This course aims to explore a common adverse childhood experience (ACE) known as bullying. This will include associated terminology, statistical data, risk factors for victimization and perpetration, screening and assessment considerations, management steps, and prevention strategies for health care 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
Bullying
Disclosure Statement
This course aims to explore a common adverse childhood experience (ACE) known as bullying. This will include associated terminology, statistical data, risk factors for victimization and perpetration, screening and assessment considerations, management steps, and prevention strategies for health care 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.
Upon completion of this course, learners should be prepared to:
- Define relevant associated terminology and review statistics related to ACEs, youth violence, bullying, and cyberbullying.
- Identify victimization and perpetration risk factors associated with bullying and cyberbullying.
- Describe the screening and assessment process for the 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.
Introduction
ACEs are defined as preventable traumatic potential 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 use, mental health problems, parental instability, or separation. An estimated 61% of adults in the U.S. have experienced at least one type of ACE, and approximately one out of every six adults has experienced at least four. 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, unintended pregnancy or pregnancy complications; mental health conditions such as depression, suicide, or substance use; and chronic diseases such as diabetes or cancer). ACEs have also been shown to adversely impact education, job opportunities, and earning potential (Centers for Disease Control and Prevention [CDC], 2021, 2024a).
The CDC (2024c) defines youth violence as the use of intentional physical power or force to cause harm or threaten others by young individuals ages 10 to 24. Youth violence can include physical fighting, gang-related activities, bullying, or using weapons with threats. A young individual can be a victim, witness, or offender of the violence. To varying degrees, youth violence negatively impacts all community and demographic groups. In 2019, the third leading cause of death in individuals ages 10 to 24 was homicide. An estimated 800 young individuals are treated daily in emergency departments for non-fatal physical assault-related injuries, which result in approximately 122 billion dollars annually in medical expenses and lost productivity. Youth violence can lead to long-term effects on an individual's physical, mental, and social health (e.g., an increased risk for mental/behavioral health problems [depression, suicide], future violence perpetration and victimization, tobacco use, weight gain, substance use, academic problems [CDC, 2024c]).
The CDC (2024b) defines bullying as any aggressive behavior(s) that is unwanted by another youth/youth group (not their siblings or current partners) that involves a perceived or observed imbalance of power (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., kicking or hitting), verbal (e.g., name-calling, inappropriate sexual comments, and teasing), relational or social (e.g., public embarrassment or gossiping), and damage to the victim’s property (Stopbullying, 2023b). Verbal is the most frequent form of bullying (Waseem & Nickerson, 2023). Bullying is widespread in the U.S., as about one in five high school students reported being bullied at school. The effects of bullying can negatively impact the victim, the perpetrator, and those who witness 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, 2024b]).
Cyberbullying is the unwanted, repeated aggressive behavior that occurs through the use of digital technology (cell phones, computers, tablets) over digital platforms (social media, e-mail, texting, instant messaging, gaming, and photo sharing) to harass, hurt, embarrass, humiliate, intimidate, or cause harm to another individual (Pacer’s National Bullying Center, 2023). Cyberbullying can include sending, posting, or sharing negative, harmful, false, or hurtful content about someone else so that other individuals can view the information. About one in six high school students reported being bullied electronically (CDC, 2024b). Depending on the extent of cyberbullying, it can be deemed unlawful or rise to the level of criminal behavior. All states have laws that require schools to respond to bullying and cyberbullying. 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, 2021d). 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
Bullying commonly occurs in schools in unstructured and unsupervised areas such as the playground, cafeteria, hallway, or bus. School administrators are often responsible for disciplinary action resulting from bullying. 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, 2024b). According to the CDC (2024d), 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, 2021e). 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 an impoverished neighborhood, experiencing food insecurity, experiencing racism, living with limited access to support and medical services, and living in homes with violence, substance use, or mental health problems. Individual risk factors for the perpetration of youth violence
...purchase below to continue the course
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 (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, 2024d; Stopbullying, 2021e)
Family risk factors for perpetration of youth violence and bullying can include the following.
- Authoritarian childrearing attitudes
- Harsh, lax, or inconsistent disciplinary practices
- Decreased parental involvement or inadequate monitoring and supervision
- Parental substance use or criminality
- Decreased parental education and income (CDC, 2024d; Stopbullying, 2021e)
Social (relationship) and community factors can also play a pivotal role in the risk of youth violence and bullying perpetration by the environment and its influence. Social/peer or community risk factors include the following.
- Gang involvement
- Peer rejection
- Decreased academic performance
- Disorganized neighborhoods
- Communities with increased crime and unemployment rates
- Impoverished residents
- Decreased involvement of the community (CDC, 2024d)
Risk Factors for Victimization
Several factors put a child at risk of being bullied or bullying others. Bullying occurs everywhere, including in urban and rural areas. In addition, the stigmatization of some groups—such as lesbian, gay, bisexual, transgender, queer/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 the following.
