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Bullying Nursing CE Course

1.0 ANCC Contact Hour

About this course:

The purpose of this activity is to initiate a conversation about child and adolescent bullying, including statistics on bullying and cyberbullying, risk factors for victimization and perpetration, screening and assessment considerations, management steps, and prevention strategies for healthcare professionals (HCPs). This course does not discuss bullying in the workplace. For more information on that topic, refer to the Civility in the Workplace course.

Course preview

Disclosure Form

The purpose of this activity is to initiate a conversation about child and adolescent bullying, including statistics on bullying and cyberbullying, risk factors for victimization and perpetration, screening and assessment considerations, management steps, and prevention strategies for healthcare professionals (HCPs). This course does not discuss bullying in the workplace. For more information on that topic, refer to the Civility in the Workplace course.

After this activity, the learner will be prepared to:

  • define relevant terminology and review statistics related to bullying and cyberbullying
  • identify victimization and perpetration risk factors associated with bullying and cyberbullying
  • describe the screening and assessment process for identification of a child or adolescent who is being bullied or bullying others
  • describe the management strategies that HCPs can use to educate parents and caregivers when their child is bullying others or being bullied
  • identify prevention strategies to reduce bullying and cyberbullying

Background

Adverse childhood experiences (ACEs) are potentially traumatic events experienced by infants and children from birth to 17 years. ACEs can result from firsthand experiences of violence, abuse, or neglect. In addition, the environment in which a child grows can also contribute to secondhand ACEs by undermining their sense of safety, stability, and bonding. Secondary experiences can include witnessing violence in the home or community and living in a household with substance abuse problems, mental health problems, or parental instability or separation. An estimated 61% of adults in the US have experienced at least one type of ACE, and approximately 1 out of every 6 adults has experienced at least four (Centers for Disease Control and Prevention [CDC], 2021). The economic impact of ACEs on families, communities, and society is estimated to be hundreds of billions of dollars each year. In addition, these childhood experiences can have lasting adverse effects on health and well-being (e.g., increased risk of physical injury, sexually transmitted infections, teen pregnancy, pregnancy complications, mental illness, substance use, involvement in sex trafficking, and a wide range of chronic diseases such as diabetes, heart disease, cancer, and suicide). ACEs have also been shown to impact education, job opportunities, and earning potential adversely (CDC, 2021). 

The CDC (2020a) defines youth violence as the intentional use of physical force or power to threaten or harm others by young people aged 10 to 24. Youth violence typically involves causing physical harm, including fighting, bullying, threats with weapons, and gang-related violence. A young person can experience youth violence as a victim, offender, or witness. To varying degrees, bullying impacts all community and demographic groups. Youth violence can be deadly, and homicide is the third leading cause of death in 10- to 24-year-old individuals. An estimated 13 young people are victims of homicide each day, with an additional 1,100 treated in emergency departments for non-fatal assault-related injuries, creating approximately 20 billion dollars annually in medical expenses and lost productivity. Youth violence can have serious and long-lasting consequences on physical, mental, and social health (e.g., an increased risk for behavioral and mental health problems, future violence perpetration and victimization, smoking, substance abuse from obesity, academic problems, depression, and suicide; CDC, 2020a).

The CDC (2020b) defines bullying as any unwanted aggressive behavior(s) by another youth or group of youths, not siblings or current partners, involving an observed or perceived power imbalance (i.e., physical strength, access to embarrassing information, or popularity). Thus, bullying is a form of youth violence and an ACE that is highly likely to be repeated. Common types of bullying include physical (e.g., hitting, kicking, and tripping), verbal (e.g., name-calling, inappropriate sexual comments, and teasing), relational or social (e.g., leaving someone out on purpose, embarrassing someone in public, or spreading rumors), and damage to the victim’s property (Stopbullying, 2020a). Bullying is widespread in the US, as about 1 in 5 high-school students reported being bullied on school property, and 1 in 6 reported being bullied electronically in the last year. The effects of bullying can negatively impact the victim, the perpetrator, and those who witnessed bullying. For example, victims of bullying can experience physical (e.g., injuries, self-harm, death), psychological (e.g., emotional distress, depression, anxiety, sleep disturbances), social (e.g., increased risk of substance use, smoking, high-risk sexual behavior, violence in adulthood), and educational harm (e.g., lower academic achievement, dropping out of school; CDC, 2020b).

