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Children and young people - Chapter 10
In memory of Stephen Rigby
‘If I had been the clinician to write Stephen’s death certificate I would have added sibling bullying as a contributing cause’
This chapter outlines the adverse health effects associated with peer and sibling bullying, definitions, risk factors, and challenges in recognising and addressing bullying. It includes a brief approach to asking and advising about both peer and sibling bullying.
Bullying is defined as ‘any unwanted aggressive behaviour(s) by a peer or sibling that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated’.10
Bullying, either by a sibling36–40 or peer,5–9,15,18,41,42 often causes harm or distress in the child targeted, including physical, psychological or social harm.
Key elements that define bullying include:
Intention can be hard to establish, even in older children. The bully’s harmful intention and the victim’s perception of harmful intention are important when considering whether a peer interaction constitutes bullying.43
Bullying (both sibling and peer) can be:
Bullying categories include:
Four types of bullying are typical described: physical, verbal, relational, and damage to property.10,44–46
Sibling rivalry can be defined as: ‘competition between siblings for the love, affection, and attention of one or both parents or for recognition or gain’.48 It is common and can lead to ongoing conflict between siblings.49
The rivalry is two-way (ie both given and received). Distinguishing sibling rivalry from sibling bullying can be difficult. It can be categorised as sibling bullying if it:10,19,49
The severity, frequency, pervasiveness and chronicity of bullying varies partly with context, definitions of bullying2 and victim age. Estimates of prevalence of bullying vary depending on the types of bullying considered: victim only, bully only or bully–victim (ie someone who is both a bully and is bullied).
A 2019 meta-analysis found that the lifetime prevalence of ‘traditional’ (non-cyber) peer bullying among children and adolescents in the Australian setting is 25.1% for victimisation and 11.6% for bullying perpetration. The 12-month prevalence of bullying victimisation was 15.2% and bullying perpetration was 5.3%.1
Sibling bullying prevalence estimates vary from 15–50% for victimisation and 10–40% for perpetrating.2,10,50 Sibling bullying can start in toddlers (typically aged two to five years) and is common between the ages of six and nine years.51,52 Sibling bullying can involve two-way sibling bullying, with both parties being a bully and a victim.50,53
Table 10.1 provides information on risk factors for peer and sibling bullying
Aggressive behaviour in pre-school years strongly predicts later aggression and bullying.54,55 Environmental factors (including the nature and quality of parenting) play an important role in the persistence or remission of aggression/bullying through primary school and adolescence.55,56
Children and adolescent bully is a complex issue.57
In two recent longitudinal cohort studies, structural family-level characteristics (eg birth order, ethnicity, and number of siblings, being the firstborn and having older brothers) were found to be the strongest predictors of sibling bullying involvement. Bullying is more likely between siblings close in age, and even more likely between consecutive siblings. Child-level individual differences (eg emotional dysregulation and gender) were also important risk factors for sibling bullying.50,58
Parenting style (eg harsh parenting) has a variable impact on the likelihood of sibling bullying.50,58 although poor relationships with parents and harsh parenting behaviour predicted greater sibling aggression.59–61 In some studies, bullies commonly exhibit low levels of empathy62,63 and poor theory of mind skills64 (which refers to the ability to understand the desires, intentions and beliefs of others, and is a skill that develops between three and five years of age in typically developing children).
Table 10.1 Risk factors for peer and sibling bullying
Physical (eg overweight, disability, chronic illness)
Social (eg poorer social cognition, theory of mind)
Behavioural (eg externalising and disruptive behaviours(a) including aggression, learning disability)
Gender (eg LGBTQIA+)
Emotional dysregulation(b) (eg impulsivity)
Adverse childhood experiences(c)
Structural family characteristics (eg first born, having an older brother, having step-siblings)
36, 50, 81
10, 50, 61
Negative family dynamics (eg conflicting partnerships, arguing, hostile communication), interparental conflict
Parenting quality (eg harsh discipline or failure to discipline, lack of parental warmth, neglect, inter-parental hostility and abuse)
50, 58–60, 79, 86, 87
In Australia, it is estimated that more than 8% of annual mental health expenditure,18 7.8% of the burden of anxiety disorders and 10.8% of the burden of depressive disorders6 can be attributed to bullying victimisation.
