Adolescent health

Bullying
Michael Carr-Gregg
Ramesh Manocha
Effects, prevalence and strategies
for detection
Bullying is a form of aggression, characterised by repeated
Background psychological or physical oppression, involving the abuse of
The mental, physical, social and academic consequences
power in relationships to cause distress or control another.1,2
of bullying have an enormous impact on human and social
It is a complex and serious problem, which expresses
capital.
differently according to age, gender, culture and technology.
Objective
This article describes the effects and prevalence of bullying Although bullying is traditionally understood as physical aggression,
on young people and presents strategies for its detection.
there are many other strategies that young people use to control and
Strategies for the facilitation of a multidisciplinary
distress others (Table 1).
approach to bullying in adolescents are also presented.
More recently, the phenomenon of cyberbullying3 has become
Discussion prevalent. It specifically involves communication technology,
Given the existing high rate of bullying, assessment should especially the internet, mobile telephones and text messaging,
be incorporated into a standard psychosocial screening to cause distress to individuals. (For detailed information about
routine in the general practitioner’s clinic. Effective
cyberbullying see Resources.)
management is a multidisciplinary effort, involving parents,
teachers and school officials, the GP, and mental health Bullying and young people
professionals. Given the variable effectiveness of schools in
tackling bullying, GPs play an important role in identifying Normal adolescent development is characterised by a mismatch
at risk patients, screening for psychiatric comorbidities, between fundamental drives and self regulatory skills which manifests
counselling families about the problem, and advocating for as difficulty expressing thoughts and feelings, seeing another’s point
bullying prevention in their communities. of view and predicting the consequences of one’s actions.4 This
explains why bullying occurs most frequently in late primary school
Keywords: adolescent; child, bullying
and early high school, when this mismatch peaks. It also makes
it unlikely that bullying behaviour can ever be entirely eliminated,
although it can certainly be minimised. Nevertheless, as outlined in
the Kandersteg Declaration,5 every young person has the right to be
respected and safe, and bullying is a violation of this basic human
right. It is the responsibility of adults to ensure that these rights are
defended and that healthy development and citizenship are promoted.

Prevalence
Although bullying has long been perceived an inevitable part of
growing up, a recent American survey shows that children aged
8–15 years rate bullying as a greater problem than racism or peer
pressure to have sex or use alcohol and other drugs.6 Australian
data appears to reflect this trend; a 1996 study found 1 in 6 children
reported being bullied weekly and being bothered by it.7 A recent
Federal Government commissioned Australian study surveyed 7000
children from 124 schools nationally and found that bullying peaked
in the final years of primary school, with 32% of students stating they

98 Reprinted from Australian Family Physician Vol. 40, No. 3, March 2011
 Table 1. Types of bullying Early detection
Given the high prevalence of bullying, GPs should incorporate an
• Physical bullying: hitting, poking, tripping, pushing or
damaging someone’s belongings assessment for bullying into their standard psychosocial screening
• Verbal bullying: name calling, insults, homophobic or routine, ideally with every encounter with a young person.17
racist remarks and verbal abuse Young people are often reluctant to disclose that they are being bullied
• Social (covert) bullying: lying, spreading rumours, because they are ashamed, think it is their fault, may fear retaliation, or
playing a nasty joke, mimicking and deliberately regard disclosure as ‘dobbing’. An Australian study18 of 415 high school
excluding someone students found that more than half (54%) would not report bullying to
• Psychological bullying: threatening, manipulation and adults. Of those that would report, students more frequently said they
stalking would tell a parent, followed by a school friend, and then a teacher.
• Cyberbullying: using technology (eg. email, mobile Although young people are unlikely to spontaneously disclose the
telephones, chat rooms, social networking sites) to
issue during a general practice consultation,17 parents/relatives or
bully verbally, socially or psychologically
another third party may report it or a school may refer the victim to a GP.
Bullying is not:
Many presentations should prompt consideration of bullying (Table 3).
• mutual arguments and disagreements
Interestingly, young people who perpetrate bullying are just as
• single episodes of social rejection or dislike
likely as the victims to report these types of symptoms, and young
• single episode acts of nastiness or spite
people who both bully and are victimised might be at greatest risk.19,20
• random acts of aggression or intimidation.
Young people who bully are also more likely to report alcohol and
Source The National Centre Against Bullying www.
ncab.org.au/Page.aspx?ID=206 substance use.21