Cyberbully is defined as using technology (i.e., cell phones, computers, online forums, or social media) to harass, hurt, embarrass, humiliate, or intimidate another person repeatedly and intentionally (Pacer’s National Bullying Center, 2019). Cyberbullying can include sending, posting, or sharing negative, harmful, false, or mean content about someone else, with some cyberbullying rising to the level of criminal behavior. With the prevalence of social media and online forums, strangers and acquaintances can view comments, photos, and posts. Even when cyberbullying is identified and stopped, the content posted may remain permanently online (Stopbullying, 2020b). Cyberbullying can occur in many forms, including sharing nude photos, spreading lies and false accusations, threatening to hurt someone or telling them to kill themselves, creating a malicious webpage about someone, and doxing (i.e., posting personal information such as someone’s address, social security number, and credit card information as a form of revenge; Stopbullying, 2018).  

Risk Factors

Since bullying frequently occurs in school settings, school administrators are often responsible for disciplinary action. Reports of bullying are highest in middle schools (28%), followed by high schools (16%), combined schools (i.e., schools with multiple overlapping grade levels; 12%), and primary schools (9%). Similarly, cyberbullying is highest in middle schools (33%), followed by high schools (30%), combined schools (20%), and primary schools (5%). In addition, 14% of public schools report daily or at least weekly disciplinary action because of bullying (CDC, 2020b). Bullying often occurs in unstructured areas such as playgrounds, cafeterias, hallways, and buses. Children's most common form of bullying is verbal, followed closely by physical bullying and cyberbullying (Waseem & Nickerson, 2021). According to the CDC (2020c), a combination of individual, family, relationship, and community factors contribute to the risk of experiencing and perpetrating youth violence and bullying.  

Risk Factors for Perpetration

Children and teenagers who feel secure and supported by their family and friends are less likely to bully (Stopbullying, 2021c). One of the most significant risk factors for youth violence bullying perpetration is toxic stress. Toxic stress can be defined as prolonged and repeated stress resulting from living in impoverished neighborhoods, experiencing food insecurity, experiencing racism, living with limited access to support and medical services, and living in homes with violence, substance abuse, or mental health problems. Individual risk factors for the perpetration of youth violence and bullying can also include the following:

  • history of violent victimization
  • attention deficit hyperactivity disorder (ADHD) or other conditions related to cognitive or information-processing abilities
  • history of early aggressive behavior or poor behavioral control
  • high emotional distress
  • low intelligence quotient (

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IQ)
  • involvement with drugs, alcohol, or tobacco
  • desire to attain social power or elevate their status among peers
  • feelings of insecurity and low self-esteem
  • conditioned to view violence in a positive way (CDC, 2020c; Stopbullying, 2021c)
  • Family risk factors for perpetration of youth violence and bullying can include:

    • authoritarian childrearing attitudes 
    • harsh, lax, or inconsistent disciplinary practices
    • low parental involvement or inadequate monitoring and supervision
    • parental substance abuse or criminality
    • low parental education and income (CDC, 2020c; Stopbullying, 2021c)

    Social and community factors can also play a pivotal role in the risk of youth violence and bullying perpetration. Social or peer risk factors can include gang involvement, social rejection by peers, and poor academic performance. Community factors (e.g., socially disorganized neighborhoods, impoverished residents, and low community involvement) can also influence the likelihood of committing youth violence or bullying (CDC, 2020c). 

