Identifying and Addressing Bullying

Etiology

What creates a bully? Bullying results from a complex combination of individual, social, and environmental factors, and many youths who engage in it have specific backgrounds and qualities. Likewise, victims often share similar traits. 

Exposure to adverse childhood events increases the likelihood of becoming a bully. Associated characteristics include aggression, frustration, lack of empathy, poor impulse control, a tendency to blame others for their problems, an inability to accept responsibility for one's actions, a desire for power, the perception that others are hostile, and having friends who are bullies. Bullies have also been noted to exhibit more antisocial behaviors and use more marijuana and alcohol than their peers.[3] Bullies do not always need to be physically stronger than their victims. The perceived power imbalance is derived from many factors, including popularity, socioeconomic status, peer group, and cognitive ability. Bullies frequently use their behavior to gain social status within their peer group.[4] Some perpetrators may not consciously consider themselves bullies, especially those previously victimized. 

Bullying affects all socioeconomic groups, and lower socioeconomic status (SES) has been associated with higher rates of victimization. Still, higher SES does not necessarily prevent an individual from being targeted.[5][6] Children from dysfunctional families or those exposed to violence at home are more vulnerable. However, protective factors include being connected with a supportive family or caring adult, strong peer relationships, and having close friends.[7][Bass, P and Scholar, S. How to Identify and Treat Bullying. Contemporary PEDS Journal] Empowering children with skills to cope with their feelings has been shown to shield them somewhat from bullying's negative effects.[8] 

Children perceived as "different" from their peers are more likely to experience bullying.[9] This includes youth from racial and ethnic minorities, who may also be disproportionately impacted by other factors associated with bullying, such as adverse community and school environments. A strong ethnic identity and positive cultural and family values, however, may protect these children from the hurtful effects of bullying.[10] Likewise, youth from religious minorities or immigrant and refugee groups are targeted more often than their peers. Other examples include children with noticeable physical features, such as birthmarks, tall or short stature, disabilities, and chronic medical conditions, including severe acne, seizures, neurofibromatosis, autism spectrum disorder, attention deficit disorder (ADHD), and obesity.[11] Teens with obesity are twice as likely to be bullied as their normal-weight peers.[12] Children who are socially isolated, unpopular, lacking in interpersonal skills, or those with few friends are vulnerable as well. 

Bullying frequently serves to enforce perceived social norms within adolescent peer groups, such as heterosexual relationships and traditional gender roles. Students who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ)  often find themselves the targets of bias-based bullying, with a reported incidence nearly twice that of other students. They experience higher rates of verbal bullying, physical bullying, and cyberbullying, leading to injuries, emotional distress, and even suicide.[Earnshaw et al. LBGTQ Bullying. AAP] 

Some individuals who engage in bullying behavior may have experienced bullying or victimization themselves. These "bully victims" are at even higher risk of psychosomatic and behavioral problems than their uninvolved peers and report increased rates of suicidal ideation and attempts.[Flannery et al. Bullying and School Violence. Pediatrics Clinics of North America] 

Epidemiology

According to the National Center for Educational Statistics' School Crime Supplement (2019), 22% of students aged 12 to 18 report being bullied at school. Teachers and academic administrators consider it a frequent disciplinary problem, with 14% saying they deal with it daily or at least weekly. The types of bullying reported include being the subject of rumors (15%), verbal taunting (14%), exclusion from activities (6%), being pushed, shoved, tripped, or spit on (5%), physical threats (4%), and coercion for students to do things they did not want to or the destruction of their possessions. (2%)

The CDC (Preventing Bullying, 2023) reports that about 20% of US high school students report being bullied at school, with 17% overall and as many as 30% of girls reporting cyberbullying. Half say that cyberbullying is a "major problem."[Vogels, Emily. Teens and Cyberbullying 2022]

About 40% of children report witnessing bullying at their school.[13] This is a global issue, with cited rates internationally ranging from 5% to 45%.[14] Most studies report a greater prevalence among boys than girls, especially among middle school children. For boys, physical and verbal bullying is typical, but girls experience more verbal and social bullying.[15] Traditional bullying peaks around age 12 and then gradually declines. Recent research suggests that social and cyberbullying continue to increase during adolescence.[15][16] Racial, religious, and ethnic minority youth are disproportionately influenced by bullying, and Black teens experience bullying more than other groups.[17][18] They are twice as likely as Hispanic or White teens to report they feel their race made them a target of cyberbullying.[Vogels, Emily. Teens and Cyberbullying 2022]

