Bullying, Its Effects, and the Role of Pediatricians

Did the Ugly Duckling Have PTSD? Bullying, Its Effects, and the Role of Pediatricians

Draco Malfoy of Harry Potter, Nellie Oleson of Little House on the AUTHORS: Mark A. Schuster, MD, PhDa,b and Laura M. Prairie, Lumpy Rutherford of Leave it to Beaver, Amber Von Tussle of Bogart, PhDa,b Hairspray, Nelson Muntz of The Simpsons, Regina George of Mean aDivision of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts; and bDepartment of Girls, all 3 Heathers of the eponymous movie, and last but not least, Pediatrics, Harvard Medical School, Boston, Massachusetts pretty much all the ducks in the Ugly Duckling: regardless of one’s Drs Schuster and Bogart drafted and revised the initial generation, such bullies are a staple of child and adolescent life in manuscript, and approved the final manuscript as submitted. literature, movies, and television. Throughout the media, bullied kids’ ABBREVIATION “ ” crimes are varied: they may have a different race, religion, or PTSD—posttraumatic stress disorder sexual orientation; they may be too poor, too rich, too heavy, too Opinions expressed in these commentaries are those of the short; they may suffer for their lineage, as do the magical children authors and not necessarily those of the American Academy of of Muggles in Harry Potter. Sometimes they are just the new kid in Pediatrics or its Committees. town. Sometimes they are the socially clumsy kid without friends, www.pediatrics.org/cgi/doi/10.1542/peds.2012-3253 an easy target for a bully who wants to assert power and impress doi:10.1542/peds.2012-3253 others. What happens to bullies in fiction, beyond driving the plot? Accepted for publication Oct 23, 2012 Sometimes they get sent to the principal, sometimes they get a talking- Address correspondence to Mark A. Schuster, MD, PhD, Division to by an embarrassed parent, and sometimes they get a knowing wink of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: [email protected]. and an at-a-boy from a parent when the principal is not looking. They edu often get their comeuppance in the end of the movie or book, having PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). the tables turned on them or developing a newfound respect for their Copyright © 2013 by the American Academy of Pediatrics target. FINANCIAL DISCLOSURE: The authors have indicated they have Although the bully has been a stock character for years, something no financial relationships relevant to this article to disclose has recently changed in the United States. The bully has jumped off FUNDING: Preparation of this commentary was supported by the page and out of the screen, and into everyday life and legislation National Institutes of Health grant RC4 HD066907 (M. A. Schuster, principal investigator). Funded by the National Institutes of and pediatric practice. The bully is no longer simply a representation Health (NIH). of a moral lesson or a source of humor. We have come to recognize COMPANION PAPERS: Companions to this article can be found the bully as a real person with complex needs and motives who can on pages e1 and e10, online at www.pediatrics.org/cgi/doi/10. inflict great harm on others, not to mention on his or herself. The rise 1542/peds.2012-1106 and www.pediatrics.org/cgi/doi/10.1542/ peds.2012-1180. of cyberbullying,1–5 with its potential for broad public humiliation, has highlighted the damage that bullying can cause. Since 1999, al- most all US states have enacted antibullying legislation and have established requirements that school districts implement antibullying policies.6 In research studies, bullying is typically defined as intentional and repeated perpetration of aggression over time by a more powerful person or group against a less powerful person or group.7,8 In study after study, a substantial proportion of youth report having been bullied,3–5,8–13 with the prevalence peaking in middle school.4,8,10 Most studies find that at least 1 in 10 middle school students report being bullied in the previous year,4,8,10 and the proportions are much higher in some studies.3,4,8–12 The variation across studies may reflect differences in setting, timeframe, and specific questions asked. Re- search also shows that bullies, who are often perceived as popular by their peers, are motivated to denigrate others to attain a dominant social position.14–16 Moreover, bullies have a tendency to target others