    Risk Factors for Victimization

    There is no single factor that puts a child at risk of being bullied. Bullying can occur in any context, including cities, suburbs, or rural towns. In addition, the stigmatization of some groups—such as lesbian, gay, bisexual, transgender, and queer, or questioning (LGBTQ) youth and those with disabilities—can place them at increased risk of bullying. Other risk factors that increase the likelihood of being bullied include:

    • young people who are perceived as different from their peers (e.g., being overweight, underweight, wearing glasses, wearing different clothing, or being new to the school)
    • those who are depressed, anxious, or have low self-esteem
    • those who are less popular than others and have few friends
    • those who do not get along well with others
    • those who are perceived as weak or unable to defend themselves (Stopbullying, 2021c)

    According to the National Center for Education Statistics (NCES, 2019), results from the National Crime Victimization Survey found a slightly higher percentage of females (24%) than males (17%) being bullied at school. Students reported the reason for being bullied was most often related to physical appearance, race, ethnicity, gender, disability, religion, or sexual orientation. Bullying was found to occur across racial groups, as 23% of African American students, 23% of Caucasian students, 16% of Hispanic students, and 7% of Asian students reported being bullied at school. Sexual orientation was one of the most significant risk factors for being bullied at school: 70.1% of LGBTQ students reported being verbally bullied (e.g., experiencing name-calling or threats), 28.9% were physically bullied (e.g., being pushed or shoved), and 48.7% experienced cyberbullying in the past year based on their sexual orientation (NCES, 2019).

    Screening and Assessment

    HCPs working with children and adolescents must recognize the warning signs of bullying. A child or an adolescent may be embarrassed or fearful to disclose bullying to their parents, caregivers, and healthcare professionals (Mayo Clinic, n.d.). HCPs play an essential role in screening early for bullying, recognizing signs of bullying, focusing on prevention, and supporting children and adolescents affected by bullying and their families (Stephens et al., 2018). 

    Screening

    HCPs should screen for youth violence and bullying risk factors at routine healthcare visits. Unfortunately, there are no specific screening tools to help identify young people bullying or being bullied. HCPs working with children and adolescents can consider using the home environment, education and employment, eating, peer-related activities, drugs, sexuality, suicide/depression, safety (HEEADSSS) tool as a general approach to assess risk factors and inquire about bullying during routine visits (Smith & McGuinness, 2017; Stephens et al., 2018). The screening questions vary depending upon the child’s age, developmental stage, and cultural background. Screening should address individual, family, social, and community risk factors for bullying perpetration and victimization (Sege, 2021). Early screening is essential, as the risk of being bullied increases as the child moves from elementary to middle school. In addition, HCPs should be cautious in their screening approach to children and adolescents.  Utilizing open-ended questions to prompt patients to describe the behaviors of themselves or others can facilitate disclosure. The HCPs should also ask questions about their online or electronic lives to screen for cyberbullying. The following questions can assist HCPs in screening young patients regarding bullying and school experiences (Stephens et al., 2018):

    • Do you feel safe at school?
    • How do you get along with teachers and other students?
    • Have your grades change recently?
    • Many young people experience bullying at school or through social media. Have you ever had this happen to you or anyone you know? Are you or is anyone you know being bullied through social media or other electronic means?
    • Follow-up questions: Is there anyone at school or home you can talk to about your concerns? How could your parent(s) help you with this problem?

    HCPs should also ask parents or caregivers about any changes in their child’s behaviors or attitudes. In addition, parents or caregivers should be asked if they have witnessed their child bully someone else or experience bullying. Finally, parents or caregivers should be encouraged to talk with their children about bullying routinely. Although parental involvement can help identify risk factors for bullying, at least part of the screening should be conducted with the child or adolescent alone to provide a confidential opportunity for disclosure (Stephens et al., 2018).

    Assessment

    Not all children and adolescents are willing or able to disclose their experiences related to bullying. HCPs should be aware of the warning signs that a child or adolescent is being affected by bullying, and they should counsel parents and caregivers to monitor for these warning signs at home. Physical, psychological, and social problems that indicate the need for further investigation into bullying include:

    • injury or illness without a physical explanation
    • lost or damaged belongings
    • physical symptoms of headaches, nausea, anorexia, and/or abdominal pain
    • feelings of anxiety and depression, including thoughts of self-harm or suicide
    • changes habits such as bedwetting, difficulty sleeping, or frequent nightmares
    • avoidance of school or social situations
    • difficulty concentrating
    • declining grades
    • feelings of helplessness or decreased self-esteem
    • substance use
    • distress after spending time online or on the phone
    • abrupt avoidance of electronic devices (Stephens et al., 2018; Stopbullying, 2021c; Waseem & Nickerson, 2021)

