Bullying: Information and Interventions for the Primary Care Provider

Alexandra Hayley Quinn, PsyD Swedish Medical Group What is Bullying? The use of physical or emotional power to control or harm others

Repetitive Power Imbalance

Intentional

Bullying Stopbullying.gov Language has Power • When children are labeled as "bullies" or "victims" it may: • Send the message that the child's behavior cannot change • Fail to recognize the multiple roles children might play in different bullying situations • Disregard other factors contributing to the behavior such as peer influence or school climate • Instead of labeling the children involved, focus on the behavior.

How Prevalent is Bullying?

0 Elementary School Middle School High School

% of kids reporting victimization in past 12 months 12 past in victimization reporting % of kids Jansen et al., 2012, The National Bullying Prevention Center, 2018; CDC, 2019 Types of Bullying and Common Bullying Behaviors

Verbal Teasing Name Bullying Calling

Physical Spitting, Harm or Physical Tripping, Threats Bullying of Harm etc

Taking/ Excluding & Damaging Alienating Personal Property

Creating Relational Embarrassing Spreading Aggression Situations Rumors

Stopbullying.gov; Bradshaw, et al. (2017) Bullying Trends by Age Group & Type Cyberbullying: A Deep Dive • Rarely occurs in isolation • Pervasive and Persistent • Difficult to remove • Occurs 24/7 • Wider audience • Spreads more rapidly • Perception of anonymity • Higher prevalence among girls and peaks later than “traditional” forms of bullying

Zuckerman (2016) Cyberbullying Continued

Type Description Harassment Repetitive, offensive messages sent to a target Outing and trickery Discovering personal information about someone and then electronically sharing that information without the individual’s permission Exclusion Blocking an individual from electronic groups/chats Impersonation Pretending to be the victim and electronically communicating negatively or inappropriately with other as if the information is coming from the victim Cyberstalking Talking someone by sending repeated threatening messages Sexting Sending nude/inappropriate photos of another person without that individual’s consent Flaming Posting aggressive insults directed at the target Kowalki et al. (2014) What is the Difference?

Intimate Partner Hazing Harassment Stalking Teasing Meanness Violence

Violence or Unwelcome Repeated Use of Comments that Behaviors that threats of conduct based on harassing or embarrassing and are intended to are meant to violence that a protected class threatening often dangerous be playful, funny, upset or hurt the occur between that is severe, behavior such as or illegal activities or to get feelings of two young pervasive, or following a by a group to attention in some another person people who are, persistent and person, damaging initiate new way; perceived as that occurs one or once were, in a creates a hostile a person’s members. benign or hurtful or two times. relationship. environment. property

Stopbullying.gov Risk Factors for Being Bullied

Ethnic minority Physical Obesity or Different Chronic illness or immigrant disability Underweight appearance status

Behavioral Learning Foster Poor family Problems & Poor Poverty disability care/group home functioning Self-Esteem

Familial Parental Lack of close Internalizing Exposure to interpersonal substance use or relationships Problems & Poor trauma Self-Esteem violence MH problems

McClowry et al. (2017), National Bullying Prevention Center (2017) Outcomes of Being Bullied

• Less adherence with treatment plans • Poor management of chronic conditions • Stress • Depression, anxiety, suicidal ideation • Involvement in crime • Substance use • Somatic complaints • Increased absenteeism • Insomnia • Reduced investment in academics • Young adults who were victimized as children have higher rates of: • Agoraphobia • Depression • Anxiety • Panic disorder • Suicidal ideation McClowry et al. (2017), National Bullying Prevention Center (2017) Horner, G. (2018), Stopbullying.gov Local Data: Bully Victimization x Psychological Adjustment Signs and Symptoms of Being Bullied

• School avoidance • Somatic complaints • Sudden non-compliance or poor management of health conditions • Changes in appetite/eating • Emotional lability or behavioral outbursts • Increased or emergence of substance use • Suicidal ideation • Depression and/or anxiety

Eisenberg & Aalsma (2005) Risk Factors for Children who Bully

• Two subtypes of children who Bully: • Well-connected to their peers, have social power, are overly concerned about their popularity, and like to dominate or be in charge of others. • Isolated from their peers and may be depressed or anxious, have low self esteem, be less involved in school, be easily pressured by peers, or not identify with the emotions or feelings of others. • Risk Factors: • Witnessing or experiencing abuse • Permissive parenting style • Seeing or experiencing bullying by siblings • High need for power/Challenging authority • High levels of Intolerance or general negative view of others • Difficulty following rules • Have a positive view of violence • Have friends who are Bullies

Espelage & Swearer (2003), Stopbullying.gov Children who Bully and Associated Problems

Dropping out of More likely to carry Increased substance Earlier sexual school/academic a weapon on and off use* activity failure* campus*

Depression, anxiety, More fights & Intimate partner Criminal convictions and increased fighting related violence or child as an adult* suicidal injuries* abuse ideations/attempts*

*Also true for kids who are bullied and Low self-esteem* Bully-victims

Juvonen & Graham 2014), Nansel et al., (2003), & Zuckerman (2016) Risk Factors for being a Bully-Victim

• All of the risk factors for being bullied and bullying others • Emotional dysregulation • Hyperactivity • Low social competence • Poor problem-solving skills • Poor self-esteem • Negative perceptions about others • Peer rejection and isolation • Negative influences from those peers with whom the child interacts • Disconnectedness from school