- Perceived difference from their peers (e.g., weight [over/under], clothing, wearing eyeglasses)
- Those who appear to be anxious, have a depressed mood, or have low self-esteem
- Those who have less friends and are less popular than their peers
- Those who seek attention or do not get along well with others
- Those who are perceived as vulnerable or weak (Stopbullying, 2021f)
According to the National Center for Education Statistics (NCES, 2022), results from the National Crime Victimization Survey of students who are ages 12 to 18 found a slightly higher percentage of females (25%) than males (19%) 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 all racial-ethnic groups: African American students (20%), Caucasian (25%), Hispanic (18%), and Asian (14%) students reported being bullied at school. The most commonly reported form of bullying was gossiping and insulting (NCES, 2022).
Screening and Assessment
HCPs and other individuals 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 HCPs. 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 (Johnstone, 2023).
Screening
It can be difficult to identify bullying, cyberbullying, and aggression in children in schools and home environments. Therefore, the CDC has a compendium of assessment tools to measure bullying from victims, perpetrators, or bystanders. This compendium is an important resource for school nurses, social workers, and administrators. It can be used as a universal screening tool with all students, in the school or classroom, within small groups or with individual students. The tool identifies factors related to bullying and measures progress when implementing interventions that target bullying and aggressive behaviors. This compendium consists of 33 assessment tools designed to obtain self-responses from children/adolescents (Bratica, 2020).
HCPs should screen for youth violence and bullying risk factors at routine health care visits. HCPs working with children and adolescents can consider using the Home, Education /Employment, Peer-Related Activities, Drug Use, Sexuality, Suicide/Depression (HEADSS) tool or Strengths, School, Home, Activities, Drugs, Emotions, Sexuality, Safety (SSHADESS) tool to assess for risk factors and inquire about bullying during routine visits. The screening questions will vary depending on the child’s age, developmental stage, and cultural background. Screening should address individual, family, social, and community risk factors for bullying perpetration and victimization. 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 children to describe their behaviors or those of 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.
- Do you feel safe at school?
- How do you get along with teachers and other students?
- Have your grades changed 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 (Sege, 2023; Waseem & Nickerson, 2023; Coble et al., 2023).
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 the following.
- Injury or illness without a cause
- Insomnia, frequent nightmares
- Headaches, nausea, anorexia, and/or abdominal pain
- Regressive behaviors such as bedwetting
- Avoidance of social activities or school
- Falling grades
- Feelings of helplessness, anxiety, decreased self-esteem, depression, or thoughts of self-harm
- Substance use
- Distress after spending time online or on the phone
- Difficulty focusing
- Abrupt avoidance of electronic devices (Stopbullying, 2021d; Waseem & Nickerson, 2023)
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 the following.
- 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, 2021d)
HCPs should ask parents or caregivers if they have seen their child physically or verbally bully another child. Parents or caregivers may tend to minimize their child's role in bullying (Stopbullying, 2021d).
Management of Bullying
Once bullying is suspected or confirmed, the HCP needs to manage the problem by speaking with the child privately and directly in a safe manner. A few questions to ask include the following.
- Is someone bullying you?
- How often does this occur?
- How long has this been happening?
The HCP should also distinguish between physical, verbal, and cyberbullying, as the approach to intervention would be different. After the information is gathered from the child, further information can be obtained from parents, teachers, and caregivers, if needed. Most incidents of bullying can be managed with anticipatory guidance (Waseem & Nickerson, 2023).
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 and make appropriate referrals when needed. See Table 1 for possible short-term and long-term effects for a bully, victim, and bully-victim (Stopbullying, 2021b).
Table 1
Short-Term and Long-Term Effects of Bullying
| Short-Term Effects | Long-Term Effects |
Bully | - Involvement in fighting, shoplifting, vandalism
- Substance use (tobacco, alcohol, or drugs)
- Engaging in early sexual activity
| - Traffic violations
- Aggressive behaviors
- Criminal record
- Substance and alcohol use
- Intimate partner violence
|
Victim | - Anxiety and depression
- Health concerns
- More likely to bring a weapon to school for safety or retaliation
- Poor academic performance
| - Depression and anxiety
- Changes in eating and sleeping patterns
|
Bully-victim | - Depression and anxiety
- Fighting
- Increased risk of suicide or suicidal ideation, self-harm
- Greater likelihood of carrying weapons to school
- Social ostracization by peers
- Substance use
| - Depression
- Increased risk of suicide or suicidal ideation
- Substance use
- Post-traumatic stress disorder
|
(Stopbullying, 2021b; Waseem & Nickerson, 2023)
The long-term effects of cyberbullying are significant because many people can be involved, and harmful information can remain active or easily accessible on the internet or social media permanently (Johnstone, 2023). 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. The HCP should then 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 concerns (e.g., headaches and abdominal pain), depression or 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 (Waseem & Nickerson, 2023).
HCPs should also provide appropriate educational information to the parents or caregivers of children or adolescents who are bullied or being bullied. For example, the American Academy of Pediatrics (AAP, 2021) has generated educational material and guidance for parents or caregivers to facilitate a discussion about bullying with their child, such as the following.
- Talk with your child about bullying. Consider asking questions such as: “How are things at school?” or “Does anyone get bullied or picked on?”
- 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 how and when 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 others. 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, 2021).
Additionally, HCPs should guide parents or caregivers whose children are 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 the following.