    Frequent and thorough screening and assessment of children and adolescents can help ensure proper identification and timely, effective treatment to manage the effects of bullying. In addition, HCPs can help prevent bullying by assessing for warning signs that a child or adolescent may be bullying others. These warning signs can include: 

    • involvement in physical or verbal fights
    • increasing aggression
    • associating with friends who bully others
    • receiving frequent discipline at school or home
    • blaming others for their problems and demonstrating an inability to accept responsibility for their actions
    • acting overly competitive and worrying about their reputation or popularity
    • having unexplained extra money for new belongings (Stopbullying, 2021c)

    HCPs should ask parents or caregivers if they have seen their child physically or verbally bully another child. Parents or caregivers may be able to minimize their child's role in bullying (Stopbullying, 2021c).

    Management of Bullying

    Bullying can have short-term and long-term effects on the victim, bully, and victim-bully (i.e., a child or adolescent who was bullied and now exhibits bullying behaviors toward others). In addition, harmful effects can be experienced by friends, family, and the community. Therefore, HCPs must evaluate and monitor for comorbid conditions and potential short-term and long-term effects when bullying is disclosed. See Table 1 for possible short-term and long-term effects for a bully, victim, and bully-victim (Stephens et al., 2018; Stopbullying, 2021b).

    The long-term effects of cyberbullying are significant since many people can be involved, and harmful information can remain active or easily accessible on the internet or social media permanently (Mayo Clinic, n.d.). HCPs play a crucial role in providing support after disclosure. Building a supportive network of empathy for the child or adolescent is the first step. If the parent or caregiver is unaware of the bullying, HCPs should assist the child or adolescent in disclosing this to the parent or caregiver. Provide the parent or caregiver with clear, direct information about bullying to engage them in a plan to improve their child’s overall health. Bullying is a complex problem requiring a team approach for effective prevention and management. The priority of care is to ensure the immediate safety of the child or adolescent, which includes treatment of any physical injuries, symptomatic complaints (e.g., headaches and abdominal pain), depression, and anxiety, as well as screening for suicidal or self-injurious thoughts. Referral to a social worker or psychologist may be appropriate for children or adolescents with significant psychological or mental health concerns. For bullying in schools, HCPs can help connect the patient and family with an appropriate school-based health center, guidance counselor, school nurse, or administrator (Stephens et al., 2018).

    HCPs should also provide appropriate educational information to the parents or caregivers of children or adolescents who are bullying or being bullied. For example, the American Academy of Pediatrics (AAP, 2015) has generated educational material and guidance for parents or caregivers to facilitate a discussion about bullying with their child, such as:

    • Talk with your child about bullying. Consider asking questions such as: “How are things going at school?” or “Does anyone get picked on or bullied?”
    • Teach your child how to respond to a bully (e.g., stay calm or walk away from the situation). Practice addressing bullying behavior with your child (e.g., “I don’t like what you are doing” or “Please do not talk to me like that.”).
    • Teach your child when and how to ask for help. Some children are embarrassed about being bullied, so explain consistently that being bullied is not their fault.
    • Encourage your child to seek friendships with other children. Children who are loners are more likely to attract bullying.
    • Support activities that interest your child. Participating in activities such as team sports will help your child develop critical social skills.
    • Set boundaries with technology. Educate your child about cyberbullying and utilize safeguards (e.g., monitoring online profiles, monitoring text messages, and keeping a family computer in a public area for children to use). 
    • Alert school officials when bullying has occurred in a school setting (AAP, 2015).

    Additionally, HCPs should guide parents or caregivers whose child is bullying others. When a child or adolescent is bullying others, their conduct should be taken seriously. Unfortunately, when bullying is not addressed early, these behaviors often continue into adulthood. Recommendations for parents or caregivers when their child is bullying others can include:

    • set firm and consistent limits for the child
    • increase supervision and parental or caregiver involvement
    • be a positive, consistent role model
    • show children they can meet their needs without teasing, threatening, or hurting someone
    • use effective, non-physical discipline, such as loss of privileges
    • help the child understands how bullying hurts other children
    • develop practical solutions with others (e.g., teachers or counselors; AAP, 2015)

