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. 2023 Aug 22;16(4):881–888. doi: 10.1007/s40653-023-00569-3

Prevalence of Bullying Victimization and Perpetration Among Youth with Chronic Health Conditions in the United States

Justin A Haegele 1,2,3,✉, Xihe Zhu 1,2,3
PMCID: PMC10689641  PMID: 38045843

Abstract

Background

Bullying perpetration and victimization have gained widespread recognition as major public health issues. However, few studies focused on exploring prevalence rates across impairments or chronic health conditions exist in the literature. The primary purpose of this analysis was to provide current estimates of bullying victimization and perpetration among US youth with 24 chronic health conditions. A secondary purpose was to examine associations between the number of chronic health conditions and bullying victimization and perpetration.

Methods

Data from the 2019–2020 National Survey of Children’s Health, nationally representative cross-sectional probability sample of noninstitutionalized youth, were used. This study focused on 29,285 adolescents (aged 12–17 years), including 14,203 with a chronic condition. Pearson’s χ2 tests were used to examine proportional equivalence on bullying perpetration and victimization, and logistic regression analyses were used to explore associations between the number of chronic conditions and bullying behaviors.

Results

A significantly higher proportion of adolescents with chronic health conditions engaged in bullying perpetration and victimization compared to those without a chronic health condition. Those with autism spectrum disorder, developmental delay, and depression were noted as having elevated proportions of bullying victimization, whereas those with behavioral or conduct problems, blood disorders, and depression had higher rates of perpetration.

Conclusions

This analysis helps to identify several groups of adolescents in need of targeted interventions to help reduce bullying rates. Those experiencing more than one chronic health condition were 3.56 and 2.97 times as likely to engage in bullying victimization and perpetration, respectively, compared to those with no condition.

Keywords: Bullying, chronic disease, disability, violence, autism, depression

Introduction

It has been estimated that between about one quarter to one third of adolescents experience bullying, either as a perpetrator or victim, internationally (Lebrun-Harris et al., 2019; Man et al., 2022; World Health Organization, 2020). For example, an analysis of a representative sample of adolescents aged 12–17 years from the 2016 National Survey of Children’s Health (NSCH) in the US indicated that approximately 21.2% and 5.59% were victims and perpetrators of bullying, respectively (Lebrun-Harris et al., 2019). Abroad, a survey involving 40 developing countries demonstrated that about 42% and 37% of boys and girls, respectively, experienced bullying in some way (World Health Organization, 2020). Defined as intentional and repetitious interpersonal aggression characterized by an imbalance of power between perpetrator and victim that inflicts physical, psychological, social, or educational harm (Haegele et al., 2020; Stough et al., 2016), bullying has gained widespread recognition as an international public health issue due to its high prevalence among adolescents, its common occurrence in school contexts, as well as associated deleterious physiological and psychological health outcomes (Jackson et al., 2019; Man et al., 2022). That is, bullying perpetration and victimization have been associated with higher rates of depression and anxiety, diminished psychological well-being, higher criminality and deviant behavior, increased drug and alcohol use, and a higher likelihood of suicidal ideations, attempts, and completions during adolescence and throughout the lifespan (Han et al., 2017; Jackson et al., 2019; Man et al., 2022). In addition, those engaged in bullying as victims or perpetrators tend to experience school-related issues, such as having lower self-perceived academic competence and sense of school belonging, less engagement in extracurricular school activities, and higher rates of school dropout (Gage et al., 2021; Ma et al., 2019).

Adolescents with chronic health conditions, including those with physical, cognitive or sensory impairments, those with developmental disorders, or those with pre-existing mental health concerns, have been identified as a socio-demographic group that has a high prevalence of engagement in bullying perpetration and victimization (Gage et al., 2021; Haegele et al., 2021; Iyanda, 2022; Rose and Gage, 2017; Rose et al., 2015). For example, in an analysis of a nationally representative sample from the 2016 NSCH by Haegele and colleagues (2021), 44.5% and 12.63% of adolescents aged 10–17 years receiving special education services were identified as experiencing bullying victimization or perpetration, in comparison to just 19.8% and 5.02% of those who did not receive such services. According to Jackson and colleagues (2019), adolescents with chronic health conditions may be at a higher likelihood for bullying involvement because they “may be outwardly or conspicuously different from other children and make for an easier ‘target’” (p. 60). Others have argued that adolescents with chronic health conditions appear to fit the mold for those who dominated in bullying relations because of the perceived vulnerability and non-aggressiveness (Veenstra et al., 2007) as well as ostracization or isolation by peers (Twyman et al., 2010), or may bully others as a way of expressing or responding to others because of communication or language struggles (Maiano et al., 2016; Rose et al., 2011). Of concern, adolescents with chronic health conditions tend to experience additional negative effects of bullying beyond physiological and psychological health and education-based concerns previously expressed for those without chronic health conditions (Hartley et al., 2017; Jackson et al., 2019). For example, Jackson and colleagues (2019) reported that adolescents with chronic health conditions who were victims of bullying were more likely to experience additional health difficulties (e.g., respiratory issues, chronic pain) relative to nonvictims.

