Sibling and peer bullying

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.

Definitions

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 sibling^36–40 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:

• an unwanted, aggressive attack or intimidation tactic that is intended to cause fear, distress or harm to the victim
• an imbalance of power between the bully and victim
• repetitive occurrences of the behaviours.

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:

• direct (physical or verbal)
• indirect (relational/social, social exclusion, spreading rumours, psychological/stalking).

Bullying categories include:

• bully (instigator)
• victim (recipient)
• both bully and victim.

Four types of bullying are typical described: physical, verbal, relational, and damage to property.^10,44–46

• Relational bullying/aggression refers to deliberate social exclusion of children, such as ignoring, excluding them from games or parties, spreading gossip or humiliation.
• Relational aggression seeks to damage the relationships and social reputation of the victim.⁴⁷
• Cyberbullying is performed via electronic or digital means. Repetition is not a prerequisite for the behaviour to count as bullying, as a post on social media can potentially be seen by many individuals. Cyberbullying is discussed in more depth in Chapter 12: Dating violence and technology-facilitated abuse.

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

Examples include:

• verbal or physical fighting
• name-calling, teasing, squabbling or arguing among themselves
• telling tales and bickering

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

• becomes more one-sided
• is part of an escalating and repeating pattern of sibling aggression
• is associated with undesirable or harmful effects.

Prevalence

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

Risk factors and predictors

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 empathy^62,63 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).

1. ‘Disruptive behaviour in children’ refers to behaviours that occur when a child has difficulty controlling their actions. Examples of disruptive behaviours include temper tantrums, interrupting others, impulsiveness with little regard for safety or consequences, aggressiveness, or other socially inappropriate acts. Further information is available at Disruptive behaviours in children: What parents should know.
2. ‘Emotion regulation’ refers to the dynamic interaction of multiple behavioural, psychophysiological, attentional and affective systems that allow young children to participate effectively in their social world.⁸⁸ The definition of ‘emotional dysregulation’ includes five overlapping not mutually exclusive dimensions – decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity, and cognitive reappraisal difficulty.⁸⁹
3. Adverse childhood experiences include physical, emotional and sexual abuse or neglect, bullying, parent mental health problems, harsh parenting, parent substance abuse and housing problems.⁹⁰

Burden of morbidity

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:

• increased the risk of involvement in bullying in school. A clear dose–effect relationship of involvement of bullying at home and at school and behavioural or emotional problems was demonstrated in a review of sibling bullying studies.⁹² Those involved in both settings were at significantly increased risk of behavioural or emotional problems compared to those involved in only one setting or not at all
• increased the risk of subsequent behaviour problems
• increased the risk of subsequent mental health disorders.^11,91 Children who were frequently bullied by their siblings were approximately twice as likely to have depression, self-harm and have anxiety compared to children who were not bullied by siblings.³⁶

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

Names have been changed in this case study, which was written by the GP who first learned about David’s case from a patient, David’s sister Denise.

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.

Postscript

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.

There are a number of reasons why GPs should be alert to bullying and respond to it.

Opportunity in a ‘neutral’ environment

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.

The burden of morbidity

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.

The cumulative impact of poly-victimisation

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

Understanding sibling bullying

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:

• how to do this fairly^133,134
• empathy, respect and seeing things from another person's point of view^62,135,133
• about how to negotiate and compromise^133,134
• through reflection and practice to working it out themselves,¹³³ eg what worked and what didn’t work?
• problem-solving skills (further information available at Ages & stages: How children learn to solve problems)^136,137
• strategies that avoid any persistent harms.

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

Quality and style of parenting influences the likelihood of sibling bullying and abuse

While sibling bullying can occur in all families, there is an increased risk for both peer and sibling bullying/abuse^{50,58,79,116,141} 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

Challenges for identifying and managing sibling bullying

Lack of awareness and recognition of sibling bullying

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.

Normalisation of sibling bullying by parents

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

Normalisation of sibling bullying among children

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:

• who are either harsh in their parenting^59,61
• whose own behaviour role models aggressive or bullying behaviour^10,50
• who are over-protective.¹⁴⁶

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 prevention

Primary bullying prevention programs are generally population-based and engage the community. These may include home visits from a nurse^156–158 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 directly^25,29,164 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

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:

Ask

• Request permission to ask about bullying.
• Have a high index of suspicion if a child presents with a psychosomatic problem.

Assess

• Assess nature, extent and severity of the bullying.
• Inquire about what the victim and parents have done to address the bullying.
• Explore parent’s perceptions of discipline and managing sibling rivalry or aggression.

Advise

• Highlight possible short- and long-term impact.
• Stress the importance of parental awareness, surveillance and support as well as parents modelling effective strategies to deal with conflict and aggression.
• Provide websites that can provide parent education, parenting programs, support and strategies to promote child–parent relationships and child resilience (refer to Resources).
• Offer to speak with or contact the school principal if peer bullying.