were targeted.8 This data suggests that the prevalence of bullying is Assessment
increasing and that Australia has one of the highest rates of bullying in Many adolescents are willing to discuss health concerns with their
the developed world. A recent review9 concluded that the effectiveness GP if engaged in an ‘adolescent friendly’ way. General practitioners
of school antibullying measures are modest at best,indicating that are legally and ethically bound to keep information that is disclosed
bullying is likely to be an ongoing problem. by patients confidential. Concerns about confidentiality are a major
barrier for young people,22 so it is important to reassure them that the
Social and emotional impact information they disclose will be kept confidential except in extreme
Although bullying among young people can occur in any setting, it circumstances. (Where, for example, the patient’s life may be in
typically occurs at school or on the way to and from school. Young danger, public interest or mandatory reporting obligations occur.)
people involved in bullying are at risk of poor school functioning, as So, once the young person’s mental competence is established, it is
measured by attitudes toward school, academic performance and important to ensure that at least part of each consultation is conducted
absenteeism.10 They may suffer significant psychological distress,11,12 without the presence of the parent. Removing the parent from the
and in rare instances take their own life.13 Young people with serious consultation room can be presented as usual protocol with a statement
psychosocial problems might experience problems associated with such as, ‘Well Mrs Jones, before you leave, and I talk to Amy alone, do
attention, behaviour, and emotional regulation, which interfere with you have any more questions?’
their ability to learn.10
Table 2. Tasks for the GP in managing young
The evidence base demonstrating a link between the experience
people affected by bullying
of being bullied with mental health problems in later life is growing.14
Therefore, although bullying and victimisation might occur early in • Early detection
• Assessment of the severity and impacts
life, longitudinal studies indicate that its effects can be long lasting.
• Counselling and support
Longitudinal studies also indicate that the tendency to bully at school
• Encouraging the young person to disclose the bullying
significantly predicts subsequent antisocial and violent behaviour.15 A
to parents
study from the United States of America also found that the attackers
• Developing an action plan with the family
in more than two-thirds of 37 mass school shootings felt ‘persecuted, • Appropriate referral
bullied, threatened, attacked, or injured by others’, and that revenge • Broader roles as required such as:
was an underlying motive.16 – advocating on behalf of the young person to school
officials or other community agencies
The role of the GP – encouraging parents to engage their children in
General practitioners have a critical role to play in the assessment and positive school and community activities
management of young people affected by bullying. The key aspects of – helping other adults to recognise the physical and
this role are outlined in Table 2. psychological symptoms associated with bullying

Reprinted from Australian Family Physician Vol. 40, No. 3, march 2011 99
 FOCUS Bullying – effects, prevalence and strategies for detection

The HEADSS (Home, Education and Employment, Activities,

Table 3. Common clinical indicators of
Drugs, Sexuality, Suicide/depression) psychosocial assessment bullying29,30
strategy17 is a common method of establishing a meaningful rapport
• School refusal or excuses for school avoidance (eg.
between the GP and the young person. It is a useful clinical tool, can
feeling sick)
usually be completed within the scope of most consultations, and
• Wanting to go to school a different way (eg. changing
provides a framework for GPs to effectively assess for bullying the route, or being driven instead of catching a bus)
(see Resources). • Being tense, tearful and unhappy before or after school
The GP should ascertain the type of bullying, ie. physical, verbal, • Talking about hating school or other children
psychological (social exclusion, rumours, putdowns), sexual (which can • Suspicious bruises or scratches
be physical or verbal) or cyber, and determine if mandatory reporting is • Damage to, or loss of, personal belongings
necessary. If there are concerns about online behaviour that involves • Sleeping difficulties including nightmares and
sexual exploitation of a child this should be reported to the Australian enuresis
Federal Police Child Protection Operations team (see Resources). • Social withdrawal
Further practical strategies to facilitate disclosure are described in • Refusing to discuss what happens at school
Table 4 and 5. • Somatic symptoms such as headache or abdominal
pain
Counselling and supporting the young
person
Ongoing review and support of the young person and their family is Table 4. Useful questions about school1
very important. Although counselling skills are beyond the scope of this • What do you like about school?
article, some cognitive behaviour therapy-style techniques that can be • What are you good/not good at?
useful to teach young people include: • How do you get along with teachers and other
• ‘fogging’ – when other people make hurtful remarks, don’t argue students?
and try not to become upset. Imagine that you are inside a huge, • Is there an adult you can talk to at school about how
white fog bank: the insults are swallowed up by the fog long before you feel?
they reach you • Have your marks changed recently?
• staying in the neutral zone – reply to taunts with something short • Many young people experience bullying at school or at
home via the net or mobile telephone, have you ever
and bland: ‘that’s what you think’ or ‘maybe’, then walk away.
had to put up with this?
Interactive websites such as MoodGYM23 and Reach Out Central24
offer cognitive behavioural strategies to help reframe negative thinking
patterns (see Resources). Table 5. Example of a bullying history
There are five key messages that the GP should convey to the
young victim of bullying. The ‘many young people’ technique allows sensitive
questions to be asked in a nonthreatening way
1. That they have shown great courage coming forward and the good
• I have heard that many young people your age,
news is that they don’t have to face it on their own
experience bullying at school or at home – online or by
2. It’s not their fault – but is most likely a reflection of the insecurities phone – have any of your friends ever had to put up
of the bully with this?
3. All students have a legal right to learn in a safe environment • Remembering what we said about confidentiality,
4. They should not try to tackle the bully by themselves that this was just between the two of us, can you
5. That bullies thrive on secrecy and the best option is to tell someone tell me whether you have ever experienced this sort
in authority. of harassment at school or at home – online or by
telephone?
Encourage disclosure to parents • What type of bullying was this (ie. is it cyberbullying,
physical, psychological)?
Baring in mind the young person’s right to confidentiality, GPs should
• Have you told anyone about this?
encourage the victim to disclose the facts of the bullying to their
• How often has this occurred? (assess intensity)
parents or legal guardians as soon as possible.
• How long has this been going on for? (assess duration)
Some young people are reluctant to disclose this information to
• (If cyberbullying) – did you save any of the messages
an adult carer. However, it is generally considered essential to involve on your phone or computer as evidence?
parents in the remediation process. A GP may tackle this situation • How many different places or relationships does the
by providing a range of choices to empower the young person. For bullying occur in?
example, ‘I can appreciate that you may not want mum or dad to know

