(p. 39) Bullying and Mental Health
Bullying, once regarded as a rite of passage, is now recognized as a serious mental health and public health issue. Bullying is a form of aggressive behavior that includes an intention to cause physical or psychological harm, a power imbalance that makes it difficult for the target to defend himself or herself, and repeated occurrence (Nansel et al., 2001; Olweus, 1993). Bullying can be physical (e.g., hitting, kicking), verbal (e.g., name calling), indirect (e.g., exclusion, rumor spreading), or electronic, also known as cyber-bullying (Crick, Casas, & Ku, 1999). Mental health is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organization, 2011). In this chapter, the impact of bullying on various aspects of mental health, including emotional functioning, relationships, academic performance, and other outcomes, is reviewed for perpetrators, targets, bully-victims, and bystanders.
Bullying others is associated with a range of concurrent and long-term externalizing problems. Students who bully others are more likely than their peers to engage in other high-risk behaviors, such as weapon-carrying (Dukes, Stein, & Zane, 2010) and substance abuse (Carlyle & Steinman, 2007; Kaltiala-Heino, Rimpelä, Rantanen, & Rimpelä, 2000; Kim, Catalano, Haggerty, & Abbott, 2011). Bullying behavior may be a precursor to escalating problems in later life. In a seminal study, Olweus (1991) found that 60% of students identified as bullies in middle school had at least one lifetime criminal conviction, with 35% to 40% of bullies having three or more criminal convictions in later life. More recent studies have found that former bullies are more likely to engage in violent crime (Farrington & Ttofi, 2011; Lӧsel & Bender, 2011), and to have more criminal convictions and traffic violations than their peers (Renda, Vassallo, & Edwards, 2011; Sourander et al., 2011). Individuals identified as bullying someone else at least once in their youth by self- or parent-report are also at increased risk for a diagnosis of antisocial personality (p. 40) disorder in young adulthood (Copeland, Wolke, Angold, & Costello, 2013). Bullies are more likely than their peers to sexually harass others later in life (Espelage, Basile, & Hamburger, 2012). They are also more aggressive in general, especially toward their spouses (Kim et al., 2011). Individuals who bullied others are more likely than their peers to use alcohol, marijuana, and other drugs in young adulthood (Farrington & Ttofi, 2011; Kim et al., 2011).
Bullying others is related not only to externalizing problems, but also to academic and physical problems. Students who bully others have been found to have poorer school adjustment and less school success (e.g., difficulty completing homework, problems getting along with others) than both targets and typical peers (Brown & Taylor, 2008; Nansel, Haynie, & Simons-Morton, 2003). In addition, these students are more likely to feel sad and unsafe in school than their peers who are not involved in bullying (Glew, Fan, Katon, Rivara, & Kernic, 2005). Perpetration also has physical implications, with females who bully others reporting higher rates of anorexia (Kaltiala-Heino et al., 2000). Bullies are also at higher risk for psychosomatic problems than non-involved peers, although these rates are lower than those for victims and bully-victims (Gini & Pozzoli, 2009).
There is a growing body of literature indicating that bullying others is also associated with depression, suicidal ideation, and suicide attempts (Klomek, Marrocco, Kleinman, Schonfeld, & Gould, 2007; Nickerson & Slater, 2009). Suicidal ideation is present in 43% of physical bullies, and suicidal behavior is present for 35% of this group, compared to less than 12% for uninvolved peers (Espelage & Holt, 2013). Additional research has found that males who frequently bullied others at age 8 were at increased risk for suicidality at age 25 compared to their non-involved peers (Klomek et al., 2009).
It is important to note that bullying accounts for only a small amount of the variance in suicidality (Hinduja & Patchin, 2010; Kowalski & Limber, 2013), indicating the need to distinguish specific risk and protective factors associated with this complex issue. Self-injurious behavior and increased negative emotionality have been indicated as risk factors across groups; however, a history of physical or sexual abuse, bringing weapons to school, mental health problems, running away from home, and self-identifying as being overweight are also risk factors for suicide among perpetrators (Borowsky, Taliaferro, & McMorris, 2013). Feelings of connectedness to parents and having caring friends were found to be protective factors for all youth involved in bullying; for perpetrators, connectedness to other caring adults such as relatives or community members was an additional protective factor (Borowsky et al., 2013).