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 targeted. LGBTQ students are bullied twice as often as their heterosexual and cisgender peers and are less likely to report it.[19][20]

History and Physical

Bullying may be the chief complaint for an appointment in a clinical setting. However, many children do not disclose they are targets of bullying, and clinicians should be suspicious when the review of systems is positive for somatic complaints and nonspecific symptoms or warning signs appear in the social history. Bullied children can present with insomnia, nightmares, bedwetting, appetite changes, headaches, and stomachaches. When asked, they may endorse mood swings, feelings of helplessness, poor self-esteem, or suicidal thoughts. Children who are bullied may exhibit psychosomatic symptoms or have previously been diagnosed with anxiety or depression.[21][22] Social history clues include school absenteeism, declining grades, loss of friends, and lost or damaged belongings such as school books and clothing. 

Recognizing at-risk children early may avert long-term consequences. Identifying risk factors can help prevent bullying, and early detection is the first step in intervention. Clinicians who screen for bullying can support affected families and direct them to appropriate resources. They can utilize validated screening tools such as the HEADDS (Home, Education/employment, Activities, Drugs, Sexuality, Suicide/depression) assessment[23] or the Bright Futures questionnaires from the American Academy of Pediatrics.[Hagen et al. Bright Futures. AAP] The Bullying, Cyberbullying, and Social Media Use Pediatric Checklist is available online from the Massachusetts Aggression Reduction Center (www.MARCcenter.org) and is free for clinicians. Identifying victims can be tricky since many children do not readily disclose their involvement in bullying. Clinicians should, therefore, foster an inclusive and affirming healthcare environment where youth feel safe discussing their identities and experiences.[24] This is especially important for LGBTQ patients who may not view their homes or schools as supportive.

About 70% of victims do not want to admit it to an adult, and indirect questioning during the medical history-taking may yield additional information. Inquiring about how school is going or if kids have friends to sit with at lunch may provide insight into how bullying might be a problem.[25]

Physical examination is usually unremarkable, but weight gain or loss alerts clinicians to possible appetite issues, and unexplained bruises or cuts may indicate physical altercations or self-inflicted injuries, necessitating further evaluation. 

Primary care clinicians are often asked to evaluate children for learning or behavior problems, including possible ADHD. An example is a teen boy who previously was a strong student, active in sports, and a musician in the school band who presents with declining grades. The teacher questions attention issues since he no longer completes his homework and says he "forgets to do it."  Further questioning reveals that a classmate has been confronting him daily after school, grabbing his backpack and dumping its contents. Therefore, he leaves his bag in his locker to avoid these unpleasant encounters and no longer finishes or turns in his assignments. He will not require an educational or psychiatric evaluation for ADHD once the clinician identifies that bullying is the underlying cause of his declining grades. 

Another example is a teen immigrant girl with weight loss whose mother is concerned she does not like American school lunches. However, a thorough history and physical examination reveal she has been feeling isolated, and she reports that kids tease her incessantly about her lack of English language skills. No one will sit with her at lunchtime, so she avoids the cafeteria. She admits to mood swings, and the physical examination is notable for self-inflicted cutting scars on her forearms. The clinician must elicit further information to determine if she is at risk of suicidal ideation or behavior before developing a management plan and arranging follow-up.

Bullying belongs to the spectrum of recurrent traumatic experiences of childhood, with similar physiologic, psychologic, social, and cognitive outcomes as child maltreatment or family violence.[Campbell, Kristin. Bullying and Victimization. AAP] According to the American Academy of Pediatrics (AAP), trauma-informed care is medical care that recognizes the results of traumatic stress on children and their families. Clinicians are often the first professionals who interact with those affected by trauma and have the opportunity and obligation to respond sensitively. They can ensure a patient's safety and confidentiality, use respectful language, and support autonomy.[26] A trauma-informed physical examination serves to establish trust and reduce feelings of vulnerability or potential triggers of prior traumatic events.[27][28] In the case of the teen with cutting scars, this may be the first occasion anyone has seen her skin lesions that are usually covered by her clothing. Performing the examination calmly and privately will foster confidence and encourage the girl to relate further relevant details about her unfortunate experiences.