e288 SCHUSTER and BOGART Downloaded from www.aappublications.org/news by guest on September 28, 2021 COMMENTARY who have stigmatizing characteristics, consequences. It has been associated lead them to bully. They can teach that is, attributes that are socially with stress-related physical and men- children what to do when they witness devalued and discriminated against tal health symptoms, including depres- bullying. And they can comfort children (eg, being obese; being lesbian, gay, sion, anxiety, posttraumatic stress, and who are bullied and help them figure bisexual, or transgender).5,17 suicidal ideation.8,26–34 When bully- out how best to respond. Parents, This month’s issue of Pediatrics in- ing is motivated by discrimination or teachers, coaches, religious leaders, cludes 2 articles on bullying,18,19 both an attack on someone’s core identity and pediatricians and other clinicians of which not only suggest that health (eg, their sexual orientation), it can can all make a huge difference in the issues are a consequence of bullying, have especially harmful health con- life of a child who is being bullied by but also reinforce that health issues sequences.32–35 The effects of bully- providing an accepting and safe envi- can motivate bullying. The article by ing are not limited to the bullied. ronment to discuss and address the Puhl et al builds on previous research Bystanders who witness bullying may situation. At school, where bullying on bullying and obesity17,20 by doc- experience mental health consequences often occurs, teachers and coaches umenting substantial weight-based (eg, distress) as well.36,37 can institute clear rules and imple- victimization in a sample of children The American Academy of Pediatrics ment swift discipline against bullying, receiving obesity treatment at weight- and other major professional organ- which can undermine bullies’ motiva- loss camps.18 The study highlights an izations have issued policy statements tions for dominance, popularity, and additional consequence of the growth recognizing bullying as a serious social reward. in obesity rates in recent decades: the medical and public health issue that These same adults, however, can be increase in the number of children at pediatricians and other clinicians part of the problem,18,45–49 sometimes risk for being bullied. The second ar- should address jointly with parents, serving as negative role models, ig- ticle, by Shemesh et al, calls attention educators, and community organiza- noring the issue of bullying, failing to to another health issue, food allergies, tions.38–44 Professional organizations notice its signs, or actually bullying which provide a visible target for recommend that clinicians take con- children themselves. For example, a cli- bullies. Some bullies even threaten crete steps to respond to bullying. For nician who is trying to motivate a child allergic children with the food to example, clinicians can incorporate to lose weight might use language, which they are allergic (eg, by waving bullying into anticipatory guidance for tone, and facial expressions that are or throwing the food at them).19 Food children and parents by describing undermining, scolding, and even bully- allergies are becoming more com- bullying and its consequences, whether ing. A parent or coach shouting at a mon,21–23 and schools have adopted the child is bullying, being bullied, wit- boy, “You throw like a girl!” or “Don’tbe varying strategies to address them.24,25 nessing bullying, or all 3. In addition, asissy!” may not consider the impact Students who are not allowed to clinicians can learn to recognize indi- on the child if he is gay or even if he bring peanut butter to school be- cators of possible bullying such as un- is not; importantly, research finds that cause a classmate has an allergy explained bruises, cuts, and scratches, boys of any orientation who are bullied might bully the classmate to gain as well as school avoidance, social iso- by being called “gay” show worse dis- popularity with others who resent lation, anxiety, depression, substance tress in comparison with boys who are the limitation. The potential for bul- use, and chronic physical symptoms (eg, bullied in other ways.34 Clinicians have lying underscores the importance of headaches, stomachaches). They should a role to play not only in monitoring addressing food allergies in a way be particularly alert when patients have their own actions when counseling that protects but does not stigmatize stigmatizing characteristics that could children with stigmatized character- children who have them. lead to bullying (eg, obesity, disabilities, istics, but also in helping other adults, Bullying can have immediate physical gender nonconformity). Clinicians may especially parents, to recognize and and emotional effects that warrant the also want to teach parents, who, are not address their own aggressive and bul- awareness and involvement of pedia- always aware of bullying (as Shemesh lying behaviors. tricians and other clinicians. But the et al point out19), how to recognize clues Achieving broad cultural change and effects of bullying do not necessarily that bullying might be occurring. promoting public discourse on what is stop when the bruises heal or the We generally think of adults as part of acceptable behavior may be the most graffiti is sandblasted off the wall or the solution. They can teach children promising ways to reduce bullying. the Ugly Duckling becomes the Swan. not to bully and help bullies identify Although there has been a rapid in- Bullying can have life-long health and manage the challenges that may crease in antibullying laws and school

PEDIATRICS Volume 131, Number 1, January 2013 e289 Downloaded from www.aappublications.org/news by guest on September 28, 2021 antibullying programs, we need a cul- This is a ﬁeld that begs for multidis- interventions that use a solid the- tural evolution in awareness and re- ciplinary input by anthropologists, cli- oretical basis to create norms for be- pudiation of bullying. We have witnessed nicians, educators, epidemiologists, havior toward the bullied,52 to prompt such a shift with sexual harassment, research psychologists, sociologists, bystanders to take action when they which was once considered to be ac- and others. There is a need for more witness bullying,53 and to integrate ceptable and normative. Although sexual methodological research, including lon- stigma reduction strategies against harassment has not been eradicated, gitudinal research that may help prejudicial attitudes and discrimina- the national reaction to it has mark- to disentangle the effects of bullying tory behaviors.54 Interventions are edly changed.50,51 The experience with on long-term health problems from also needed to help clinicians recog- sexual harassment can serve as a the effects of other factors, such as nize signs of bullying and take steps model for the kind of societal dis- preexisting mental health issues. There to help children who are targets or cussion that can beneﬁt antibullying is a need for descriptive studies that witnesses address bullying. Having efforts. We need to create a dialogue advance our knowledge of the types everyone who engages with children on what bullying is and why bullying is of children who bully and are bullied, participate in shifting the culture of not acceptable, even if it has been with a particular focus on how to bullying provides our best hope for tolerated or applauded for decades or protectchildrenwithstigmatizing tackling this challenging problem. centuries. characteristics. It is also critical to The science of bullying is still young explore the types of community, ACKNOWLEDGMENTS in the United States, although Europe family, and individual-level factors We thank Maria C. Bryant, BA, Dorothy has a longer tradition of studying and that reduce involvement in bullying L. McLeod, AB, Elizabeth T. Schink, BA, addressing bullying. Researchers can and that promote resilience among Michaela S. Tracy, BA, and Katherine build on this previous work, which has targets of bullying. D. Vestal, MPH, for research assistance. helped to operationalize the concept of Perhaps most importantly, there is We thank Stewart L. Adelson, MD, Jay G. bullying; elucidate the health correlates a need for research on how clinicians, Berry, MD, MPH, Hans C. Oettgen, MD, of bullying among bullies, bystanders, parents, educators, and other advo- PhD, and Sara L. Toomey, MD, MPH, and targets; and develop antibullying cates for youth can best tackle the MPhil, MSc, for providing feedback on programs in schools.7,16,18–20,25,31,33–35 issue. We need rigorously tested drafts of the commentary.

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