Three UK longitudinal cohort studies have investigated sibling bullying and subsequent adverse health outcomes. 11,36–39,58,91
Experience of sibling bullying:
It is perhaps not surprising that the adverse consequences are significantly higher for children who are bullied both at home and at school; they have no safe haven.11 Likewise, adolescents involved in bullying perpetration in multiple contexts (home and school) have higher odds of engaging in antisocial behaviour, criminal involvement, and illicit drug use, compared with bullying in only one context.38
David never really talked with his GP about the bullying he was subjected to over his lifetime. His sister, Denise, who was a patient of mine, outlined most of the events after it became clear that David’s plight was having a major impact on her mental health. She felt powerless to change things for the better for David. I did see David on two occasions when he was persuaded by his sister to come along to see me.
David’s earliest memories were of being regularly punched, kicked and demeaned by his older brother and his father. He was beaten either with a leather belt buckle or a bamboo cane with nails attached by his father. David grew up with a sense that he was unworthy and deserving of his treatment. He had a strong feeling that nobody liked him and that he was unlovable.
His mother and older sister were intimidated daily by his father and David’s older brother, Mike; both David and Denise recalled that their mother never intervened on behalf of either David or his sister. David reported that the abuse and violence was both physical and emotional from a very early age. He never felt safe and lived in fear until he left home. Despite this, his older sister remembers David as a bright very funny boy with an acute sense of humour that made all around him laugh.
David initially did well in school until suddenly in grade four his school started reporting that he lacked attention, was easily distracted and his grades started to drop. David had a few friends but not a lot, being shy and a bit withdrawn with strangers. David told me he found it difficult to make friends easily. His sister felt he had limited skills at social interaction, was withdrawn and that he passively responded to bullying in the school yard as he did at home.
David said that his de facto partner (and the mother of his two boys) was demeaning of his behaviour and regularly verbally bullied him. David’s partner had numerous affairs, including with his best friend. David was separated from his partner in his 50s, when he was ‘kicked out’ of the house with only a few possessions (despite David paying the deposit for the house).
David had limited contact with his older sister when he grew up. He reconnected with his sister after his myocardial infarction in his 50s but had only intermittent contact; he allowed a relationship to flourish between her and his children, who would stay with his sister. David was estranged from his parents after the one time he had allowed his parents to see his children and his father abused the older child physically. David ended up being a bit of a loner. He said he ‘didn’t trust folk’. He felt he never was able to achieve anything academically but others saw him as a talented writer and he enjoyed painting, which provided great solace to him.
David had a history of heavy marijuana use and alcohol abuse starting in his 30s. He also became quite overweight at this time. The marijuana and alcohol use had largely stopped when he developed type 2 diabetes in his 40s although he was initially poorly adherent to lifestyle advice and taking medication.
In his 40s David became quite depressed and attempted suicide. He was admitted to a psychiatric inpatient unit for a number of weeks.
David had a large myocardial infarction in his early 50s. He ignored chest pain for six hours before attending the emergency department; he subsequently had a three-vessel coronary bypass artery bypass. In the subsequent six years he was fully adherent to treatment and medical advice. David moved around GPs and was an infrequent attender. He subsequently admitted to his older sister that he had never told any GPs about his bullying in the family. On Christmas day in 2014, his oldest son, then age 18 years, visited David’s home for a planned Christmas drink with his father that afternoon. His son found David slumped in a chair, dead. A subsequent coroner’s investigation found that David had died at least two days before Christmas day of an arrhythmia associated with a heart attack. There were no suspicious circumstances.
In the last contact with his sister in October, David stated that he was okay and he was happy for the first time in his life as he was pursuing his art, felt better without daily contact with anyone and he did not deserve anything better. Despite all that happened to David, he is remembered as having been a bright lad with an acute sense of humour that made all around him laugh. He was gentle, giving and generous throughout his life. If I had been the GP signing his death certificate, I would have added life-long bullying and abuse as a significant contributing factor. As a GP, I wish I had heard about David’s sibling bullying much earlier so that I could have tried to intervene. The sibling bullying compounded the issues associated with parental abuse within the family.
Whether earlier intervention would have made any difference is speculative but in more recent times, I make a point of asking children about bullying more routinely, both within and external to the family.