Espelage & Swearer (2003) Bullying and Suicide

• Suicidal ideation is more common among kids who are involved in bullying • Girls are at higher risk than boys • Kids who identify as LGBTQIA and kids with learning disabilities are at particularly high risk • Bully-victims are the most impacted group • Bullying involvement explains only a small proportion of the variability in suicidal ideation

Hinduja & Patchin (2010), Kim & Leventhal (2008) Protective Factors

• When bystanders intervene, bullying stops within 10 seconds 57% of the time • improves self-esteem and more peer acceptance of the victim • Labeling an incident as bullying can be important because it influences whether students tell an adult, as well as how adults respond to the student’s report • Culture of prioritizing diversity in schools • Having a wide peer group • High rates of resilience • Good relationships and parents and siblings

US Department of Health & Human Services, Hawkins et al. (2001) Role of the PCP: Brief Interventions to Help

Prevent • Encourage parents to talk daily with their child about relationships at school • Check screen/media use and advise parental monitoring • Reduce stigma by normalizing and validating the impact of bullying • Educate about bullying and social media safety, how to be an upstander • Encourage connection to school and self-esteem building activities

McClowry et al. (2017), Stephens et al. (2018), AAP (2019) Screen • AAP recommends annual screening started at age 6 • There are no evidence-based screening tools for identification of bullying – HEEADSSS is a good start • Start with rapport-building questions that are broad and open ended • Determine scope and intensity of the problem • How long has it been happening • Where is it occurring • Who is involved • Has it been reported/what has been done • Screen for other mental health issues and risk factors Treat • Identify a supportive network around the patient and a location that the patient can go when bullying occurs • Educate the patient and their parent about what bullying is • Convey the following key points: • It is NOT their fault. They are not to blame. • They are NOT alone. You are here to help. • It is the adults’ responsibility make the bullying stop. • Bullying is never okay and they have the right to be safe. • No one deserves to be bullied. • They have the right to feel safe at school.

Treat, continued

• Problem solve ways that the patient can respond to the bullying • Provide link to school bullying policy in your area/district • Motivational Interviewing if needed to encourage disclosure to school and/or parents • Ask what the patient would like done about the bullying and what steps are needed to make that happen (See Bullying Action Plan form in presentation resource library) • Identify strengths and self-esteem building activities • Offer self-care plan and coping strategies • Monitor/treat comorbid symptoms • Refer to mental health treatment

Treat, continued

The National Bullying Prevention Center (2018) References

• Bradshaw, C.P., Sawyer, A.L., & O’Brennan, L.M. (2007). "Bullying and peer victimization at school: Perceptual differences between students and school staff." School Psychology Review, 36(3), 361-382. • Finkelhor, D., Turner, H.A., Shattuck, A., & Hamby, S.L. (2015). Prevalence of childhood exposure to violence, crime, and abuse: Results from the national survey of children’s exposure to violence. JAMA Pediatric, 169(8), 746-754. • Kowalski, R., Giumetti, G., Schroeder, A., & Lattanner, M. (2014). Bullying in the digital age: A critical review and meta-analysis of cyberbullying research among youth. Psychological Bulletin, 140, 1073-1137 • McClowry, R.J., Miller, M.N, & Mills, G.D. (2017). What family physicians can do to combat bullying. The Journal of Family Practice, 66(2), 82-89. • Horner, G. (2018). Bulllying: what the PNP needs to know. Journal of Pediatric Health Care, 32(4), 399-408. • Quinn (2015). The Moderating Effect of Resilience on Bully Victimization and Subsequent Psychological Adjustment Problems Among Adolescent Girls: A Dissertation. • Eisenberg, M., & Aalsma, M. (2005). Bullying & Peer Victimizatoin: Position paper of the society for adolescent medicine. Journal of Adolescent Health, 36, 88-91 • Espelage D.L., Swearer S.M., (2003). Research on school bullying and victimization: What have we learned and where do we go from here? School Psychology Review, 32(3), 365–383.

References, continued

• Juvonen, J., & Graham, S. (2014). Bullying in schools: The power of bullies and the plight of victims. Annual Review Psychology, 65, 159-185 • Nansel, T., Overpeck, M., Haynie, O., Ruan, W., & Scheidt, P. (2003). Relationships between bullying and violence among US youth. Archives of Pediatric and Adolescent Medicine, 157, 348-353. • Zuckerman, D. (2016). Bullying harms victims and perpetrators of all ages. Health Progress, 97(4), 63-66. • Hinduja S., Patchin J.W. (2010). Bullying, cyberbullying, and suicide. Archives of Suicide Research, 14, 206– 221. • Kim Y.S., Leventhal B. (2008). Bullying and suicide: A review. International Journal of Adolescent Medicine and Health, 20(2), 133–154. • US Department of Health and Human Services. The Role of Teachers and Other School Staff in Bullying Prevention. Retrieved on 1/12/2020 from: https://www.prevnet.ca/sites/prevnet.ca/files/factsheet/PREVNet-SAMHSA-Factsheet-The-Role-of-Teachers-and-Other-Staff-in-Bullying-Prevention.pdf • Hawkins, D. L., Pepler, D., & Craig, W. M. (2001). Peer interventions in playground bullying. Social Development, 10, 512-527. • Stephens, M.M., Cook-Fasano, H.T., & Sibbaluca, K. (2018). Childhood bullying: Implications for Physicians. American Family Physician, 97(3), 187-192.