by Randy A. Sansone, MD, and Lori A. Sansone, MD
This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked.
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.
Bullying is a well-known adversity among school-age children. According to data, approximately 10 percent of US children and adolescents are the victims of frequent bullying by peers. In the aftermath of being bullied, victims may develop a variety of psychological as well as somatic symptoms, some of which may persist into adulthood. Psychological symptoms may include social difficulties, internalizing symptoms, anxiety, depression, suicidal ideation, and eating disorders (i.e., anorexia or bulimia nervosa). Somatic symptoms may include poor appetite, headaches, sleep disturbances, abdominal pain, and fatigue. In both mental health and primary care settings, being aware of these types of psychological and somatic symptoms in vulnerable children and adolescents may expedite the identification and eradication of these abusive experiences.
Bullying is a social phenomenon that transcends gender, age, and culture. While there are wide ranges in the definition of the term, bullying is essentially characterized by one or several individuals aggressing on a vulnerable peer, primarily to assert control or power. We undoubtedly see the victims of these behaviors in our practices—whether they disclose their plights or not. In this installment of The Interface, we discuss the potential psychological and somatic consequences of bullying, which may emerge in psychiatric as well as primary care settings.
THE PREVALENCE OF BULLYING
Because of varying definitions of the term, one would expect some methodological divergences in the prevalence rates of bully victims. However, several recent US studies indicate relatively consistent percentages with regard to prevalence. For example, in a nationally representative sample of over 11,000 adolescents in Grades 6 through 10, Spriggs and colleagues found that nine percent of survey respondents reported being the victims of bullying. In this study, an additional three percent described themselves as both victims and bullies. Likewise, in a study of over 2,000 New York state students in Grades 9 through 12, nine percent reported being frequently victimized by bullies. Finally, in a California study of over 1,300 boys in Grades 7 through 12, 13.7 percent were classified as victims of bullying. To summarize, the data from recent studies indicate that approximately 10 percent of US children and adolescents are victims of bullying, with probable higher rates among male children.
In addition to US studies, a number of prevalence studies have been undertaken in other countries. For example, in an Italian study, 7.1 percent of primary school children were classified as victims of bullying. In a Canadian study of adolescents, investigators determined a prevalence rate of 6.1 percent. Victim prevalence rates among children and adolescents in other countries have varied as follows: Sweden 10 percent;the United Kingdom 39.8 percent; Norway 15 percent; and Germany 10 percent. Using a different methodological approach, Nordhagen and colleagues elicited data that were based on parent rather than victim reports; in the five Nordic countries surveyed, the prevalence rate of bully victims was 15.1 percent. Despite the wide inter-country variation in prevalence rates, bullying by peers appears to be a universal phenomenon that affects a substantial minority of children and adolescents.
POTENTIAL PSYCHOLOGICAL CONSEQUENCES OF BEING BULLIED
Social problems. A number of studies have examined the psychological consequences in the aftermath of frequent bullying. One consequence is compromised social development. In a Korean study of seventh- and eighth-grade students, investigators found that being bullied contributed to an increased risk of social problems. In this study, social problems were described as acting younger than one’s age, being overly dependent on adults, and behaving socially immature—all factors that heighten the risk of social isolation within the peer group. In an Italian study, Gini also found that victims of bullying had more social difficulties with peers.
Internalizing symptoms, anxiety, depression, and eating disorders. In addition to social difficulties, children and adolescents who are repetitively bullied may develop internalizing symptoms. For example, in a study of over 7,000 predominantly African-American and Hispanic middle- and high-school students, Peskin and colleagues found that victims of bullying reported frequent worries, sadness, nervousness, and fearfulness.
Other psychological sequelae may develop in the aftermath of repetitive bullying, including anxiety and depressive symptoms and disorders. With regard to anxiety, in a Finnish study of boys, Sourander and colleagues found that frequent bullying was a predicting factor for anxiety disorders in early adulthood. In support of these data, Gladstone and colleagues found, in men and women who were being seen in an outpatient depression clinic, that childhood bullying was associated with high levels of general state anxiety.
In addition to anxiety, studies indicate a higher risk for depressive symptoms and disorders among the bullied, both during childhood[2,15] and in adulthood. According to Brunstein Klomek and colleagues, frequent bullying may also heighten the risk for suicidal ideation and attempts.
Bullying by peers may also contribute to the development of eating disorders (i.e., anorexia and bulimia nervosa). As an example, in a large Finnish study, Kaltiala-Heino and colleagues found a statistical association between being bullied and development of eating pathology, both in female and male victims. In this latter study, bully victims also had an increased likelihood of evidencing multiple mental disorders (e.g., anxiety, depression; see TABLE 1).