Table 10.2. Short- and long-term impacts of peer and sibling bullying
Most studies have not separated out sibling aggression/bullying from peer bullying
Repeated sore throats
Recurrent colds and breathing problems
Loneliness and isolation through a more limited ability to make friends
Increased likelihood of being bullied at school
10, 11, 61, 97, 98
Decline in school performance/functioning, absenteeism from school/ home, withdrawal/avoidance
Decline in school performance/functioning
(eg bedwetting, sleeping problems, abdominal pain, difficulty concentrating, dizziness, poor appetite, and feelings of tension or tiredness)
Mental health distress
Anxiety, depression, self-harm, increased suicide ideation and suicide
6, 8, 104, 105
Anxiety, depression, psychotic symptoms
36, 37, 39, 98, 106
Drug and alcohol problems
10, 37, 101, 103, 114
Aggressiveness and conduct problems(a)
Sibling bullying victims exhibit bullying behaviour at school
10, 116, 117
Perpetrating violence (eg dating, intimate partner abuse)
38, 49, 51
There are a number of reasons why GPs should be alert to bullying and respond to it.
GPs are a trusted and important source of information and support for helping children and young people tackle bullying, by both young people and their parents.32
Eighty-three per cent of children attend a GP at least once in each year: the average visit rate per head of population is 3.8 visits per year.120 Parents can attend primary care without the stigma that may be associated with attending welfare or mental health services. A number of studies have indicated that caregivers would like GPs to be more involved in identifying and supporting children and young people who disclose to being bullied.26,33
Any approach to address bullying should be exploratory with focus on the family, with extra effort to consolidate rapport with both the parents and the children.19 Parents may be sensitive to perceived criticism of their parenting skills and may respond defensively.33 This requires additional sensitivity in use of language and avoiding potential value judgements or blame.
Bullying has a consistent, strong and graded association with a many physical and psychological symptoms which are common presentations in general practice (refer to Table 10.2). Children bullied by their siblings are much more likely to be bullied in other settings (eg school).97
Sibling bullying is the most common form of family violence.10 Sibling bullying is widespread and experienced by a large proportion of children and adolescents.
A child who is bullied at home by siblings or abused by parents is more likely to be bullied or abused in other settings.37,54,121,122 Peer bullying is generally focused on by schools, meaning that bullying within the family is often in the remit of the GP and not either identified or addressed by the school.
Early recognition and intervention can reduce future harms associated with sibling bullying and bullying in other settings.
GPs need to consider bullying from a lifespan perspective. A child who bullies is learning to achieve dominance over others through the misuse of power.28 Children do not just ‘grow out of it’.123 Children who learn how to acquire power through aggression at home or on the playground often transfer these strategies to sexual harassment, dating violence, intimate partner abuse, workplace bullying and abuse, child abuse and abuse of older people.38,124–126
Early intervention provides an opportunity to ‘break the cycle’ and minimise the longer-term harms and associated costs. To use a banking metaphor, early intervention can turn around negative compounding associated with early bullying (either as victim or instigator) into a positive balance. The seriousness of the bullying behaviour can be gauged by the level of distress it causes the victimised child.15
GPs need to be careful to focus on the behaviour rather than the label. Labelling a child a bully can be both harmful and imply that the behaviour is fixed and cannot be changed. It also suggests that the person who bullies is the main problem, when other factors may be more important. Further information is available here.
Bullying has been added to the indicators of adverse childhood experience. The Centre of Research Excellence in Childhood Adversity and Mental Health has highlighted a number of anti-bullying interventions that can be offered by a range of groups and service providers to offset the harms associated with adverse childhood experience, although most of the focus has concentrated on school-based anti-bullying programs.90
Given that fighting or repeated conflict among siblings is one of the most common issues that parents express concerns about their children, it is worth trying to understand such behaviour at a deeper level.
