CHAPTER 150

School-Related Violence and Bullying

Tracey Samko, MD, FAAP, and Catherine A. DeRidder, MD, FAAP

Violence is defined as an act of aggression that can be physical, sexual, or psychological. Its form, level of severity, and frequency are affected by biological, individual, clinical, intrapersonal, situational, and sociocultural factors. Categorization of violence is also dependent on the relationship of the perpetrator and the perpetrator’s target, as well as the age of each party. Intimate partner violence occurs among individuals in an established relationship; child abuse predominantly occurs between an adult and a minor; and bullying usually occurs between peers. School violence occurs at school, at school-related events, in transport to and from school, or on school property. From a developmental perspective, bullying may be the earliest form of violence instigated by children and can progress to intimate partner violence, criminal delinquency, suicide, or homicide in adolescence and adulthood. Although violence may be considered a social issue, it affects the physical and mental health of all involved. The primary care physician has unique opportunities to prevent violence and identify those potentially at risk.

Prevalence and Risk Factors

Suicide and homicide represent the most lethal forms of violence. Suicide and homicide are responsible for more than one-third of deaths among persons age 10 to 24 years in the United States. Approximately 3 million youths are at risk for suicide, with 37% of at-risk individuals attempting suicide (see Chapter 66), and these rates have been steadily increasing since 2005. In 2016, suicide was the second leading cause of death among both 10- to 14-year-olds and 15- to 24-year-olds. It is estimated that approximately 16 youths die each day in the United States from suicide. Homicide is also increasing among children and adolescents. According to the Centers for Disease Control and Prevention, homicide is the fourth leading cause of death for youths 10 to 14 years of age and the third leading cause of death for individuals 15 to 19 years of age in the United States.

In 2014, more than 500,000 individuals younger than 24 years were treated in emergency departments for injuries sustained because of violence. In 2017, nationwide surveys of high school students noted that 23.6% reported being in a physical fight 1 or more times in the 12 preceding months. Sixteen percent reported carrying a weapon, such as a gun, knife, or club, on 1 or more of the 30 days preceding the survey. Furthermore, 6.7% of students reported not going to school on 1 or more days in the 30 days preceding the survey because they felt unsafe at school or on their way to and from school. Bullying was found to be much more prevalent than concern about physical violence, with 19% reporting being bullied on school property and 14.9% reporting being bullied electronically. Although nearly 25% of youth have experienced bullying, only 20% to 30% of those youth ever report it to an adult.

A 2014 meta-analysis of 80 studies found a mean prevalence rate of 35% for traditional bullying and 15% for cyberbullying. Those who reported being a bully or being a target were more likely to carry weapons to school and to be involved in frequent fights. Bullying itself is most common in the middle school years. Boys and girls experience similar rates of bullying. Boys tend to participate in physical and verbal bullying, whereas girls use more verbal and relational bullying, such as rumors and social exclusion.

Risk factors associated with bullying are complex and involve the individual, family, peers, and community (Table 150.1). Children are at risk for being bullied or becoming a bully in situations of power imbalance. This includes physical differences, such as age, size, and strength; as well as popularity; demographic characteristics (eg, member of a majority racial or ethnic group or socioeconomic status); social skills; physical abilities; and access to money, information, or technology. Demonstrated individual risk factors associated with violent behavior include exposure to violence as a witness or target, childhood aggression, antisocial behavior, substance use, depressed mood, and hyperactivity. Community risk factors include high concentrations of poverty and low levels of community participation. Protective factors include academic achievement, parent-family connectedness, and engagement of families and teachers. Targets of bullying are more likely to be children who are considered different from their peers, such as those with obesity; with a developmental delay or learning disability; or who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ).

Abbreviation: LGBTQ, lesbian, gay, bisexual, transgender, questioning.

Adapted with permission from Waseem M, Ryan M, Foster CB, Peterson J. Assessment and management of bullied children in the emergency department. Pediatr Emerg Care. 2013;29(3):389–398.

Bullying and its Consequences

Bullying is defined as repeated acts of verbal or physical intimidation, coercion, and aggression. An imbalance of power exists, with the more powerful attacking the less powerful, whether because of physical size, social power, or access to money/information. Bullying occurs in an environment that supports the behavior. Participants include the bully, the target, and the bystander. The bully is often an aggressive individual who uses violence to dominate others. In contrast with common perception, bullies do not have poor self-esteem but rather have a strong desire to control others. The target may be more passive and anxious. This individual is often less secure than his, her, or their peers and may be lonely, playing alone at school. When the target is attacked by a bully, the target usually withdraws rather than retaliates. A minority of youth may be classified as a bully-target or a provocative target. These individuals are anxious and aggressive; although they are primarily targets of bullying, they may provoke the bully.

Different forms of bullying exist. Direct bullying includes physical or verbal bullying. Physical bullying can involve hitting or kicking, whereas verbal bullying can involve spreading rumors and social exclusion. Cyberbullying can include bullying via email, social networks, or texting. The bully who uses cyberbullying can remain anonymous and send aggressive messages to many people. Cyberbullying frequently occurs in a public forum in which it can be seen and/or shared both by acquaintances and strangers as well as become part of the public record, where it can be accessed in the future. Because the bullying occurs online, it may go unnoticed by authority figures, is frequently anonymous, and can be difficult to track.

