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Coding scheme used for levels of evidence and grades of recommendation
Health practitioners should ask young patients with chronic physical, social or mental health indicators about their experience of bullying
Evidence obtained from a comparative study with concurrent controls:
Health practitioners should understand that school programs can be very effective to deter and deal with bullying if supported across the whole school
Evidence obtained from a systematic review of level II studies
Bullying can be broadly defined as: acts intended or perceived as intended to cause harm. It is unwanted, aggressive behaviour among children that involves a real or perceived power imbalance. The behaviour is often but not always repeated, or has the potential to be repeated, over time146–149
Cyberbullying is defined as: repeated, harmful interactions which are deliberately offensive, humiliating, threatening and power-assertive148,149
Cyberbullying interactions are enacted using electronic equipment, such as mobile phones or the internet, by one or more individuals towards another. Cyberbullying can take the form of instant or email messages, images, videos, calls and also the exclusion or prevention of someone being a part of a group or an online community.150
Sexting is the act of: creating, sharing, sending or posting of sexually explicit messages or images via the internet, mobile phones or other electronic devices by people, especially young people151,152
Intimate images taken with consent during a relationship may, when that relationship falters, be distributed to others for the purposes of humiliation and denigration of reputation, which raises moral, ethical, legal and parenting concerns. This is particularly worrisome because the behaviour occurs at a significant period in young people’s lives, just as they are developing their sexual identity and engaging in early romantic relationships.
It is important to understand that there may be legal implications and that there are laws in place that address the issue of sexting. As Butler et al have noted, ‘Schools should be aware of the potential for cyberbullying to amount to criminal behaviour, so they may better gauge when it may be appropriate to contact police.’153 For example, under the Criminal Code Act 1995 (Commonwealth) the misuse of telecommunications to menace, threaten or hoax other persons is potentially a criminal act.
Bullying can be characterised by its mode (for example – online, in person), type (verbal, relational), and the environment (school, home). The relationship context can be either explicit – sibling, dating partner, friend or acquaintance – or implicit, due to differences in popularity, economic status, academic status that may not be clearly apparent.154
It is worth noting that bullying behaviour doesn’t have to be repeated to have an impact; some isolated violent bullying situations can have a lasting impact. A further challenge is that there is usually an imbalance of power between the victim and the bully. On occasions, the power differential can be difficult to define or identify.146–149
Social norms also influence whether the behaviour is classified as bullying – for example, until fairly recently, many regarded sibling bullying as the normal ‘rough and tumble’ of growing up. This is despite the emerging evidence of both the extent and negative impact of sibling bullying which has been shown to compound school and other forms of bullying.155–157 Other social norms may make it difficult to distinguish between ‘healthy competition’ and physicality and bullying. In these situations, the repetition of such actions would tend to skew them towards bullying.
Bullying is a significant children’s health issue for GPs and the community. It has a high annual prevalence with up to 56% of young people involved either as victim, perpetrator or both.156,158–162 These figures may be underestimates as there is often a reluctance to disclose.163–165
The pattern of bullying varies, with verbal bullying occurring more frequently than physical or cyberbullying. Typically, there are repeated incidents over a period of time.
Cyberbullying is emerging as a significant new form as bullies move from ‘behind the scenes to behind the screens’. The recent emergence of the phenomenon of ‘sexting’, involving the sending and/or exchange of sexually explicit images by electronic means, is of concern to educators, healthcare providers, lawmakers and police.
The prevalence of cyberbullying and sexting has been hard to quantify given the variability in the definition. A national survey in 2010 revealed 59% of teenagers have sent sexually suggestive emails or messages.151A government study found 7–10% of Year 4 to 9 students reported they were bullied by means of technology over the school term.162
The probability of any one child being victimised is directly related to the number of risk factors she or he experiences.166 Children with special needs are particularly vulnerable to bullying with, in one study, over 60% of children diagnosed with ASD reporting they had been bullied.167,168
It is unclear whether the prevalence of bullying is higher in rural areas although the consequences may be worse due to:169
GPs can be advocates in the school environment by voicing support for school anti-bullying programs and encouraging the parents of both bullies and victims to contact the school regarding support and additional counselling. GPs can also advocate through professional associations using policy, position statements, professional education or within local communities as opinion leaders and local champions.
The ability to cope with bullying is enhanced by involving caring adults, teaching appropriate cognitive and social skills and providing strong social support systems such as whole-of-school programs to deter and deal with bullying.