There are a number of reasons why siblings may engage in conflictual exchanges, including resources such as competing for parental attention, affection, love, and other material gains.127 Children are often expected to share lots of things, but that does not make it an easy task to do and they therefore may revert to arguing or fighting, both to express themselves or to compete for resources to get their own way. The ‘forced’ contact of siblings in an intense, complex long-term relationship before sufficient social competence has developed can compound the tension in the relationship. As Dunn summarises: ‘The emotional intensity, and the intimacy of the relationship, the familiarity of children with each other, and the significance of sharing parents mean that the relationship has considerable potential for affecting children’s well-being’.128
Some have suggested that there are many potential positives that can emerge from sibling conflictual exchanges such as an increase in children’s social and emotional competence, the development of self and identity formation, and a more robust sibling relationship quality, and the subsequent parenting of one’s own children.129 Others have highlighted that sibling aggression/conflict and bullying can have a significant long-term detrimental impact on health.36,38–40,130
Most would agree that siblings need to learn to be able to effectively manage conflict in relationships.129,131,132 The challenge is for siblings to learn:
If children think they are not being treated fairly (or equally) by their parents then they may act out their frustrations on their sibling.138 That fact that sibling dyads are hierarchical in nature, unless they are twins, with age difference and order of appearance in the family dictates a formal rank ordering. This often means that older siblings are considered to be physically, socially and cognitively advantaged over their younger siblings. As younger siblings become more equally matched in these capacities with their older siblings, with age and development, then it is likely that interactions will become more equal139 although this may not occur if one sibling establishes dominance over the other.140
While ‘normal’ sibling conflict usually consists of a mutual disagreement over the various resources in the family (eg parental attention), sibling abuse or maltreatment consists of one sibling taking on the role of a persistent aggressor in relation to another sibling.19
While sibling bullying can occur in all families, there is an increased risk for both peer and sibling bullying/abuse50,58,79,116,141 when the family structure and processes support power imbalances,50,58 rigid gender roles, differential treatment of siblings,138,142–145 and lack of parental supervision.146 Inquiry about sibling bullying may be difficult in these contexts. Parents may be embarrassed by asking about sibling bullying. They may also minimise or even dismiss any likelihood of it occurring in their family. All of these factors can contribute to a general lack of awareness of aggression or bullying between siblings.147
Parental neglect is insinuated when the sibling abusive relationship is undetected or unaddressed.14 At the same time, a GP asking about sibling bullying as an issue may help to heighten the parents’ awareness of their children’s behaviour to consider behaviours that may go beyond sibling rivalry.148
Without familial or external validation, most cases of sibling bullying do not come to the attention of healthcare practitioners.14 Many parents clearly uphold different norms of acceptability regarding conflict management and resolution and aggressive behaviour in sibling compared with peer or other kinds of relationships.132
For example, in the scenarios in Box 10.1, the parental reaction to similar behaviour is quite different – the behaviour is acceptable between siblings, but not between one of their children and another child. However, the adverse impact of such behaviour in both settings is very similar, as discussed earlier in this chapter.
Shane, aged eight years, is playing in the school playground. An older boy, Bruce, approaches him from behind and deliberately trips him up while they are playing soccer. Shane, who didn’t have the ball at the time, falls awkwardly and hurts his wrist. He goes to the nursing station at the school. The nurse looks at his wrist and puts on a bandage. She then calls his parents, who are incensed that this could happen and demand to see the school principal to get something done.
Shane, aged eight years, is playing soccer in his backyard with his older brother. Bruce approaches him from behind and deliberately trips him up in a tackle when Shane doesn’t have the ball. Shane falls awkwardly and hurts his wrist. He goes inside to tell his mother what happened and after examining his wrist and putting a bandage on it, tells him off, indicating that he should get on with his brother better and ‘boys will be boys’.
Siblings often engage in ‘rough and tumble’ type activities, and sibling bullying behaviours can be regarded as a normal part of learning to manage conflict or rivalry. Some even see it as a rite of passage.22 However, although such activities may be seen as a part of growing up and learning to manage conflict and relationships,129 parents often express considerable concern about these aggressive behaviours and wonder how to intervene in order to foster more positive relationships between their children.149
Parents often have difficulty identifying or managing aggressive behaviour, especially when there is a clear dominance in the sibling relationship.55 The situation can be confusing for parents because the individual with less power also acts aggressively towards the more powerful sibling.150
Sibling bullying is accepted as normal among most sibling pairs.151 This a further extension of the normalisation process that occurs with aggression between siblings.
Victims of bullying often do not identify their experience (sibling bullying) as a form of abuse or violence, even when it is repeated, further downplaying its impact.152 One consequence of this is that up to 50% of children say they would rarely, or never, tell their parents, while between 35% and 60% would not tell their teacher.122 Children are even less likely to disclose to parents:
Parental behaviour further complicates the situation when there is a taboo surrounding sibling bullying.153 This norm of acceptance compounds other factors that contribute to disclosing bullying.
Young people are often reluctant to disclose that they are being bullied, either at home or at school, because they are ashamed, think it is their fault, may fear retaliation, or regard disclosure as ‘dobbing’.154 Ironically, many victims of bullying don’t see themselves as a victim. Without a greater societal recognition of both sibling and peer bullying, victims are prone to perceive and accept their experience as normative.155
Primary bullying prevention programs are generally population-based and engage the community. These may include home visits from a nurse156–158 and/or provision of parenting information, education and training.32,159–161 (Note: Most of the home visit programs had a general focus on parenting and aiming to reduce child abuse. Addressing bullying is often a very minor component.)
