienced this sort of harassment at school or at home online or by telephone? What type of bullying was this (ie. is it cyberbullying, physical, psychological)? Have you told anyone about this? How often has this occurred? (assess intensity) How long has this been going on for? (assess duration) (If cyberbullying) did you save any of the messages on your phone or computer as evidence? How many different places or relationships does the bullying occur in?

Encourage disclosure to parents

Baring in mind the young persons right to confidentiality, GPs should encourage the victim to disclose the facts of the bullying to their parents or legal guardians as soon as possible. Some young people are reluctant to disclose this information to an adult carer. However, it is generally considered essential to involve parents in the remediation process. A GP may tackle this situation by providing a range of choices to empower the young person. For example, I can appreciate that you may not want mum or dad to know

100 Reprinted from Australian Family Physician Vol. 40, No. 3, March 2011

Bullying effects, prevalence and strategies for detection FOCUS

about what you have had to put up with, but in my experience, it is very helpful to let them know what has been going on. We can do this in a variety of ways: you can sit in while I tell them whats been going on; or you can wait outside while I let them know and then bring you in; or you can tell them in front of me.

harmful effects of their actions, the unacceptable nature of their behaviour and the development of a monitored plan to remediate the situation (see Resources).

Peer mediation
Peer mediation is a process in which students resolve disputes and conflict among their peers. Peer mediators are chosen by their own peers and receive training to work with both the bully and the victim to arrive at a nonaggressive, constructive solution. It has been used successfully with children in a number of school settings.27

Develop a parental action plan

Proper parental support can be a protective factor for bullying, hence the GPs dual role in both detecting and managing bullying while educating parents about how best to prevent and manage it. Parents should be encouraged to remain calm and under no circumstances contact the parents of the bully. Table 6 lists tips for parents. Parents should be presented with a clear action plan and a follow up meeting with the GP so that progress can be evaluated and discussed. The parental action plan should include: seeking a face-to-face meeting with the students teacher, year level coordinator, deputy principal or principal to discuss the matter written communication that leaves a paper trail that may be useful should matters escalate reading the Federal Government report, What should I do if my child is being bullied? (see Resources) or individual state or territory department of education websites moving up the chain of command if parents feel that their concerns are being ignored at the school meeting, parents should be encouraged to remain calm, bring any evidence they have and ask three key questions: How will this matter be investigated? How long will this investigation take? When can we have a follow up meeting to discuss the results and any sanctions that are handed out? Encourage parents to record minutes of the meeting and create a record of what was agreed. The GP may also contact the school directly (if agreed by the young person) to discuss the matter with relevant notes made in the patients file.

Shared concern
Simple disapproval and punishment of bullies may not prevent bullying. The shared concern approach is based on the assumption that bullies typically are insensitive to the harm they are doing to the victim (see Resources). This is because of their involvement in a group which gives legitimacy to bullying, reducing their sense of personal responsibility. This model uses the fact that bullies commonly feel uncomfortable with their own behaviour. An adult mediator uses specific techniques to demonstrate the impact of the bullying on the victim. Although the method involves a nonblaming approach, it does not seek to excuse or condone bullying and has been found to be effective in many settings.28

Conclusion
Bullying is emerging as a significant but preventable mental health risk factor for young people. Once detected, a partnership involving the Table 6. Important parental dos and donts Do NOT Tell the young person to ignore the bullying as this often allows the bullying and its impact to become more serious Blame the young person or assume that they have done something to provoke the bullying Encourage retaliation Criticise how your child/teenager dealt with the bullying Contact the bully or parents of the bully Do Listen carefully. Ask who was involved and what was involved in each episode Empathise and reinforce that you are glad your child/ teenager has disclosed this Ask your child/teenager what they think can be done to help Reassure your child/teenager that you will take sensible action Contact the teacher and/or principal and take a cooperative approach in finding a solution Contact school authorities if bullying persists and escalate your communications up the chain of command

Screen for psychological distress and refer if necessary

If the bullying has been sustained, frequent or intense, then a screening questionnaire such as the K10 should be used to help detect clinically significant levels of anxiety or depression.25,26 Consider referral to a psychologist if screening indicates that the patients mental health score is above the at risk threshold or otherwise indicated.

Strategies used in schools

Schools apply rules relating to standards by which children are expected to treat each other. When bullying is identified then sanctions and punishments are appropriate. Useful strategies are outlined below.

Restorative justice
A form of conflict resolution which involves a mediated meeting between victim and offender aimed at making them understand the

Reprinted from Australian Family Physician Vol. 40, No. 3, march 2011 101

FOCUS Bullying effects, prevalence and strategies for detection

child, the parents, health professionals, teachers, and schools is more likely to lead to a positive outcome. The GP can play a central role in the detection, facilitation of a multidisciplinary approach, and ongoing management.

Resources
For GPs HEADSS: www.rch.org.au/clinicalguide/cpg.cfm?doc_ id=11710#headds Shared concern method training: www.readymade.com.au/method/ previews/index.htm Australian Federal Police Child Protection: www.afp.gov.au/online_ forms/ocset_form MoodGYM cognitive behavioural therapy training: moodgym.anu. edu.au/welcome National Centre Against Bullying provides useful resources and tips for health professionals, parents and young people: www.ncab.org.au Generation Next seminars and resources for health professionals, parents and teachers: www.generationnext.com.au Thorsborne M, Vinegard D. Restorative Justice Pocketbook. Alresford, Hampshire: Management Pocketbook Ltd, 2009 For patients and parents/carers/teachers What should I do if my child is being bullied?: www.deewr.gov.au/ Schooling/NationalSafeSchools/Pages/whattodo.aspx Cyber(smart:) provides activities, resources and advice to parents and children on using the internet safely: www.cybersmart.gov.au National Centre Against Bullying: www.ncab.org.au Reach Out information on mental health and wellbeing resources and services: http://au.reachout.com/find/articles/kids-help-line Bully Blocking information and resources, including a newsletter and books in different languages: www.bullying.com.au.