Targets of bullying experience higher levels of emotional distress and mental health issues than their peers, including sadness, loneliness, and withdrawal (Kochenderfer & Ladd, 1996; Storch & Masia-Warner, 2004; van Oort, Greaves-Lord, Ormel, Verhulst, & Huizink, 2011). They also display other internalizing symptoms including anxiety and depression (Hugh-Jones & Smith, 1999; Kochenderfer & Ladd, 1996), with a comprehensive meta-analysis postulating a reciprocal relationship between peer victimization and internalizing behaviors (Reijntjes, Kamphuis, (p. 41) Prinzie, & Telch, 2010). Targets of bullying may have a poor sense of self, perceiving themselves as failures and outcasts (Hugh-Jones & Smith, 1999). Peer victimization, although not limited to bullying per se, has been associated with characterological self-blame (i.e., attributions about victimization being due to internal, stable, and uncontrollable factors), loneliness, and low self-worth (Graham & Juvonen, 1998).
In addition to the victimization that targets experience, they often have other social difficulties with their peers. They are likely to have a low social status, marked by rejection and lack of acceptance by their peers (Ivarsson, Broberg, Arvidsson, & Gillberg, 2005; Salmivalli, Lagerspetz, Björkqvist, Österman, & Kaukiainen, 1996). Lack of reciprocated friendships and corresponding loneliness can also lead to more peer victimization (Boulton, Trueman, Chau, Whitehead, & Amatya, 1999). Furthermore, the targets of bullying tend to develop social connections with other victims, which can exacerbate their social problems and minimize the likelihood of peers’ intervening to assist them when they are bullied (Salmivalli, Huttunen, & Lagerspetz, 1997). Targets of bullying are also at higher risk for other forms of victimization, such as physical and emotional maltreatment by parents, and sexual assaults (Duncan, 1999). Students who are victimized repeatedly and in different ways (e.g., sexual abuse, bullying, sexual harassment) have poorer psychosocial outcomes than other victims and peers (Holt & Espelage, 2003).
Victimization is also associated with poor school outcomes, including lack of connectedness and feeling unsafe in school (Glew et al., 2005). Targets often engage in withdrawal and escape behaviors such as avoiding or skipping school, which can have an adverse impact on their academic and social development (Batsche & Knoff, 1994; Kochenderfer & Ladd, 1996). Individuals who are victimized by their peers may be less successful academically (Brown & Taylor, 2008; Glew et al., 2005), particularly when they have other risk factors, such as aggressive behavior or low support from teachers and parents (Beran & Lupart, 2009).
Peer victimization is also associated with physical symptoms, such as abdominal pain and frequent visits to medical professionals (Greco, Freeman, & Dufton, 2010). A meta-analysis of 11 studies with over 150,000 children between the ages of 7 and 16 revealed that victims and bully-victims were at higher risk for psychosomatic problems than their uninvolved peers (Gini & Pozzoli, 2009). A possible causal mechanism is blunted cortisol levels, as adolescents who were bullied have been shown to have lower levels of cortisol than their non-victimized peers, a pattern typically associated with prolonged stress that is present in individuals with post-traumatic stress disorder (Knack, Jensen-Campbell, & Baum, 2011). Peer victimization can also result in a poorer body image and lower self-esteem (Lunde, Frisén, & Hwang, 2006), as well as the development of eating disorders in young women (Bond, Carlin, Thomas, Rubin, & Patton, 2001).
The negative impact of victimization can be long-lasting, and depressive symptoms have been found to persist even decades after the bullying occurred (Carlyle & Steinman, 2007; Ttofi, Farrington, Lӧsel, & Loeber, 2011). Additionally, the impact of childhood victimization has been associated with an increased risk for stress symptomology (Newman, Holden, & Delville, 2004), and anxiety disorders in adulthood (Copeland et al., 2013; Sourander et al., 2007). Janson and Hazler (2004) found that when asked to recall a time they were victimized, targets experienced physical arousal (i.e., elevated heart rate and skin conductance) similar to traumatic reactions experienced by those who had been in combat or sexually (p. 42) assaulted. Previous victimization also influences job success. Victims have been found to earn less money as adults than their non-victimized peers (Brown & Taylor, 2008); they also have higher rates of job changes and termination (Sansone, Leung, & Wiederman, 2013).