Asking about bullying

• Open the lines of communication around bullying and signal that you are prepared to discuss it. Stress the importance of parental awareness, surveillance and support as well as parents modelling effective strategies to deal with conflict and aggression.
• With adolescents, use the HEEADSSS assessment,^171–175 in which the patient is asked about home life, education/employment, eating habits, activities, drug and alcohol use, sexuality, personal safety and suicidal ideation/depression (refer to Appendix 1).
• With young children, it is always useful to attempt to talk to the child alone; however, it will usually be difficult to talk to them without the parents being present. Most parents will defend the aggressive child, or minimise their behaviour. Some believe that the victim of the bullying must have done something to deserve it.¹⁷⁶
• For very young children, the GP may need to rely more on their own and parental observations.

Suggested questions to help this process are shown in Table 10.3.

Questions for children suspected (or identified) of bullying behaviour

• ‘Have you been involved in bullying others at school, in sports or in your neighbourhood?’
• If yes, continue with the following questions:
• ‘How long have you been bullying?’
• ‘How often do you bully?’
• ‘Are you involved in bullying just at school or in other places, such as at home, on a sports team or at a community centre?’
• ‘Can you tell me about the types of bullying that you have used? How do the kids you bully feel?’
• ‘Have any adults talked with you to help you stop bullying?’

Questions for parents

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

• ‘Are you concerned that your child is having problems with other children at school?’
• ‘Has your child’s teacher ever mentioned that your child is often by themselves at school?’
• ‘Does your child visit the school nurse frequently or have they come home with unexplained injuries?’
• ‘Has your child ever said that other children were bothering him or her?’
• ‘Do you suspect that your child is being harassed or bullied at school for any reason? If so, why?’

Parent of a child who is bullying

• ‘How does your child get along with other children/their siblings?’
• ‘When conflict arises, how does your child typically approach it? Do you think your child is a bully?’

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.

• ‘What do think is going on in your child? I wonder if you think it is affecting them emotionally?’
• ‘Do you have any ideas of what may be contributing to your child’s behaviour?’
• ‘It can be hard to children to change their behaviour. What have you done to try and deal with or address this behaviour?’

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.

• ‘Do think your child is mean or cruel to other children?’
• ‘Do you think your child is trustworthy?’
• ‘Do you think your child is manipulative?’
• ‘Do you believe that your child lacks guilt?’

Sibling bullying

Many parents are concerned and frustrated about how often their children argue, tease each other or even fight.

• ‘Is this an issue for you?’
• ‘Can you tell me what happens?’
• ‘Do you have any ideas about why they fight or argue?’
• ‘What strategies, if any, do you use to stop this behaviour?’
• ‘How well do your children get on with each other?’
• ‘Do you think that there is a lot of teasing and pushing/shoving that occurs between them?’
• ‘Do you think that this goes both ways (like sibling rivalry) or is it more one-sided?’
• ‘Do you have any concerns that one child may be more often on the receiving end?’

Interventions and strategies to manage bullying

A number of professional groups have highlighted a range of strategies that healthcare professionals can offer^{24,26,27,29,31,35,154,178–180} 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

Interventions targeted to children

Target those who bully and those who are victims of bullying.

For the bully:

• Use interventions to stop the aggression/bullying, promote empathy and prosocial skills and reduce peer pressure to engage in bullying. These include: teaching the child about emotional regulation,^{137,181–184} conflict management^{132,156,185,186} and mediating techniques.^132,186
• Identify and managing comorbid emotional and developmental disorders in the bullying child.⁵⁵

For the victim:

• Highlight to the child and the parents that any form of bullying is unacceptable.³¹
• Provide support for the child to develop assertive strategies and friendship skills.^{32,66,80,132,156,160,161,163,185,187–199}
• Work with the parents to develop a plan of action for peer bullying at school.^{28,30,31,154,178,180}
• Parents should meet with the school counsellor/teacher or principal to discuss the bullying.
• Clarify with the school:
• how this matter will be investigated
• how long the investigation will take
• when a follow-up meeting can be arranged to discuss how the situation will be addressed/resolved.

Interventions targeted to parents

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 school^20,154). 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:

• fear they will not be believed or taken seriously
• fear they will be made a scapegoat (either in the family or at school)²⁰¹
• feel ashamed of being a victim (ie it is actually their problem or they should have been able to deal with it)
• feel inadequate or like it is their fault
• believe it is normal or that nothing will be done anyway.

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:

• Identify: learn to identify the problem
• Determine: possible solutions getting the child involved in this identification
• Evaluate: look at the pros and cons of possible solutions
• Act: choose the best solution
• Learn: what worked, what didn’t work, what would you do next time?