Parenting programs tend to have a broad focus, with sibling aggression/bullying rarely being a significant component. Furthermore, while behavioural parenting interventions can enhance positive parenting practice, there is very limited evidence that there is much improvement in child behaviour outcomes when such programs are delivered in the primary care setting.32,159–163
Many health professional groups recommend that GPs screen for bullying in children directly25,29,164 or as part of identifying child abuse/maltreatment,165 although others have found insufficient evidence for GPs or other primary care professionals to screen for child abuse.166,167 (Note: In the Australian Government Department of Health Action plan for the health of children, while bullying is acknowledged as a significant health issue for children and that an important action was ‘work with partners to identify and promote effective anti-bullying strategies’, healthcare workers receive little mention’.121,168)
Some studies have suggested that bullying/abuse/violence among siblings may be a better predictor of later adult violence than observing violence between parents.169
Brief and early interventions programs can be either general (ie focus on parenting skills) or specific and target families with specific risk factors for bullying (both peer and sibling). If counselling is anticipated, then it is important to be aware that abusive siblings are infrequently challenged or confronted by parents.170
Indicators for when to ask about bullying are shown in Box 10.2. A brief intervention for bullying might then be as follows:
Given the prevalence of bullying, it is reasonable to ask most children whether they are being bullied. A number of factors may indicate that a child is being bullied.
Suggested questions to help this process are shown in Table 10.3.
Table 10.3. Sample questions to ask children about bullying
‘I’d like to ask you some questions about what school is like.’
‘I’d like to ask you some questions about life at home with your brother(s) and/or sister(s).’
If child answers in affirmative or says ‘sometimes’, ask follow-up questions to gather information about frequency, types of bullying, severity, how long has it been occurring and the impact:
If child answers in the affirmative or sometimes, ask questions to gather additional information such as:
Questions for children suspected (or identified) of bullying behaviour
Identify the type of sibling bullying and the extent of involvement: bully only, victim only and bully–victim, and ask about the child’s social skills. Social skills relates to a child’s ability to get along with family, peers and other adults, and a child’s knowledge of what is expected in social interactions. It includes abilities like making eye contact, listening and taking turns, and recognising emotions in themselves and in others.122
Parent of victim of bullying
Parent of a child who is bullying
If there is a pattern of repeated aggressive behaviour by the child towards their siblings or other children, then consider the following questions. It may be helpful to support the parent to put themselves in the younger child’s shoes. Parents may react strongly to any questions that imply judgement or labelling. The aim is to get more information and insight into what is happening to try and help the child and the parents.
The following questions may generate a negative reaction. It is worth making it clear you do not know the answer to the questions and it will help you to understand if the following are issues that need to be considered.
Many parents are concerned and frustrated about how often their children argue, tease each other or even fight.
A number of professional groups have highlighted a range of strategies that healthcare professionals can offer24,26,27,29,31,35,154,178–180 that can be effective in helping to address bullying. Bullying and aggression are behaviours learned through the observation, role modelling and reinforcement of aggression (eg where such behaviour enables the child to get their own way).57 Similarly, the abusive sibling will have learned that there is a payoff for the bullying behaviour.19 These learned behaviours can be ‘unlearned’ and replaced with more effective strategies to deal with conflict.57,127,132
Target those who bully and those who are victims of bullying.
For the bully:
For the victim:
Parenting interventions for youth mental, emotional and behavioural disorders have not been sufficiently tested to be adopted and sustained in primary care.161 However, a range of parenting behaviours can help to ameliorate aggression/bullying in children.
Promoting greater parental awareness
It may help to promote parental awareness of whether the child is being bullied, either at home14 or in other settings (eg online200 and at school20,154). Understanding why children do not report bullying to their parents is required.12,14 Older children might be fearful of the consequences of disclosing bullying to an adult. They may:
Children are more likely to have positive experiences when they are believed and emotionally or practically supported by the adult.12,14
Help parents to take any bullying seriously
Parents can highlight to the sibling bully that their behaviour is not acceptable and has consequences. This can include withdrawal of privileges, additional ‘tasks’ or time out.