Targets of bullying have a greater likelihood of experiencing suicidal ideation and making suicide attempts than their peers (Klomek et al., 2007; Meltzer, Vostanis, Ford, Bebbington & Dennis, 2011; Nickerson & Slater, 2009; Ttofi et al., 2011). According to Karch, Logan, McDaniel, Floyd and Vagi (2013), one in eight individuals who had experienced school-related problems prior to their suicide had reported being bullied. Adults who recalled being bullied as children were more likely to report suicidal behaviors than non-involved individuals, even after controlling for depressive symptoms (Meltzer et al., 2011). Additional research by Klomek and colleagues (2009), found that girls, but not boys, who were frequently victimized at age 8 were more likely to attempt suicide by age 25 than those who were not frequently victimized. This relationship persisted even when conduct and depressive symptoms were considered.
Despite the significant relationship between victimization and suicidality, researchers have noted that experiencing bullying accounts for less than 7% of the variance in suicidality (Hinduja & Patchin, 2010; Kowalski & Limber, 2013). It is important to note that the risk for suicidal ideation and behavior increases substantially with repeated victimization (Klomek et al., 2007; Schneider, O’Donnell, Stueve, & Coulter, 2012). Recent work by Borowsky and colleagues (2013) has found that a history of physical and sexual abuse, mental health issues, running away from home, self-injurious behavior, and increased negative emotionality were significant risk factors for suicidality among targets. Protective factors included feeling connected to parents, other adults, and peers, in addition to having a positive attitude about school (Borowsky et al., 2013).
Numerous factors have been found to influence and mediate the negative impact of victimization, including the perception of the victimization experience and isolation. Students who perceive themselves to be victims of bullying have poorer psychosocial adjustment than students who do not believe they have been victimized (Juvonen, Nishina, & Graham, 2000). In their work examining both self-blaming attributions and the impact of ethnic majority status on context in peer victimization, Graham, Bellmore, Nishina, and Juvonen (2009) found that characterological self-blame mediated the relationship between peer victimization and maladjustment for Latinos and African-Americans in schools where they were the majority ethnic group. The researchers conceptualize this as an indicator of a social misfit, where outcomes are more negative for individuals whose behavior deviates from social norms within a particular context. Interestingly, students who were harassed themselves but did not witness other students being harassed experienced elevated feelings of humiliation and anger compared to students who had been both a victim and a witness in the same day (Nishina & Juvonen, 2005). This suggests that seeing others experience similar victimization may mediate the relationship between victimization and psychological effects, probably due to reducing feelings of isolation. Indeed, victimized students who also feel isolated in school report elevated levels of stress (Newman et al., 2004). Furthermore, students who are defended by a peer have better psychosocial adjustment and social standing (Sainio, Veenstra, Huitsing, & Salmivalli, 2010). Parental support for females, and teacher, classmate, (p. 43) and school support for males moderate the relationship between victimization and internalizing distress (Davidson & Demaray, 2007).
Recent research has revealed a distinct subgroup of youth, “bully-victims,” who report both bullying others and being victimized (Haynie et al., 2001). These youth exhibit more problem behaviors (e.g., drinking, smoking, rule violations, theft, property damage), depressive symptoms, and lower social competence than peers who are either bullied or who bully others (Haynie et al., 2001; Veenstra et al., 2005). Long-term gender differences have been found among bully-victims, with increased rates of depressive disorders and panic disorder for males and females and increased risk of agoraphobia for females as young adults (Copeland et al., 2013).
Bully-victims have also been found to have greater difficulties associated with school. Bully-victims have poor academic achievement, lack a sense of connectedness, and are less likely to feel safe and involved in school than their peers (Cunningham, 2007; Glew et al., 2005; O’Brennan, Bradshaw, & Sawyer, 2009). Risk factors for low school bonding include past bullying, being female, having friends who bully, acceptance of bullying, and perceptions that teachers had low behavioral expectations (Cunningham, 2007).