100 Reprinted from Australian Family Physician Vol. 40, No. 3, March 2011
 Bullying – effects, prevalence and strategies for detection FOCUS

about what you have had to put up with, but in my experience, it is very harmful effects of their actions, the unacceptable nature of their
helpful to let them know what has been going on. We can do this in a behaviour and the development of a monitored plan to remediate the
variety of ways: you can sit in while I tell them what’s been going on; situation (see Resources).
or you can wait outside while I let them know and then bring you in; or
Peer mediation
you can tell them in front of me.’
Peer mediation is a process in which students resolve disputes and
Develop a parental action plan conflict among their peers. Peer mediators are chosen by their own
Proper parental support can be a protective factor for bullying, hence peers and receive training to work with both the bully and the victim
the GP’s dual role in both detecting and managing bullying while to arrive at a nonaggressive, constructive solution. It has been used
educating parents about how best to prevent and manage it. successfully with children in a number of school settings.27
Parents should be encouraged to remain calm and under no
Shared concern
circumstances contact the parents of the bully. Table 6 lists tips for
parents. Parents should be presented with a clear action plan and a follow Simple disapproval and punishment of bullies may not prevent bullying.
up meeting with the GP so that progress can be evaluated and discussed. The shared concern approach is based on the assumption that bullies
The parental action plan should include: typically are insensitive to the harm they are doing to the victim (see
• seeking a face-to-face meeting with the student’s teacher, year Resources). This is because of their involvement in a group which gives
level coordinator, deputy principal or principal to discuss the matter legitimacy to bullying, reducing their sense of personal responsibility.
• written communication that leaves a paper trail that may be useful This model uses the fact that bullies commonly feel uncomfortable
should matters escalate with their own behaviour. An adult mediator uses specific techniques
• reading the Federal Government report, ‘What should I do if my to demonstrate the impact of the bullying on the victim. Although the
child is being bullied?’ (see Resources) or individual state or method involves a nonblaming approach, it does not seek to excuse or
territory department of education websites condone bullying and has been found to be effective in many settings.28
• moving up the ‘chain of command’ if parents feel that their
concerns are being ignored Conclusion
• at the school meeting, parents should be encouraged to remain Bullying is emerging as a significant but preventable mental health
calm, bring any evidence they have and ask three key questions: risk factor for young people. Once detected, a partnership involving the
– How will this matter be investigated?
– How long will this investigation take? Table 6. Important parental do’s and don’ts
– When can we have a follow up meeting to discuss the results Do NOT
and any sanctions that are handed out? • Tell the young person to ignore the bullying as this
Encourage parents to record minutes of the meeting and create a often allows the bullying and its impact to become
record of what was agreed. The GP may also contact the school more serious
directly (if agreed by the young person) to discuss the matter with • Blame the young person or assume that they have
relevant notes made in the patient’s file. done something to provoke the bullying
• Encourage retaliation
Screen for psychological distress • Criticise how your child/teenager dealt with the
and refer if necessary bullying
• Contact the bully or parents of the bully
If the bullying has been sustained, frequent or intense, then a screening
Do
questionnaire such as the K10 should be used to help detect clinically
significant levels of anxiety or depression.25,26 Consider referral to a • Listen carefully. Ask who was involved and what was
involved in each episode
psychologist if screening indicates that the patient’s mental health score
• Empathise and reinforce that you are glad your child/
is above the ‘at risk’ threshold or otherwise indicated.
teenager has disclosed this
Strategies used in schools • Ask your child/teenager what they think can be done
to help
Schools apply rules relating to standards by which children are • Reassure your child/teenager that you will take
expected to treat each other. When bullying is identified then sanctions sensible action
and punishments are appropriate. Useful strategies are outlined below. • Contact the teacher and/or principal and take a
cooperative approach in finding a solution
Restorative justice
• Contact school authorities if bullying persists and
A form of conflict resolution which involves a mediated meeting escalate your communications up the chain of
between victim and offender aimed at making them understand the command

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