What is bullying?
Bullying can be physical, verbal or psychological aggression that occurs
repeatedly and is marked by an imbalance of power, intent to harm, threat of
further aggression, and creation of terror in the victim.[6] Terror becomes
established when the bullying continues without intervention, enabling the bully
to systematically intimidate without fear of recrimination or retaliation, and
rendering the bullied child completely powerless.
Bullying can occur directly or indirectly. The direct type of bullying
involves a relatively open attack with verbal taunts, name calling, threatening
gestures or physical contact. The indirect type (also called relational
bullying) takes the form of intentional exclusion from the group, which may
include spreading rumors about the victim, ignoring, and isolating the targeted
child. This form is used more commonly by girls. Indirect bullying tends to be
more insidious, can more easily pass under the radar of teachers and parents,
and has a higher impact on depression than direct bullying.[3]
In younger kids, social exclusion might mean not getting invited to birthday
parties. By fourth grade and through adolescence, exclusion takes on more subtle
forms. For example, relational bullying via instant messaging has become common.
Using the Internet, bullies feel freer to be verbally abusive. Sometimes, with
older children, this online bullying has a sexual content. Rumors and demeaning
pictures spread quickly online and are received by many classmates at once,
intensifying the effect of exclusion.
Patients at risk for becoming victims or bully-victims
Pediatricians can play an important role in detecting potential victims of
bullying, as well as identifying patients who may behave as both victims and
bullies, which is a group that is usually more troubled than pure victims or
pure bullies. These children tend to be frequent targets of bullying, respond
aggressively, and often bully children who are weaker. Researchers have found
that bully-victims have more severe conduct, academic, and peer relationship
problems, compared to bullies and children who are victims of bullying.[7]
Breaking the cycle of victimization through early identification and appropriate
intervention during the early elementary school years may prevent persistent
physical, emotional, academic, and behavioral problems in children who become
victims and bully-victims.[8]
Any child who is different may be targeted by bullies in school. Of
particular concern are patients with physical or mental disabilities, who are 2
to 3 times more likely to be bullied, have fewer friends to stand up for them,
and lack appropriate social skills to defend themselves against aggression from
peers.[6]
Bully-victims are often children with generally disruptive disorders,
including attention deficit hyperactivity disorder (ADHD). Also, children who
have been abused often behave as bully-victims.
With patients at risk for becoming targeted by bullies or becoming
bully-victims, pediatricians can take preventive measures, such as counseling
parents about resilience development and other strategies discussed in the
section on assertiveness training. It is also important to diagnose as early as
possible disorders such as ADHD, focusing particularly on patients in third and
fourth grades. Often patients with ADHD will benefit from referral to a mental
health professional, who can help them develop better social skills and provide
assertiveness training. Children with ADHD frequently find themselves in the
bully-victim role because they do not know how to be assertive without being
aggressive.
Warning signs
In addition to focusing on high risk patients, pediatricians should consider
bullying as a possible factor in any patient with recurrent sore throat, colds,
coughs, breathing problems, nausea, poor appetite, or anxiety about going to
school.[8] One study found that children 9 to 10 years of age with frequent
abdominal pain and sleeping problems were 2 to 4 times more likely to be victims
of bullying.[9] Any recurrent and unexplained somatic symptom can be a warning
sign of bullying victimization.
Table 1 also lists other warning signs that pediatricians need to watch for
during screening potential victims of bullying. Reviewing these signs with
parents can also help them identify potential problems with bullying their child
may be experiencing.
Screening for problems with bullying
Most children are reluctant to admit to being victims of bullying and rarely
will volunteer to talk about it directly. During screening, it may help to
approach the issue of bullying with more general questions in third person, such
as asking about "popular" kids in class and how they tend to treat "unpopular"
kids. Then pediatricians can probe further by inquiring about friends in school
and whether the child usually spends recess playing with other children or
alone. If the child seems to be withdrawn from peers, ask for the reason and
check if teasing, name calling or deliberate exclusion may be involved.
If a child has a chronic somatic symptom, pediatricians can use this as an
opening to ask about worrying or anxiety in respect to friends or school. Again,
it helps to begin with a general statement, such as "sometimes people get
stomachaches from worrying or feeling very bad about something," and then ask
about personal experiences, such as "do you often worry about going to school?"
or "does anyone in class make you feel scared?"