    With the increasing prevalence of cyberbullying, HCPs should also educate parents or caregivers on prevention strategies for cyberbullying. For example, parents who want to protect their children from cyberbullying can use various parental control and software-monitoring systems to restrict content, block domains, or view their child’s online activities. In addition, parental digital awareness is critical to the prevention of cyberbullying. Actions that parents or caregivers can perform to strengthen their family’s digital awareness include:

    • monitor the child’s social media sites, apps, and browsing history
    • review the child’s phone location and privacy settings
    • follow or friend the child on social media sites
    • stay up-to-date on the latest apps, social media platforms, and digital slang used by children and teens
    • know the child’s usernames and passwords
    • establish rules about appropriate digital behavior, content, and apps (Stopbullying, 2021a)

    Prevention Strategies

    Youth violence and bullying prevention programs aim to stop youth violence and bullying from occurring. Prevention strategies need to address individual, family, relational, and community factors to be successful. See Table 2 for a list of methods and approaches for youth violence and bullying prevention (CDC, 2020b).


    HCPs can provide anticipatory guidance to parents, caregivers, and patients during well-child visits starting as early as 6 years of age. In addition, by opening the discussion about bullying, the HCPs can draw attention to the problem and empower children, parents, and caregivers to seek additional information. Additional resources on bullying can be found through the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Psychological Association, Cyberbullying Research Center, CDC, and US Department of Health and Human Services at www.stopbullying.gov (Stephens et al., 2018). 


    References

    American Academy of Pediatrics. (2015). Bullying: It’s not ok. https://healthychildren.org/English/safety-prevention/at-play/Pages/Bullying-Its-Not-Ok.aspx

    Centers for Disease Control and Prevention. (2020a). Youth violence: Fast facts. https://www.cdc.gov/violenceprevention/youthviolence/fastfact.html

    Centers for Disease Control and Prevention. (2020b). Youth violence: Preventing bullying. https://www.cdc.gov/violenceprevention/youthviolence/bullyingresearch/fastfact.html

    Centers for Disease Control and Prevention. (2020c). Youth violence: Risk and protective factors. https://www.cdc.gov/violenceprevention/youthviolence/riskprotectivefactors.html

    Centers for Disease Control and Prevention. (2021). Preventing adverse childhood experiences: Fast facts. https://www.cdc.gov/violenceprevention/aces/fastfact.html

    Mayo Clinic. (n.d.) Bullying: How parents can help. Retrieved August 12, 2021, from https://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/bullying/art-20044918

    National Center for Education Statistics. (2019). Student reports of bullying: Results from the 2017 school crime supplement to the National Crime Victimization Survey. US Department of Education. https://nces.ed.gov/pubs2019/2019054.pdf

    Pacer’s National Bullying Prevention Center. (2019). Cyberbullying definition. Family Online Safety Institute. https://www.pacer.org/bullying/info/cyberbullying/

    Sege, R. D. (2021). Peer violence and violence prevention. UpToDate. Retrieved August 12, 2021, from https://www.uptodate.com/contents/peer-violence-and-violence-prevention?

    Smith, G. L., & McGuinness, T. M. (2017). Adolescent psychosocial assessment: The HEEADSSS. Journal of Psychosocial Nursing and Mental Health Services, 55(5), 24-27. https://doi.org/10.3928/02793695-20170420-03

    Stephens, M. M., Cook-Fasano, H. T., & Sibbaluca, K. (2018). Childhood bullying: Implications for physicians. American Family Physician, 97(3), 187-192. https://www.aafp.org/afp/2018/0201/p187.html

    Stopbullying. (2018). Cyberbullying tactics. United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/cyberbullying-tactics

    Stopbullying. (2020a). What is bullying? United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/what-is-bullying

    Stopbullying. (2020b). What is cyberbullying? United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/what-is-it

    Stopbullying. (2021a). Digital awareness for parents. United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/digital-awareness-for-parents

    Stopbullying. (2021b). Warning signs of bullying. United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/warning-signs

    Stopbullying. (2021c). Who is at risk? United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/at-risk

    Waseem, M., & Nickerson, A. B. (2021). Bullying. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441930/#article-35910.s2

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