Bullying predominantly occurs in unstructured school environments, such as during recess, at lunch, on the way to or from school, in hallways, or on the bus. Children often do not report bullying to adults for fear of retaliation by the bully and the concern of disbe-lief by the adult. Despite exposure to high-profile school mass trag-edies associated with bullying, many parents, teachers, and health professionals still believe bullying to be a normal behavior of children. Studies demonstrate that adults underestimate the prevalence of bullying events compared with student reports.

Bullying affects the physical and mental health of all involved. Fear and anxiety about the school environment is most common. Other clinical signs of bullying include bed-wetting, headaches, sleeping problems, abdominal pain, poor appetite, and feelings of tension or tiredness. This can progress to avoidance of school; academic problems, including lower academic achievement; and higher dropout rates. Of further concern, bullying can result in low self-esteem, depression, and suicide. Although a direct connection between childhood violence and adult outcomes has not been clearly established, temperament, social skills, biologic factors, timing (transient vs chronic), presence or absence of support by authority figures, and comorbid psychiatric conditions all likely play a role.

Six percent of adults in the United States report a lifetime history of bullying. In adulthood, higher rates of depression and poor self-esteem exist among individuals with a history of being bullied. Strong associations in adolescence and early adulthood have been made between bullying, suicide, and murder. The child who was targeted may react later in life with self-destructive acts or lethal retaliation.

Many of the recent killing sprees in the United States were committed by individuals who as children felt they were targeted. A review of 37 mass school shootings found more than two-thirds of perpetrators felt they had been persecuted, bullied, threatened, or attacked; often, they were acting out of revenge. Regardless of the scale, the rate of gun violence in the United States is higher than that of similar high-income countries.

A cohort study of 1,420 individuals age 9 to 26 years in western North Carolina found that targets of bullying had significantly higher likelihood of poor health, wealth, and social-relationship outcomes compared with children who were not bullied. Bullies who were not bullied themselves were not at increased risk for adverse outcomes as an adult when other environmental factors and childhood psychiatric disorders were controlled.

However, studies have found that boys who were bullies in middle school had at least 1 criminal conviction by age 24 years, and 35% to 40% had 3 or more convictions by age 24 years compared with 10% among a control group of boys who were not involved in bullying. Longitudinal studies report that bullies and bully-targets go on to more criminal activity than their counterparts. Those who are chronically bullied have worse outcomes than those who are bullied transiently. One study of Finnish boys reported 9% being bullies in childhood. These same individuals accounted for 33% of criminal activity in the study. Bullies were more likely to commit occasional infractions, whereas bully-targets were more likely to commit repeat offenses.

Bystanders are also affected, because bullying distracts from the learning environment. Furthermore, bystanders develop strategies to avoid being bullied themselves, including avoiding the restroom and staying home from school. One study reported that 1 in 5 secondary schoolchildren avoid restrooms out of fear at school. Another study stated that 7% of eighth graders stay home at least 1 day a month out of fear of other students.

Role of the Primary Care Physician

Assessment

Childhood bullying is a complex abusive behavior with demonstrated serious consequences. The physician is uniquely qualified to identify at-risk individuals, screen for psychiatric comorbidities associated with bullying, counsel families, and advocate for school-based interventions. Because bullies and targets commonly will not identify themselves as such, the physician needs a systematic approach to screen for this early form of violence. Integrating screening during anticipatory guidance may be optimal for toddlers and school-age children, whereas assessing risk factors at well- and acutecare visits may be necessary for adolescents.

Multiple instruments have been used in a research setting for identifying bullying or associated internalizing or externalizing symptoms, but they have not been widely implemented in the primary care setting. Screening younger patients requires conversations with the child and family members. The American Academy of Pediatrics developed Connected Kids: Safe, Strong, Secure, which can be integrated into Bright Futures for well-child care visits. This violence prevention program focuses on screening for risk, preventive education, and links to counseling and treatment resources. When talking directly with adolescents, the use of the psychosocial interview HEADSS (home, education and employment, activities, drugs, sexuality, and suicide/depression) may be useful in screening for high-risk behaviors and risk factors for violence (see Chapter 4).

When questioning a family about bullying, the physician must keep in mind that children often do not tell a parent that bullying occurred. When a parent is told about bullying, the parent may consider the situation to be normal behavior for young people and dismiss the event.

After bullying involvement is suspected, the physician can ask follow-up questions to further characterize the involvement and obtain more details (Box 150.1).

Prevention

Prevention efforts must be focused on the individual, family, and community. In early childhood, the parent can model for the child appropriate social interaction, how to resolve conflict, and how to manage frustration and anger. School-wide bullying prevention programs are effective and should be advocated. One example is the Olweus Bullying Prevention Program (www.violencepreventionworks.org), which focuses on caregivers and schools showing positive interest in students, setting firm limits for unacceptable behavior, using consistent nonphysical consequences when rules are broken, and acting as positive role models to ultimately change social and behavioral norms. For older children and adolescents, identifying psychiatric symptoms and providing the appropriate intervention may prevent more serious violent behavior. At the individual level, physicians and parents can counsel children who are bullies or targets about appropriate behaviors (Box 150.2).

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