Referral
Referral to a pediatric mental health professional for further assessment and
intervention is recommended if screening uncovers that a child is being bullied,
or even if unexplained somatic symptoms persist. A mental health professional
will provide assertiveness training and emotional counseling, usually in a group
setting, since the most effective interventions against bullying are socially
based. Often, mental health professionals will engage with the school personnel
and help implement solutions that involve the entire school milieu.
Assertiveness training
To prevent children from succumbing to the tactics of bullies, especially
children with disabilities who are at higher risk for becoming targeted by
bullies, pediatricians can review with parents several aspects that help build
children's resilience. Parents should strive to:
- Teach good social skills at play times during
preschool years
- Help develop positive self esteem while in elementary
school
- Build confidence by reinforcing the child's unique
strengths and abilities
- Teach their children to respond assertively to
negative peer statements about themselves or others
- Help create a buddy system so the child has a friend
who can stand up to bullies
- Explain to children the difference between "tattling" (just to get someone
in trouble) and "telling" (when something needs to change)
The last point is critical. Children, whether victims or bystanders, often
are reluctant to inform adults about bullying, since they are repeatedly taught
not to tattle. Parents can start teaching the distinction between tattling and
telling when children are as young as 4 years of age, and continue to reinforce
the difference with examples as they occur.[6]
Fear of retaliation from the bully also tends to keep victims silent,
prolonging the abuse. Parents need to explain to children that bullies rely on
this fear to maintain power over their victims, whereas in reality, the sooner
bullying comes to light, the sooner this harassment will stop.
Also, pediatricians can encourage parents to pay more attention to what their
children are telling them casually, particularly when they keep repeating it.
Often parents are dismissive of casual comments children make about kids being
mean to each other, especially when children are saying it without much emotion.
Children, on the other hand, think that they have told parents about bullying
and feel more helpless when they see that nothing is done to improve the
distressing situation.
Pediatricians can also advise parents to trust their children when they
mention being bothered by a classmate, as opposed to minimizing the child's
report and relying more on the teacher's perceptions. Teachers usually do not
know the extent of bullying in their classrooms, especially when bullying is
relational. In addition to involving the school in developing a long-term
solution to the bullying, parents can help their child formulate a plan to
assertively stand up to the bully.
Conclusion
Pediatricians can help prevent serious psychosocial effects of bullying by
being vigilant for signs that a child is targeted, especially during the early
elementary school years, before the victim role becomes entrenched and starts
taking its toll. Talking to parents, especially those with children at risk due
to disabilities or other disorders that may impede their acceptance by peers,
can provide parents with tools for helping their child develop good social
skills and a strong sense of self - the most important buffers to bullying.
Confirmed cases of bullying should be referred to a pediatric mental health
professional, who will often also intervene with the school to facilitate
long-term solutions to end bullying.
REFERENCES
[1.] Nickel MK, Krawczyk J, Nickel C, et al. Anger, interpersonal
relationships, and health-related quality of life in bullying boys who are
treated with outpatient family therapy: A randomized, prospective, controlled
trial with 1 year of follow-up. Pediatrics 2005 Aug;116:247-254.
[2.] Glew GM, Fan M, Katon W, et al. Bullying, psychosocial adjustment, and
academic performance in elementary school. Arch Ped Adolesc Med 2005
Nov;159:1026-1031.
[3.] van der Wal MF, de Wit CAM, Hirasing RA. Psychosocial health among young
victims and offenders of direct and indirect bullying. Pediatrics 2003
June;111:1312-1317.
[4.] Fleming M, Towey K, eds. Educational Forum on Adolescent Health: Youth
Bullying. Chicago: American Medical Association; 2002 May. Available at:
http://www.ama-assn.org/go/adolescenthealth. Accessed January 31, 2006.
[5.] Council on Scientific Affairs. Bullying Behaviors among Children and
Adolescents. CSA Report 1-A-02. Chicago, Ill: American Medical Association;
2002. Available at: http://www.ama-assn.org/go/csa. Accessed January 31, 2006.
[6.] Coloroso B. The Bully, the Bullied, and the Bystander. New York, NY:
HarperCollins Publishers Inc; 2003.
[7.] Juvonen J, Graham S, Schuster MA. Bullying among adolescents: The
strong, the weak, and the troubled. Pediatrics 2003 Dec;112:1231-1237.
[8.] Wolke D, Woods S, Bloomfield L, Karstadt L. Bullying involvement in
primary school and common health problems. Arch Dis Child 2001;85:197-201.
[9.] Williams K, Chambers M, Logan S, Robinson D. Association of common
health symptoms with bullying in primary school children. BMJ 1996;313:17-19.
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