Evaluation

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

A simple approach is to ask these three questions:

• Are you being bullied?
• How often does this happen?
• How long has this been going on?[29]

Understanding the nature and extent of the episodes is essential for effective intervention. The clinician must differentiate between physical, verbal, social, and cyberbullying, as each requires a unique approach. Assessing the severity of the incidents helps prioritize support and resources and determine if a child's welfare is threatened and if reporting to child protective services is mandated. Clinicians should also inquire about other forms of victimization, such as child maltreatment and domestic violence, during the confidential interview. 

Further evaluation usually co-occurs with treatment and management, as presented in the next section. 

Treatment / Management

How can clinicians manage bullying? When bullying is suspected or confirmed, they should gather additional information about the circumstances and context from the patient, caregivers, and teachers if indicated. Next, they must decide whether to provide anticipatory guidance, direct families to helpful resources, refer them to a mental health specialist, or contact the school or appropriate law enforcement authorities.[8] In all cases, clinicians should first ensure the child's safety. Most cases of bullying are not emergencies, but at times, a child is in imminent danger, has been the victim of physical or sexual abuse, or has expressed thoughts of suicidal ideation. Clinicians must know when to elevate the level of care and facilitate transporting such children to the nearest emergency facility for evaluation.[8](A1)

When clinicians treat victims of bullying in an outpatient setting, they must first ensure that children feel safe and realize that they are not at fault. Clinicians can teach them skills to use when confronted by bullies. Children should tell the bully to stop, then walk away and notify a trusted adult. They must inform another adult if they have already reported the circumstances and nothing was done. Clinicians can participate in brief role-playing activities with their patients and encourage parents and caregivers to rehearse successful, assertive behaviors at home with their children. Many parents do not know where to start when their child is a target of bullying and appreciate information from trusted clinicians about the signs and effects of bullying and how to convey their concerns to teachers and counselors. Caregivers can be directed to valuable resources such as stopbullying.org and marccenter.org and encouraged to promote youth activities that build self-esteem, such as sports and hobbies. Clinicians can advise parents and caregivers not to call the bully's parents or try to retaliate but allow the school to investigate. Parents may also benefit from training to discuss bullying and other issues with their children.[25] They must monitor children's online activity, discuss the possible consequences of their media use, and ask if they have experienced any problems online. Clinicians can recommend never forwarding or responding to hurtful messages and advise keeping evidence of inappropriate digital media, blocking cyberbullies, and always informing a trusted adult about inappropriate content. Clinicians can arrange counseling and mental health services when indicated and work with schools and other agencies as applicable to protect victims from further harm. 

Most structured bullying interventions occur in academic settings, and clinicians should know about local programs when caregivers and schools seek their expertise in addressing bullying. All states in the US require schools to develop anti-bullying policies and procedures, and similar initiatives exist in many other countries.[14] Clinicians should understand their community's statutes and develop step-by-step strategies to investigate reports when necessary.[30] School-based initiatives vary, but successful programs promote empathy for victims, strengthen coping and socialization skills, educate staff and families, and foster a schoolwide anti-bullying culture.[31] Schools can empower bystanders to intervene when they witness bullying. In one study, 57% of episodes ceased within ten seconds when an onlooker spoke up, but they only did so 15-20% of the time.[32].[Salmivalli, C. Bullying and the Peer Group. Aggression and Violent Behavior.] On the other hand, bystanders who actively support or encourage bullies can empower them to continue their aggressive behavior. Multidisciplinary interventions targeting peer groups rather than individuals involving families, schools, and communities may have the most impact.[33][34] Unfortunately, such multifaceted programs are costly, and the effects are difficult to measure.[35] A meta-analysis of such school initiatives reported a mean decrease of approximately 20% in bullying rates, demonstrating room for improvement.[36] (A1)

Outside their practices, clinicians can advocate locally, in their states, and nationally to support anti-bullying initiatives. They can work to improve community education and services and lobby to strengthen anti-bullying laws and evidence-based policies that prohibit bullying based on racial, ethnic, or sexual stereotypes.

