Bullying: It's not just a school problem

How much attention should physicians pay to bullying? All children disagree from time to time; when does disagreement have important consequences? Bullying has been defined as the exposure of someone repeatedly and over time to the negative actions of one or more other persons (1). Bullying can be direct, characterized by open attacks on the victim, or indirect, characterized by social isolation of the victim and exclusion from a group. The three key elements of bullying are a power imbalance, negative intent and repetition (1). In a 1991 study using self-report data from children in 22 Toronto, Ontario schools, 8% of the children reported being bullied weekly and 20% of the respondents reported being bullied once or twice per term (2). Seventy-four per cent of those bullied reported being hit or kicked, 23% reported being teased only, and 9% were threatened, intimidated, confined or suffered other types of bullying (2). Bullies come from homes in which there is harsh discipline and a lack of warmth (3). There is a higher likelihood that bullies come from single mother families with low cohesion, and that they tend to perceive their siblings as being powerful (4). Bullying affects victims, the children who bully and even the peers who observe the bullying. An Australian study (5) showed that bullies tend to be unhappy with school and have a higher prevalence of psychosomatic symptoms than nonbullies. Sixty per cent of boys who were identified as bullies by their grade 6 to 9 peers had at least one court conviction by the age of 24 years (3). Aggressive children followed to adulthood had increased risks of criminal behaviour, spousal abuse, alcoholism, antisocial personality disorder and other psychiatric disorders (6). Children who witness bullying have been studied through interviews and observation on the schoolyard. When interviewed, observers of bullying responded that they disliked bullying and would assist the victim in an encounter. When observed on videotape, however, peers spent only 25% of their time intervening on behalf of victims. Seventy-five per cent of the time, they reinforced bullies by passively watching (54%) or actively modelling bullying behaviours (21%) (7). Victims of bullying are often rejected by their peers (8), and are at risk for depression and dropping out of school (9). The behaviour of victims during actual school bullying incidents was captured by hidden videocamera and tape recorder in an elegant study conducted in two elementary schools in Toronto. Victims fell into two broad groups: passive and active-aggressive. Passive victims avoided conflict, were withdrawn, and lacked the humour and prosocial skills that would allow them to manage conflict effectively. Active-aggressive victims responded to teasing with anger, were argumentative and persistently attempted to enter peer groups where they were unwelcome. These aggressive responses tended to escalate bullying behaviour. Passive responses did lead to a decrease in bullying, but at the cost of the submission of the victim to the bully and the consequent reduced self-esteem of the victim (10). The heartfelt concern expressed in the present issue of Paediatrics & Child Health (pages 418 to 420) by Dr John Grant, a practising community paediatrician, highlights the importance of the bullying problem in North American society and the impact on the lives of patients. The anecdote that Dr Grant describes is not an isolated incident, but could be elicited in any family physician or paediatrician's office. Dr Grant suggests a variety of useful actions that parents, schools, paediatricians and government agencies should undertake to stop bullying. Many of these actions are directed toward changing the school climate by promoting peace, monitoring signs of violence and screening for potential victims. More interventions for the victims of bullying can be added to this list. The victim must be offered a safe haven in which he or she can discuss the impact of bullying and where he or she can be reminded of personal strengths as a counter to negative self-images. He or she must be encouraged to increase his or her network of friends and be taught strategies to avoid or confront bullies. Unfortunately, this is easier said than done. Victims are chosen because they are socially isolated, and lack the social skills to prevent bullying from being reinforced or to ask for help from friends to stand up to bullies. Although schools, agencies and paediatricians can do much at the community level to mitigate bullying and its effects, the problem is clearly societal in scope. Bullying cannot be stopped with a single intervention or by a single social agency. The use of violence to solve problems is repeatedly illustrated through television and other visual media. Many parents of bullies believe that it is appropriate for their children to learn how to compete in the schoolyard and do not see bullying as an issue. Too many children in our society are exposed to domestic violence directed towards parents and themselves. Too many children are born into adverse family situations, including low maternal age at the birth of the first child, low education and employment status of the parents, and poor parenting practices, which are documented risk factors for chronic aggressive behaviours in children (11). Dr Grant (page 419) outlines several methods by which paediatricians can assist victims of bullying who present to their offices. From a public health perspective, this is an important tertiary preventive activity. To apply secondary or even primary preventive interventions, physicians must act from the first encounter with a family, ideally before the birth of an infant. Physicians who understand the relationship or lack thereof between the parents, the upbringing of the parents themselves, their degree of love and warmth toward their children, and the methods of discipline used will be in a better position to promote a peaceful and nurturing home environment. Paediatricians, family physicians and organizations, such as the Canadian Paediatric Society, must continue to advocate for increased funding and better structuring of health services for children and youth to reduce mental health problems such as bullying and its sequelae. Where are the potential advances in reducing bullying and aggression in our children? In my view, there are priorities for clinical practice, policy and future research. Several longitudinal studies have charted the developmental course of aggression from childhood to adulthood. Unfortunately, few of these started in early childhood, and there are no published studies that recruited participants during pregnancy or at the birth of the child. As well, relatively little is known about the interplay between genes, and the physical and social environment on the development of the fetus, infant and toddler. Prospective, longitudinal studies that begin with a cohort of pregnant women to ensure the collection of high quality physical and social data prospectively are needed. Effective interventions cannot be planned without an understanding of causation. Human and capital resources are scarce. Why waste these precious resources implementing programs that have never been evaluated? In recent years, several effective school programs have been reasonably well evaluated. The Internet home page of the National Center for Injury Prevention and Control at the American Centers for Disease Control and Prevention in Atlanta lists many of these programs. Many intervention studies have applied a single intervention and assessed outcomes a few weeks or a few months later. In addition to interventions for school-aged children, there is a need for intervention studies that begin during pregnancy and infancy. The studies should extend over several years rather than several months; apply a variety of interventions at individual, community and societal levels; and randomly select large units, such as schools or communities, to allow for the measurement of individual and group level effects. The targets of such interventions must include parenting practices, adolescent pregnancy and appropriate support for single mothers. Although expensive and difficult to execute in community settings, the randomized controlled trial remains the gold standard for evaluating such interventions. A public that is knowledgeable about bullying will not minimize it on the one hand or reach for simplistic solutions on the other. For example, several jurisdictions are now enforcing ‘zero tolerance' policies under which students are automatically suspended for aggressive behaviour. Such policies are not based on a psychobiological model of bullying that provides a framework for understanding causation and prevention. They ignore the factors operating throughout the development of a child that contributed to the bullying behaviour of that child. Although such policies may be effective in the short term, the likelihood that they will improve the course of bullying and aggression in children as they grow does not fit with the current understanding of why some aggressive children become aggressive adults. Family physicians and paediatricians can work with school officials and policy-makers to implement policies that are based on sound science and that have been shown to work in other jurisdictions.

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