Skarstein et al. BMC Psychol (2020) 8:112 https://doi.org/10.1186/s40359-020-00478-2 RESEARCH ARTICLE Open Access It hurts inside: a qualitative study investigating social exclusion and bullying among adolescents reporting frequent pain and high use of non-prescription analgesics Siv Skarstein* , Sølvi Helseth and Lisbeth Gravdal Kvarme Abstract Background: Being bullied and socially excluded interferes with the fundamental need for humans to belong to a social group, which is necessary for well-being. This might underpin pain and the use of non-prescription analgesics. Aim: The aim of the study was to gain insight into how social exclusion and bullying afect well-being in adolescents reporting frequent pain and high use of non-prescription analgesics. Methods: A phenomenological hermeneutical method based on in-depth interviews was used. Nineteen teenagers, 14–16 years of age voluntarily participated in the study. Those included had frequent pain and used non-prescription analgesics daily or several times a week. Results: Bullying and social exclusion afects thoughts, feelings and attitudes and thereby the quality of life of the adolescents we interviewed. They described feelings such as sadness, loneliness and depression, and a sense of being an outsider among peers was common. It also appears that bullying has signifcant potential to spread in a school environment. Conclusion: The adolescents were self-aware and well-articulated. They conceptualised their experiences of being socially excluded and bullied. They described being socially excluded and bullied by peers as painful and they used non-prescription analgesics to alleviate pain. Teachers and health professionals should be aware of frequent pain and high use of non-prescribed analgesic medication as signs of psychosocial stress caused by social exclusion and bully- ing. Social exclusion and bullying should be systematically mapped, and targeted interventions implemented. Background adolescents’ social life, for example in the form of their Pain among children and adolescents has been identifed inability to pursue hobbies, disturbed sleep, absence from as a common and increasingly important social problem school, and inability to meet friends [3]. Stress may be [1]. Pain is a complex psychosomatic experience that can conceptualised as a biological predisposition in the form be related to diferent kinds of stressors, such as physi- of headaches or stomach aches, and intervening variables cal activity, sleep problems, poor eating habits, bullying, such as cognitive appraisal and coping strategies can harassment, schoolwork pressure, and poor treatment afect people’s perception of pain, pain sensitivity, pain by teachers and peers [2]. Pain has a negative impact on experience and pain behaviour [2, 4–6]. An increasing number of teenagers state that they experience a combi- *Correspondence: [email protected] nation of frequent pain, stress, anxiety and depression [7]. Faculty of Health and Science, Oslo Metropolitan University, St. Olavs Anxiety and depression show a strong relation to chronic Plass, P.O. Box 4, 0130 Oslo, Norway pain and may contribute to both the development and © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Skarstein et al. BMC Psychol (2020) 8:112 Page 2 of 9 preservation of pain and, in turn, to the use of analgesics from bullying is associated with medicine use, even when as a necessary tool for achieving pain relief [7, 8]. Adoles- controlling for the higher prevalence of symptoms among cence is considered a particularly vulnerable period when bullied victims [25]. More specifcally, being the victim of a person goes through the transition from childhood into bullying is associated with an increased use of analgesics, adulthood. At this stage of life, friends become an impor- even after controlling for self-reported pain [26]. tant addition to the family network [9, 10]. To our knowledge, the well-being of adolescents Te concept of quality of life broadly encompasses how reporting frequent pain and high use of non-prescrip- an individual measure the ‘goodness’ of multiple aspects tion analgesics has not been studied through their own of their life. Tese evaluations include one’s emotional stories, including their thoughts, feelings and attitudes. reactions to life occurrences, disposition, sense of life ful- Such knowledge might be useful to teachers and health flment and satisfaction, including satisfaction with work professionals alike when planning interventions to sup- and personal relationships [11]. In the literature, the term port adolescents reporting frequent pain and high use of ‘quality of life’ is also often referred to as well-being [12]. non-prescription analgesics. One important aspect of this is that a person’s well-being when young can form the foundation for their quality of Aim life in adulthood [13, 14]. Te aim of the study was to gain insight into how social Bullying can be direct, either physically or verbally (say- exclusion and bullying afect well-being in adolescents ing ‘nasty’ things to a person), or it can also be intention- reporting frequent pain and high use of non-prescription ally hostile [15]. It also encompasses indirect aggression analgesics. characterised by its typically covert nature and use of third parties, involving, for example, gossiping, spreading Methods malicious rumours and social exclusion, such as deliber- A phenomenological hermeneutical method based on in- ately not allowing a person into a group [16]. Being bul- depth interviews was chosen for the study, an approach lied has negative long-term health consequences and that provides insight into the experiences of the partici- it is widely recognised as one of the most signifcant pants and provides rich data [27]. Tis phenomenological public health problems in adolescence [17]. According hermeneutical method for interpreting interview texts to the World Health Organization’s (WHO) collabora- is inspired by the theory of interpretation presented by tive cross-national survey, 9–13% of children aged 11 Paul Ricoeur [28] and further described by Lindseth and to 15 years reported being bullied in the past couple of Norberg [29]. Such qualitative methods have also been months [17]. In a meta-analysis on the prevalence of bul- described as ‘the method of choice when straight descrip- lying and cyberbullying, the authors estimated a mean tions of phenomena are desired’ [30, p. 339]. prevalence of 35% for traditional bullying (both perpe- tration and victimisation roles) and 15% for cyberbully- Participants ing involvement [18]. Social exclusion interferes with the Nineteen teenagers, four boys and 15 girls, between 14 fundamental need for humans to belong to social groups, and 16 years of age voluntarily participated in the study. which is required for their well-being and positive emo- Tose included had frequent pain, in addition to a daily tions [19]. Studies show that being social excluded and/or to several times a week (high) intake of non-prescription bullied can modify stress responses or lead to long-term analgesics for at least four continuous weeks over the last increases in health problems such as sleep disturbances, 12 months, this without having any known diagnosis. headaches, pain and fatigue [13]. According to Olweus Te interviews were conducted on a one-to-one basis, [20], bullying occurs in a relationship in which there is an each lasting approximately one hour, during 2015, at an imbalance of power or strength. A robust literature docu- ofce at their school or at the researcher’s workplace ments that victims of bullying often have low self-esteem during working hours. Te participants chose the place and feel depressed, anxious and lonely [21]. Research for the interview. Participants had to be able to read and from developmental psychopathology have shown that understand the Norwegian language. Participants were stressful life events can lead to the onset and mainte- recruited and interviewed until the research group con- nance of depression and anxiety, and that for many ado- sidered that saturation was reached [31]. lescents, victimisation is a major life stressor [22]. In addition, peers very often dislike those who are victims, Data collection particularly during the middle school years [23]. Depres- Te head teacher of 20 randomly chosen schools repre- sive symptoms have been found to be signifcantly asso- senting urban, suburban and rural districts in Norway ciated with analgesic consumption among adolescents were invited by phone to participate. Te head teach- [24]. Further, statistics have shown that victimisation ers of ten of these schools consented to informing the Skarstein et al. BMC Psychol (2020) 8:112 Page 3 of 9 students at their schools. One researcher visited these spontaneously. One researcher (a psychiatric nurse) con- ten schools and gave a 15 min presentation of the project ducted all the one-to-one interviews, either in a meeting to all classes in years 9 and 10, comprising a total of 52 room in the researcher’s workplace or at the adolescents’ classes with an average of 25 students in each.