Clinicians are also likely to care for the perpetrators of bullying. It is essential to denounce the behavior but not the child. Bullies themselves may well have been victims and need to tell their stories. Clinicians should listen without interrupting, remain nonconfrontational, and express concern for the victim. They can set boundaries for acceptable behavior, ask the patient to describe their actions, and suggest ways to improve. Effective clinicians communicate that bullying is always inappropriate and will not be tolerated, but also seek to appreciate the underlying causes or circumstances. They can recommend consistent disciplinary consequences, such as removing privileges or making reparations. They can connect with the child's school and advocate for penalties such as mandated community service rather than suspension or expulsion, which should be reserved for youth exhibiting severely disruptive or aggressive behavior. Overly harsh policies often ignore the underlying social and behavioral issues contributing to bullying and may lead students to abandon formal education early. Bullies should be assessed for psychosocial problems and offered mental health counseling if indicated. Some children may even cease bullying when they become aware of the hurt they have caused others and learn alternative coping methods for their feelings. 

Differential Diagnosis

Clinicians can usually elicit a history of bullying if they take the time to ask relevant questions and listen carefully to the patient's responses. However, symptoms frequently associated with bullying may be nonspecific and result from other concerning circumstances, such as peer conflict, dating violence, family dysfunction, harassment, or hazing.[37] These issues must be addressed and treated accordingly. When bullying is identified as the problem, clinicians should evaluate victims for mental health consequences, including posttraumatic stress disorder, anxiety, depression, and suicidal ideation, understanding that the presence of multiple coexisting issues may worsen the patient's physical and emotional health.  

Prognosis

In the medical model, prognosis predicts disease outcomes, such as recovery, recurrence, and death. Bullying, however, is not a disease, and the focus centers on consequences and complications rather than prognosis. In general use, however, the word prognosis forecasts a likely outcome. The medical and educational literature indicates that unless effective prevention and intervention measures are adopted, the prognosis for bullying is grim, and it will continue to take its toll on children and youth around the globe. 

Complications

Bullying is associated with short and long-term adverse physical and mental health outcomes.[38][39] Even when adequately treated, some physical injuries may cause lingering disabilities. Victims often experience academic difficulties, such as worsening grades, absenteeism, and concentration problems. In recent years, unfavorable consequences have been increasingly recognized for both victims and bullies, including social isolation, anxiety, depression, suicidality, and illicit substance use.[40][41] These sequelae often continue into adulthood. Stigma-based bullying has been even more strongly associated with health problems than bullying in general.[24]

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.[42][43] In one study, victims of bullying in grade 5 used more tobacco, marijuana, and alcohol in grade 10.[44] The self-medication hypothesis suggests these substances are consumed to cope with painful emotions related to psychological trauma.[44] Depression, anxiety, relationship problems, poor health, failing academic performance, suicidal ideation and attempts, and sleep problems have all been associated with being bullied.[45][46] Another study demonstrated homophobic name-calling by nonfriends was linked with increased psychological distress among LGBTQ students, and LGBTQ youth who commit suicide are nearly five times as likely to have been bullied compared with their non-LGBTQ peers who take their own lives.[47][May 26, 2020. doi:10.1001/jamapediatrics.2020.0940] LGBTQ bullying is also associated with increased rates of adolescent substance use, including tobacco, alcohol, marijuana, and illicit drugs[48] 

Teens who have been physically threatened or in a fight are more likely to bring a weapon to school than other bullying victims or nonvictims. They are also more inclined to display violent behaviors at school, contributing to an unsafe academic environment.[Pham et al. Weapon Carrying Among Victims of Bullying. AAP]

Youth who bully often exhibit a negative attitude towards school and may leave before graduating, especially if they are punished by expulsion. Long-term associated consequences include criminal activities and arrests, intimate partner violence, delinquency, and antisocial behavior.[49]]

Youth who are "bully victims" may experience even worse outcomes than their peers. They have been reported to have higher rates of child mental health issues, more thoughts of self-harm and suicidality, and increased substance use.[50][51][52] Supportive adults at home and school may serve to buffer youth from the effects of bullying on future substance use. Still, controlled studies are lacking because it is difficult to separate bullying from other issues contributing to substance use, such as anxiety or other significant traumatic childhood events.