The associations between bully-victim status and physical well-being have also been documented. A meta-analysis by Gini and Pozzoli (2009) identified bully-victims as more likely to develop psychosomatic problems than non-involved peers. In addition, increased rates of bulimia have been found among male bully-victims; both male and female bully-victims have increased rates of anorexia (Kaltiala-Heino, Rimpelä, Rantanen, & Rimpelä, 2000).
Although a significant issue among all bullying groups, bully-victims have been found to have the highest rates of suicidality, with rates as high as 60% for ideation and 44% for suicidal behaviors (Espelage & Holt, 2013). Researchers have found conflicting results related to gender and suicidality within the bully-victim group. Increased rates of suicidality have been reported among young adult males who were bully-victims in childhood and adolescence (Copeland et al., 2013; Klomek et al., 2009), whereas other findings indicate higher rates among females (Espelage & Holt, 2013). Significant risk factors for suicidality among bully-victims include self-injurious behavior and negative emotionality, but connectedness to parents and having caring friends were found to be protective factors (Borowsky et al., 2013).
Bullying has been conceptualized as a “group process” (Salmivalli et al., 1996), with peer bystanders witnessing more than 80% of bullying episodes but intervening less than 20% of the time (Atlas & Pepler, 1998; Hawkins, Pepler, & Craig, 2001). Although less is known about the impact of bullying on bystanders, Rivers (2011) makes a cogent argument that bystanders take different roles in bullying situations, and may suffer mental health consequences similar to children who (p. 44) witness domestic violence and other types of abuse. Indeed, children who witness bullying and do not intervene report this to be an emotionally isolating experience (Hutchinson, 2012). Empirical studies have also found that bystanders report increased anxiety, depression, hostility, and paranoia (Nishina & Juvonen, 2005; Rivers, Poteat, Noret, & Ashurst, 2009). When college students were asked to recall observing bullying incidents, they reported elevated levels of trauma symptomology similar to that of survivors of natural disasters and mass-shooting witnesses (Janson & Hazler, 2004).
Summary and Conclusions
A review of the literature indicates that bullying has concomitant and long-term effects on perpetrators, targets, and even bystanders. These effects include internalized and externalized symptoms, interpersonal relationship difficulties, physical problems, substance abuse, and impaired functioning in school, work, and community contexts. Clearly, this is a salient public health and mental health issue. Research has begun to reveal factors that place individuals involved in bullying at greater risk for negative outcomes, such as multiple victimization experiences, characterological self-blame, being bullied and bullying others, and lack of support. Connectedness and social support appear to be key protective factors, underscoring the important role of parents and teachers, medical and mental health providers, and policy makers.
Suggestions for Providers, Parents, Teachers, and Policy Makers
Medical and Mental Health Providers
• Ask about peer relationships and bullying as part of routine visits.
• Educate parents about the prevalence of bullying, its impact, and signs to look for.
• Stay attuned to the relationship between bullying and stress, anxiety, depression, conduct problems, body-image distortions, and physical symptoms to assess and intervene accordingly.
• Use evidence-based interventions matched to symptoms associated with the effects of bullying.
• Conduct suicide and threat assessments to determine the level of risk and intervention needs.
Parents and Teachers
• Be attuned to signs that could suggest a child is suffering from involvement in bullying (e.g., physical signs of bruises, torn clothing; behavioral indicators of withdrawal, avoidance).
• Keep lines of communication open about peer relationships.
• Model, explicitly teach, and reinforce social-emotional skills (e.g., resolving conflict, feeling empathy, accepting others).
• Refer to a mental health professional if concerned about signs of depression, anxiety, or aggression.
(p. 45) • Advocate comprehensive approaches in schools, such as Positive Behavior Support, social-emotional learning, and creating norms of accepting and willingness to intervene to help others.
• Conceptualize bullying within the larger framework of mental health and public health concerns.
• Promote policies that (1) use data at the local level, (2) promote training, education, and coordinated preventive efforts, and (3) use evidence-based interventions instead of reliance on zero tolerance and punitive approaches.
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