Authors

Michael Carr-Gregg PhD, is an adolescent psychologist, Victoria. [email protected] Ramesh Manocha MBBS, BSc, PhD, is Senior Lecturer, Discipline of Psychiatry, Sydney Medical School, The University of Sydney, New South Wales. Conflict of interest: none declared.

References

1. Juvonen J, Graham S. Peer harassment in school: the plight of the vulnerable and victimized. New York, NY: Guilford Press, 2001. 2. Olweus D, Pepler D, Rubin K. Bully/victim problems among school children: some basic facts and effects of a school-based intervention program. The development and treatment of childhood aggression. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc, Publishers, 1991, p. 41148. 3. Smith PK, Mahdavi J, Carvalho M, Fisher S, Russell S, Tippett N. Cyberbullying: its nature and impact in secondary school pupils. J Child Psychol Psychiatry 2008;49:37685. 4. Carr-Gregg MRC, Shale E. Adolescence: a guide for parents. Finch Publishing, 2002. 5. Kandersteg Declaration. Available at www.kanderstegdeclaration.com/ original-in-english-2007/ [Accessed 13 January 2011]. 6. Kaiser Family Foundation. Children now. Talking with kids about tough issues. Available at www.childrennow.org/nickelodeon/ new-booklet.pdf [Accessed 27 August 2004]. 7. Rigby K. Bullying in schools and what to do about it. Melbourne: ACER, 1996. 8. Cross D, Shaw T, Hearn L, et al. Australian Covert Bullying Prevalence Study (ACBPS). Perth: Child Health Promotion Research Centre, Edith Cowan University, 2009.

9. Merrell K, Isava DM. How effective are school bullying intervention programs? A meta-analysis of intervention research. School Psychology Quarterly 2008;23:2642. 10. Nishina A, Juvonen J, Witkow MR. Sticks and stones may break my bones, but names will make me feel sick: the psychosocial, somatic, and scholastic consequences of peer harassment. J Clin Child Adolesc Psychol 2005;34:3748. 11. Salmon G, James A, Smith DM, Bullying in schools: self reported anxiety, depression, and self esteem in secondary school children. BMJ 1998;317:9245. 12. Arseneault L, Walsh E, Trzesniewski K, Newcombe R, Caspi A, Moffitt TE. Bullying victimization uniquely contributes to adjustment problems in young children: a nationally representative cohort study. Pediatrics 2006;118:1308. 13. Marr N, Field T. Bullycide Death at playtime: an expos of child suicide caused by bullying. Success Unlimited, 2001. 14. Bond L, Carlin JB, Thomas L, Rubin K, Patton G. Does bullying cause emotional problems? A prospective study of young teenagers. BMJ 2001;323:4804. 15. Rigby K. Consequences of bullying in schools. Can J Psychiatry 2003;48:58390. 16. United States Secret Service, Educational Resources Information Center. Safe school initiative: an interim report on the prevention of targeted violence in schools. Washington, D.C.: U.S. Department of Education, Office of Educational Research and Improvement, Educational Resources Information Center, 2000. 17. Goldenring J, Rosen D. Getting into adolescent heads: an essential update. Contemp Peds 2004;21:64. 18. Royal Melbourne Institute of Technology. RMIT research confirms bullying problem. Available at www.rmit.com.au/browse;ID=eee2oapnuddq. 19. Kaltiala-Heino R, Rimpel M, Rantanen P, Rimpel A. Bullying at school an indicator of adolescents at risk for mental disorders. J Adolesc 2000;23:66174. 20. Brunstein Klomek A, Marrocco F, Kleinman M, Schonfeld IS, Gould MS. Bullying, depression and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry 2007;46:409. 21. Pepler DJ, Craig WM, Connolly J, Henderson K, Wekerle C, Wall AM. Bullying, sexual harassment, dating violence, and substance use among adolescents. The violence and addiction equation: theoretical and clinical issues in substance abuse and relationship violence. New York, NY: Brunner/Rouqtledge, 2001, p. 15368. 22. Veit FC, Sanci LA, Coffey CM, Young DY, Bowes G. Barriers to effective primary health care for adolescents. Med J Aust 1996;165:1313. 23. The MoodGYM Training Program. Available at www.moodgym.anu.au/ welcome. 24. Burns J, Ellis L, Mackenzie A, Stephens-Reicher J. Reach Out: online mental health promotion for young people. Counselling, Psychotherapy, and Health 2009;5:17186. 25. K10 Symptom Scale. Clinical Research Unit for Anxiety and Depression. A WHO Collaborating Center. School of Psychiatry, University of NSW, 2000. Available at www.crufad.unsw.edu.au/K10/k10info.htm. 26. K10 download. Available at www.health.sa.gov.au/pros/portals/0/BR%20 200214%20Kessler%2010.pdf. 27. Cremin H. Peer mediation: citizenship and social inclusion revisited, Buckingham: Open University Press, 2007. 28. Duncan A. The shared concern method for resolving group bullying in schools. Educational Psychology in Practice 1996;12:948. 29. Williams K, Chambers M, Logan S, Robinson D. Association of common health symptoms with bullying in primary school children. BMJ 1996;313:179. 30. Due P, Holstein BE, Lynch J, et al. Bullying and symptoms among schoolaged children: international comparative cross-sectional study in 28 countries. Eur J Public Health 2005;15:12832.

102 Reprinted from Australian Family Physician Vol. 40, No. 3, March 2011