School programs can be very effective if supported across the whole school.145,170,171 Some have had good evidence of impact – for example, the KiVa school based anti - bullying program.173–175
Research is now identifying factors that may be associated with the increased likelihood that children will engage in bullying others. For example, parental anger with their children is associated with the increased likelihood of children engaging in bullying behaviour, while parental communication with their children and meeting their child’s friends is associated with a lower likelihood of children bullying others.166 In relation to young people who are victimised, recent research suggests that interventions are more likely to be successful if they focus on both the psychosocial skills of adolescents and their relationships with their family.173
There is a considerable burden of illness in both the short and long-term for both victims and bullies.155,176–182
The impact of cyberbullying on mental health and emotional response is only just beginning to be understood.183–185 It has been suggested that it will be significant due to the 24 hour nature of it, the anonymity aspects and the broader audience that can be targeted through the visual electronic media.
Bullying has a consistent, strong and graded association with a large number of physical and psychological symptoms.143,158,178,179,186–190 In the short-term, it is associated with:
In the longer term, children who are bullied have:
Bullies also experience negative long-term impacts including:
Some myths about bullying
For more information about myths refer to stop bullying and bullying facts
GPs can identify cases, or ‘case-find’ by thinking about whether bullying is occurring in typical presentations as outlined above.164,165,206–208
You have the opportunity to identify and support children who have been bullied through a careful history taking (refer to Box 5) followed up by counselling and support. It is important to listen and believe.
Many people experience bullying at school or via the net or phone or at home. Has this ever happened to you? How often? How long has this being going on for? What happens? How do you feel? Have you told anyone about it? Who can you go to for help if you are being bullied?
How is school going? What do you like about school? What are you good/not good at?
How many good friends do you have in school? How do you get along with others at the school and the teachers? Do you ever feel afraid to go to school?209
Up to 60% of victims of bullying have seen a GP in the last 12 months with a range of somatic or other symptoms. GPs should ask about bullying when children and adolescents present with unexplained psychosomatic and behaviour symptoms; when they experience problems at school or with friends; if they begin to use tobacco, alcohol, and other drugs; and if they express thoughts of self-harm or suicide.
Support includes acknowledging that:165,207
GPs can be advocates for the child who is bullied.165,206–208,210 This can be done within the consultation by getting the family involved and encouraging them to take an active role in monitoring their children and engaging them in positive school and community activities.
In summary, the issue of school bullying in all its forms is now on the national and international research and policy agenda for all those concerned with the health, wellbeing and education of young people.
As noted in this chapter, the matter of school bullying has been identified as a significant public health issue. GPs who are interested in treating the child and family unit as a whole are at the forefront in advocating for the wellbeing of young people. The following case study highlights the significant role of GPs in addressing and treating bullying.
Kristy is 11 years old. She attends with her mother, Liz, holding out her arms and complaining of painful wrists that hurt when she moves them. The doctor does not know the family particularly well. Kristy has attended the practice intermittently for several years. It is only after the consultation that the doctor discovers that there has been a prior consultation where anxiety has been an issue. She is clearly perfectly well today – a bright young person who, while a little subdued, is easy to get on with. She allows the doctor to move her wrists passively through the full range of movements without wincing.
The doctor then asks about any stress in the background. Her mother discloses a torrent of troubles caused by the out-of-control behaviour of Kristy’s teenage brother Sam. The aggression, the opposition and the teasing of Kristy has escalated to an intolerable level.
The doctor has not seen Sam – a situation that appears likely to change.
In answer to a direct question, her mother says there has been recent bullying at school but that this has been attended to.
Given Kristy’s early adolescent stage of development and the ‘concrete thinking’ she displays that is typical of early adolescence, the doctor concludes this 10-minute consultation with some concrete declarations in conversation with Kristy.
Kristy and her mother leave with an apparent sense of purpose and relief. A further – and long – consultation is planned with Kristy’s mother alone. This consultation will brainstorm ways of improving family functioning and ways of minimising the impact of the current state of affairs on Kristy. The doctor needs to explore Kristy’s social and academic functioning and understand the nature of the bullying at school and at home, mentioned but not closely examined today. This will also involve planning an assessment of Sam’s issues with a view to intervention.
Skimming the notes afterwards the doctor discovers that she has seen Kristy a year earlier with weekday morning headaches but no school absence. Factors that emerged at the time included the mother’s own history of anxiety and the fact that Kristy had been excluded from socialising with a particular group of girls in the playground. It is also evident that Kristy had not been presenting recurrently with unexplained physical symptoms – a red flag for social or emotional distress. So that was promising.
The risk of medicalising this presentation was avoided.
The consultation satisfies the important principle ‘to consider and address biomedical and psychosocial issues concurrently’.211
This is all done in just under 10 minutes.
Please refer to Appendix 7 for resources nationally and in your area.
National Safe Schools Framework
Bullying. No way!
Child and Adolescent Psychological and Educational Resources
Promoting relationships and eliminating violence network (PREVnet)
National Centre against Bullying
Kidsmatter: a nationally recognised resource for addressing the mental health of young people
Australian Medical Association (AMA) Guidance for Doctors on Childhood Bullying
Student Wellbeing and the Prevention of Violence (SWAPv), Flinders University Research Centre
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