- Set firm and consistent limits on the child's aggressive behavior.
- Increase supervision and parental or caregiver involvement.
- Be a positive, consistent role model.
- Demonstrate to the child how to meet their needs without bullying (teasing, threatening).
- Use effective, non-physical discipline, such as loss of privileges.
- Help the child understand how bullying hurts others.
- Develop practical solutions with others (e.g., teachers or counselors [AAP, 2021]).
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 or 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 the following.
- Monitor the child’s browsing history of social media apps and sites.
- Review the location and privacy settings of the child's phone, and set privacy/security settings for the child when gaming.
- Follow your child on social media sites or ask another Individual.
- Be familiar with current digital terminology and trends with apps and social media.
- Know the child’s usernames and passwords.
- Establish rules for digital behavior and social media/game time.
- Teach the child the importance of not sharing personal information or clicking on links while gaming.
- Observe the child periodically when playing online games with others (Stopbullying, 2021a, 2021c, 2023a).
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, 2024d).
Table 2
Strategies and Associated Approaches for Youth Violence and Bullying Prevention
Strategies | Approaches |
- Promote family environments that support healthy development.
| - Early childhood home visitation
- Parenting skill and family relationship programs
|
- Provide high-quality education early in life.
| - Preschool enrichment with family engagement
|
| - Universal school-based programs
|
- Connect youth to caring adults and activities.
| - Mentoring programs
- After-school programs
|
- Create protective community environments.
| - Modifying the physical and social environment
- Reducing exposure to community-level risks
- Street outreach and community norm change
|
- Intervene to lessen harm and prevent future risks.
| - Treatment to lessen the harms of violent exposures
- Treatment to prevent problem behavior and further involvement and violence
- Hospital-community partnerships
|
(CDC, 2024d)
HCPs can provide anticipatory guidance to parents, caregivers, and patients during well-child visits starting as early as age 6. 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 U.S. Department of Health and Human Services at www.stopbullying.gov.
References
American Academy of Pediatrics. (2021). Bullying: It’s not ok. https://healthychildren.org/English/safety-prevention/at-play/Pages/Bullying-Its-Not-Ok.aspx
Bratica, R. B. (2020). A compendium of assessment tools for measuring bullying. Children & Schools, 42(1), 67–69. https://doi.org/10.1093/cs/cdz027
Centers for Disease Control and Prevention. (2021). Adverse childhood experiences prevention strategy. https://www.cdc.gov/aces/media/pdfs/ACEs-Strategic-Plan_Final_508.pdf
Centers for Disease Control and Prevention. (2024a). Adverse childhood experiences (ACEs): Preventing adverse childhood experiences. https://www.cdc.gov/aces/prevention/index.html
Centers for Disease Control and Prevention. (2024b). Youth violence prevention: About bullying. https://www.cdc.gov/youth-violence/about/about-bullying.html
Centers for Disease Control and Prevention. (2024c). Youth violence prevention: About youth violence. https://www.cdc.gov/youth-violence/about/index.html
Centers for Disease Control and Prevention. (2024d). Youth violence prevention: Risk and protective factors. https://www.cdc.gov/youth-violence/risk-factors/
Coble, C., Srivastav, S., Glick, A., Bradshaw, C., & Osman, C. (2023). Teaching SSHADESS versus HEADSS to medical students: An association with improved communication skills and increased psychosocial factor assessments. Academic Pediatrics, 23(1), 209–215. https://doi.org/10.1016/j.acap.2022.09.012
Johnstone, N. (2023). What is cyberbullying, and how can it be prevented? Mayo Clinic Press. https://mcpress.mayoclinic.org/parenting/what-is-cyberbullying-and-how-it-can-be-prevented/
National Center for Education Statistics. (2022). Bullying at school and electronic bullying. Condition of education. US Department of Education, Institute of Education Sciences. https://nces.ed.gov/programs/coe/indicator/a10.
Pacer’s National Bullying Prevention Center. (2023). Cyberbullying definition. Family Online Safety Institute. https://www.pacer.org/bullying/info/cyberbullying/
Sege, R. D. (2023). Peer violence and violence prevention. UpToDate. Retrieved July 7, 2024, from https://www.uptodate.com/contents/peer-violence-and-violence-prevention?
Stopbullying. (2018). Cyberbullying tactics. United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/cyberbullying-tactics
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) Effects of bullying. United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/effects
Stopbullying. (2021c). Prevent cyberbullying. United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/cyberbullying/prevention
Stopbullying. (2021d). Warning signs of bullying. United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/warning-signs
Stopbullying. (2021e). What is cyberbullying? United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/what-is-it
Stopbullying. (2021f). Who is at risk? United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/at-risk
Stopbullying. (2023a). Cyberbullying and online gaming. United States Department of Health and Human Services. https://www.stopbullying.gov/cyberbullying/cyberbullying-online-gaming
Stopbullying. (2023b). What is bullying? United States Department of Health and Human Services. https://www.stopbullying.gov/bullying/what-is-bullying
Waseem, M., & Nickerson, A. B. (2023). Identifying and addressing bullying. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441930/#article-35910.s2