Encourage and assist

Encourage parents to:

• Avoid ‘negative’ labels that become truisms (eg the child is labelled a ‘whiner’ by their parents). The child labelled in this way will often then feel bad about themselves. The siblings will pick up on the label and repeat it. The label is often hard to shake off.
• Be careful when making comparisons between children. Children are very sensitive to any perception of favouritism^138,202 and dislike being compared to a sibling who is seen as the ‘standard’. For example, avoid saying things like, ‘Why don’t you try as hard as your older brother?’
• Praise cooperative behaviour between siblings when parents observe it. It helps to reward such behaviour.
• Develop, with assistance, skills that promote positive parent–child interactions (eg demonstrating enthusiasm, following child’s interests, offering appropriate recreational options, providing positive attention^160,161,190 and improving communication with their children¹⁹⁰). These can be effectively achieved by both face-to-face and online participation.¹⁹⁸ Quality time with their children can give the child a ‘boost’ and also gives the parent a good opportunity to better understand their child (eg what they like, how they deal with issues).
• Become involved in school-based anti-bullying programs, as such involvement has a significant impact on reducing bullying perpetration and victimisation.²⁰³

Highlight to parents:

• the need to believe the child if the child tells you they are being bullied
• how to recognise the physical and psychological symptoms associated with both being the victim or instigator of the bullying
• the importance of ensuring the child has a trusted adult to turn to if bullying occurs, who will take positive and appropriate action and believes them.

Further assistance

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 management^{132,156,185,186} 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}

• Parents should meet with the school counsellor/teacher or principal to discuss the bullying.
• Clarify with the school:
  • How will this matter be investigated?
  • How long will this investigation take?
  • When can they have a follow-up meeting to discuss how the situation will be addressed/resolved?

Names have been changed in this case study.

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.

Postscript

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:

• Recommend parenting programs that have good evidence of effectiveness in a range of parenting skills, including bullying.^{162,185,198,204,205}
• Refer to local services (eg psychologists, family therapists) and connect children and their parents with available community resources (refer to Resources).

Interventions for the general practice

Make the practice more accessible and friendly to young people.^206–209 Strategies include:

• accessibility
• appointment flexibility
• staff attitude (ie child and youth friendly – someone who treats them ‘like a friend’ and is interested in non-medical aspects of their lives)
• communication that is direct and includes clear technical information but without lecturing
• age-appropriate environment
• confidentiality – assure these groups it is safe to talk with their GP
• involvement in healthcare – young people stress their need to be involved in their healthcare.

Strategies for the wider setting

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

General

• National Centre against Bullying  – provides useful resources and tips for health professionals, parents and young people.
• No way! 
• Australian Childcare Alliance: Be You (previously KidsMatter) –  the Australian Government’s renewed and expanded investment in children’s mental health and wellbeing, covering the early years through school and up to the age of 18.
• Child  and   Adolescent  Psychological  and  Educational  Resources 
• Blue Knot – a support organisation for people who have experienced childhood trauma or abuse, for their families and close friends, and for professionals who would like to learn how to more effectively work with these people.
• Emerging Minds – develops mental health policy, services, interventions, training, programs and resources in response to the needs of professionals, children and their families.

Prevalence and impact

• Australia’s Children – a 2020 report from the Australian Institute of Health and Welfare.

Myths about bullying

• National Centre against Bullying 
• Myths about Bullying 

Cyberbullying

• eSafety Commissioner – has good information and resources on how to keep children safe when they are online.
• Australian Federal Police Child Protection – is involved in many prevention and awareness raising initiatives, particularly in relation to keeping young people safe online.

Outside Australia

• Stop Bullying (United States)
• Child Mind Institute (United States)
• Promoting relationships and eliminating violence network (PREVNet) (Canada)
• Bullying tip sheet from family physicians and primary care
• Anti-Bullying Alliance (United Kingdom) 
• How to talk to your children about bullying: Tips for parents (UNICEF) 

For GPs

• HEADSS: Psychosocial interview for adolescents 
• Australian Medical Association Guidance for Doctors on Childhood Bullying 
• Anti-Bullying Alliance advice for GPs (United Kingdom)
• Generation Next – education, seminars and resources for health professionals, parents and teachers about the prevention and management of mental illness in children and youth.
• Building resilience in children aged 0–12: A practice guide  – from Beyond Blue, 2017.
• e-Mental health in practice – provides a range of resources including brochures, factsheets, videos, webinars and modules.

For parents

• Australian Institute for Family Studies, Child Family Community Australia – an information hub for evidence, resources and support for professionals working in the child, family and community welfare sector. It provides a summary of many of the parenting programs on offer to address children’s behaviour problems.
• Parenting Research Centre – helps children and families thrive by driving improved ways of supporting parenting by helping governments and community agencies to put best-practice parenting support into action. They have also developed a tool kit for health workers and other professionals 
• Triple P: Positive Parenting Program 
• Incredible Years 

For patients and parents/carers/teachers

• Kids Helpline – phone or online support for kids from age five years.
• Reach Out – information on mental health and wellbeing resources and services, as well as bullying and friendship issues and their impact on young people’s mental health and wellbeing.
• Disruptive behaviour in children: What parents should know – a NSW Government resource.
• Helping your child stop bullying: A guide for parent – from the Australian Institute of Family Studies.
• Teasing versus bullying tip sheet – from PREVNet.

Other resources

• Dr Deborah Temkin talks about bullying in childhood with a focus on peer bullying: identification, context and strategies to manage 
• Strategies to manage sibling bullying
• Distinguishing sibling rivalry from sibling bullying
• What can be done to manage sibling rivalry