Provide strategies parents can use to help children learn to deal with conflict, for example, IDEAL:
Encourage and assist
Encourage parents to:
Highlight to parents:
For the bully: Interventions to stop the aggression/bullying, promote empathy and prosocial skills and reduce peer pressure to engage in these activities include teaching the child about emotional regulation,137,181–184 conflict management132,156,185,186 and mediating techniques.132,186
For the victim of bullying: Provide support for the child to develop assertive strategies and friendship skills.32,66, 80,132,156,160,161,163,185,187−199
Identifying and managing comorbid emotional and developmental disorders in the aggressive/bullying child are essential.55
Work with the parents to development a plan of action for peer bullying at school.28,30,31,154,178,180
Stephen (aged 10 years) and John (aged 7 years) were brothers. Stephen was a lot bigger and stronger than John. They would come to stay with their aunt Kate and uncle Charlie in Melbourne.
In the last few visits, John seemed a bit withdrawn, hard to engage and appeared to be distressed a lot of the time. The behaviour seemed out of character. John’s father had mentioned that John had truanted from school a few times in the last 12 months and that his grades had declined in the last six months. John’s dad wasn’t sure whether John was being bullied at school as John had denied any bullying.
One day the boys were building card houses. Whenever Kate left the room, John’s card house collapsed with a complaint and tears from John that Stephen had nudged the carpet.
Kate began paying closer attention. The final straw was when Stephen did a judo manoeuvre on John and John fell awkwardly to the floor. Stephen hadn’t noticed that Kate had seen the incident through the doorway.
Kate and Charlie did not have their own children and were hesitant about speaking about the behaviour with John and Stephen’s parents (who had recently separated).
Kate spoke with her GP when she was seeing them for a blood pressure review. The GP told Kate that this behaviour indicated that John was being bullied by Stephen. The GP explained that bullying was unacceptable, but it could be managed. The GP suggested that they implement a reward system (points) for treats that both boys would enjoy together. The GP also suggested that the behaviour that they wanted to extinguish (eg the niggling or unnecessary rough play) would be penalised by withdrawal of points. Kate asked the boys what special treat they would like.
They both agreed on doing a quad bike ride. Kate and Charlie set a target number of points needed and made it clear to both boys that points would be deducted for any evidence of niggling or uncooperative behaviour.
Kate felt that over the following two weeks of the boys’ stay that there seemed to be less aggravating behaviour.
The boys, now in their teens, get on quite well. Much of the niggling stopped completely after John had a growth spurt and ended up being taller and stronger than Stephen. John did say recently that he had been bullied at school but when he grew a lot taller, that stopped. In his mid-teens, John told Kate that he had appreciated her intervention and that it had given him confidence. Kate told her GP how things had ended up and also her appreciation for the advice. Kate reflected that John might have been in a situation where he had no safe place.
Where there is evidence of abuse or long-term sibling bullying:
Make the practice more accessible and friendly to young people.206–209 Strategies include:
Given that bullying occurs in multiple settings (eg internet, families, schools and workplaces), the need for a public health approach will be important and likely more effective and efficient.210–212
Prevalence and impact
Myths about bullying
For patients and parents/carers/teachers
A resource from the Royal Children’s Hospital
who, where, recent changes (moves or new people), relationships, stress or violence, smartphone or computer use (in home versus room)
Education and employment:
where, year, attendance, performance, relationships and bullying, supports, recent moves, disciplinary actions, future plans, work details
Eating and exercise:
weight and body shape (and relationship to these), recent changes, eating habits and dieting, exercise and menstrual history
extra-curricular activities for fun: sport, organised groups, clubs, parties, TV/computer use (how much screen time and what for)
Drugs and alcohol:
cigarettes, alcohol and illicit drug use by friends, family and patient. Frequency, intensity, patterns of use, payment for, regrets and negative consequences
Sexuality and gender:
gender identity, romantic relationships, sexuality and sexual experiences, uncomfortable situations/sexual abuse, previous pregnancies and risk of pregnancy, contraception and STIs
Suicide, depression and self-harm:
presence and frequency of feeling stressed, sad, down, ‘bored’, trouble sleeping, online bullying, current feelings (eg on scale of 1 to 10), thoughts or actions of self-harm/ hurting others, suicide risk: thoughts, attempts, plans, means and hopes for future
serious injuries, online safety (eg meeting people from online), riding with intoxicated driver, exposure to violence (school and community), if high risk – carrying weapons, criminal behaviours, justice system
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