POTENTIAL SOMATIC CONSEQUENCES OF BEING BULLIED
In addition to the psychological consequences of impaired social development, internalizing symptoms, anxiety, depressive symptoms, and eating pathology, a number of studies indicate that victims of bullying may develop psychosomatic symptoms as well (TABLE 1).[4,9,10] For example, in a study of over 1,600 US children, ages 6 through 9 years, being bullied was associated with a higher likelihood of repeated sore throats, colds, coughs, and poor appetite. In a study by Fekkes and colleagues of Dutch school children ages 9 to 12 years, being bullied was associated with a greater likelihood of headaches, sleeping problems, abdominal pain, bed-wetting, and feeling tired. Srabstein and colleagues surveyed nearly 16,000 US students in Grades 6 through 10 and found that being bullied was associated with headaches, stomachaches, backaches, dizziness, and sleep disturbance. Finally, in the study by Kaltiala-Heino and colleagues, being bullied was associated with neck and shoulder pain, low back pain, stomachaches, sleep difficulties, headaches, and fatigue. From a different perspective, in a study of over 5,000 Danish students in Grades 5, 7, and 9, Due and colleagues determined that being bullied was associated with an increase in the use of medications for both pain and psychological problems.
Regardless of definition or empirical construct, bullying by peers during childhood and adolescence affects a significant minority of individuals. Not only is bullying an adverse experience, but there appears to be a variety of potential short- and long-term psychological as well as somatic sequelae. Psychological sequelae may include social difficulties, internalizing symptoms, anxiety and depression, suicidal ideation, and eating disorders. Somatic sequelae may entail a host of various types of psychosomatic symptoms. Being alert to these associations in both mental health and primary care settings may expedite the identification of bully victims and the subsequent eradication of these abusive experiences.
1. Spriggs AL, Iannotti RJ, Nansel TR, Haynie DL. Adolescent bullying involvement and perceived family, peer and school relations: commonalities and differences across race/ethnicity. J Adolesc Health. 2007;41:283–293.
2. Brunstein Klomek A, Marrocco F, Kleinman M, et al. Bullying, depression, and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry. 2007;46:40–49.
3. Stein JA, Dukes RL, Warren JI. Adolescent male bullies, victims, and bully-victims: a comparison of psychosocial and behavioral characteristics. J Pediatr Psychol. 2007;32:273–282.
4. Gini G. Associations between bullying behaviour, psychosomatic complaints, emotional and behavioural problems. J Paediatr Child Health. 2007 Jun 29. [Epub ahead of print]
5. Volk A, Craig W, Boyce W, King M. Adolescent risk correlates of bullying and different types of victimization. Int J Adolesc Med Health. 2006;18:575–586.
6. Ivarsson T, Broberg AG, Arvidsson T, Gillberg C. Bullying in adolescence: psychiatric problems in victims and bullies as measured by the Youth Self Report (YSR) and the Depression Self-Rating Scale (DSRS). Nord J Psychiatry. 2005;59:365–373.
7. Wolke D, Woods S, Bloomfield L, Karstadt L. Bullying involvement in primary school and common health problems. Arch Dis Child. 2001;85:197–201.
8. Haavet OR, Straand J, Saugstad OD, Grunfeld B. Illness and exposure to negative life experiences in adolescence: two sides of the same coin? A study of 15-year-olds in Oslo, Norway. Acta Paediatr. 2004;93:405–411.
9. Richter M, Bowles D, Melzer W, Hurrelmann K. Bullying, psychosocial health and risk behaviour in adolescence. Gesundheitswesen. 2007;69:475–482.
10. Nordhagen R, Nielsen A, Stigum H, Kohler L. Parental reported bullying among Nordic children: a population-based study. Child Care Health Dev 2005;31:693–701.
11. Kim YS, Leventhal BL, Koh YJ, et al. School bullying and youth violence: Causes or consequences of psychopathologic behavior? Arch Gen Psychiatry. 2006;63:1035–1041.
12. Peskin MF, Tortolero SR, Markham CM, et al. Bullying and victimization and internalizing symptoms among low-income Black and Hispanic students. J Adolesc Health. 2007;40:372–375.
13. Sourander A, Jensen P, Ronning JA, et al. What is the early adulthood outcome of boys who bully or are bullied in childhood? The Finnish “From a Boy to a Man” study. Pediatrics. 2007;120:397–404.
14. Gladstone GL, Parker GB, Malhi GS. Do bullied children become anxious and depressed adults? A cross-sectional investigation of the correlates of bullying and anxious depression. J Nerv Ment Dis. 2006;194:201–208.
15. Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Bullying behavior and associations with psychosomatic complaints and depression in victims. J Pediatr. 2004;144:17–22.
16. Srabstein JC, McCarter RJ, Shao C, Huang ZJ. Morbidities associated with bullying behaviors in adolescents. School based study of American adolescents. Int J Adolesc Med Health. 2006;18:587–596.
17. Kaltiala-Heino R, Rimpela M, Rantanen P, Rimpela A. Bullying at school—an indicator of adolescents at risk for mental disorders. J Adolesc. 2000;23:661–674.
18. Due P, Hansen EH, Merlo J, et al. Is victimization from bullying associated with medicine use among adolescents? A nationally representative cross-sectional survey in Denmark. Pediatrics. 2007;120:110–117.
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