Surveillance of the prevalence of bullying victimization and perpetration among adolescents with chronic health conditions is a worthwhile endeavor, as it may help inform the prioritization of funding, research, and interventions. Although some research has examined the prevalence of bullying victimization and perpetration among broadly defined categories of youth with disabilities or chronic health conditions (Haegele et al., 2020; Jackson et al., 2019), or of specific disability groups (Charania et al., 2022; Iyanda, 2022; Joseph et al., 2022), few have explored prevalence rates across impairments or conditions. For example, some prior work has noted that those with high incidence disabilities, those educated in integrated contexts, and those with observable conditions were less likely to be bullying victims than those with physical disabilities, those educated in self-contained contexts, and those with invisible conditions (Rose et al., 2011; Swearer et al., 2012). However, recent estimates are largely unavailable that comprehensively consider the most common chronic health conditions experienced by US youth. Thus, the current study aimed to utilize the 2019–2020 NSCH data to provide current estimates of bullying victimization and perpetration among US youth with 24 chronic health conditions. Because of the multiplicative effects of chronic health conditions (Jackson et al., 2019), where those with more than one chronic health condition may experience higher likelihoods of bullying victimization and perpetration, and higher likelihood of other comorbid conditions (Shapira et al., 2021), a secondary purpose was to examine associations between the number of chronic health conditions and bullying victimization and perpetration.

Methods

Data Source

Data from the 2019–2020 NSCH combined dataset were used. The 2019–2020 NSCH is a nationally representative, cross-sectional probability sample of noninstitutionalized youth aged 0 to 17 in the United States (n = 72,210). This cross-sectional survey, conducted by the US Census Bureau, identified households via the Census Master Address File and included 2 modes of participation, a web-based survey and a mailed paper survey. Households were randomly contacted to identify households with children younger than the age of 18 years. In instances where selected households included more than one child, one was randomly selected, and parents/guardians completed the questionnaire. The overall weighted survey response rate was 42.4% for both the 2019 and 2020 data collection. Further information about the 2019–2020 NSCH combined dataset can be found in the US Census Bureau’s fast facts document (2021). Informed consent was collected from all parents or guardians.

Sample

This study focused on 29,285 adolescents (aged 12–17 years); 15,082 without a chronic condition and 14,203 with a chronic condition. Participants were identified as having a chronic condition via two questions: (a) has a doctor or healthcare provider ever told you that this child has (a chronic health condition)? (b) does this child currently have the condition? If a “yes” option was checked for question (b), the child was considered to have a chronic health condition. The 2019–2020 included questions asking parents to identify if their child had one of 24 chronic health conditions, which included (1) Attention Deficit Disorder (ADD) or Attention-Deficit Hyperactivity Disorder (ADHD), (2) allergies, (3) anxiety problems, (4) arthritis, (5) asthma, (6) autism spectrum disorders, (7) behavioral or conduct problems, (8) blindness or visual impairment, (9) blood disorders, (10) cerebral palsy, (11) cystic fibrosis, (12) deafness or hearing problem, (13) depression, (14) developmental delay, (15) diabetes, (16) Downs syndrome, (17) epilepsy or seizure disorder, (18) genetic or inherited condition, (19) heart conditions, (20) headache (frequent, include migraine), (21) intellectual disability, (22) learning disability, (23) speech or language disorder, and (24) Tourette syndrome. Participants were identified as those whose parents reported that they had been told by a healthcare professional that their child has the condition and that they currently have the condition. As per recommendations by Healy and colleagues (2020), in instances when youth were reported to have multiple diagnoses, they were included in the analysis for each group/s they represented since data pertaining to primary diagnosis were unavailable.

Measurement of Bullying Behaviors

Items measuring bullying perpetration and victimization in this study are consistent with those used in prior research exploring these constructs among adolescents in the US using the NSCH (Haegele et al., 2020; Lebrun-Harris et al., 2019). To measure bullying perpetration and victimization, parents were asked “During the past 12 months, how often did this child bully others, pick on them, or exclude them?”, and “During the past 12 months, how often was this child bullied, picked on, or excluded by other children?”, respectively. Response options for both questions included “never”, “1–2 times in the past 12 months”, “1–2 times per month”, “1–2 times per week,” and “almost every day.” A dichotomous variable was created for both bullying perpetration and victimization, by combining the last four options into a ‘yes’ variable, and including responses of “never” into a ‘no’ variable. As per Haegele and colleagues (2020), the construction of dichotomous variables provided a description of the frequency in which children and adolescents experienced bullying perpetration and victimization, rather than the degree to which it was experienced.

Data Analysis

We conducted descriptive and frequency analyses on adolescents with and without chronic health conditions. Specifically, frequency analyses were done on the demographic variables of sex, race/ethnicity, household income, highest education of any parent in the household, and adolescents with each of the 24 chronic health conditions and the reported experiences of bullying perpetration and victimization within 12 months. The proportional equivalence in bullying perpetration and victimization was examined using Pearson’s χ2 tests. Then, we conducted logistic regression analyses on adolescents’ experiences of bullying perpetration and victimization, respectively, using the status of chronic health condition (no chronic health condition as the referent), while adjusting the participants’ sex, race/ethnicity, household income, highest parent education, and the number adverse childhood experiences. To provide proper estimates and account for the sampling plan of NSCH, we incorporated the 2019–2020 NSCH analysis plan and ran all above analyses using Complex Samples of SPSS (ver. 28, IBM, Armonk, NY), with α = 0.05.

Results

The demographic description of the adolescents with and without chronic health conditions is displayed in Table 1. The mean age was 14.47 ± 1.70 years old, the average number of adverse childhood experiences were 3.26. The overall sample is balanced with both sexes, but there were slightly more adolescent boys with chronic health conditions (52.4%).

Table 1.

Demographic description of the adolescents with and without chronic health conditions (n = 29,285)

Variable Adolescent without chronic condition (%) Adolescent with chronic condition (%) Overall sample (%)
Sex

 Female

 Male

50.1% (48.2–52.1%)

49.9% (47.9–51.8%)

47.6% (45.8–49.4%)

52.4% (50.6–54.2%)

48.9% (47.6–50.2%)

51.1% (49.8–52.4%)
Race/Ethnicity

 Asian

 Black

 Hispanic

 White

 Other/multiracial

6.1% (5.4–7.0%)

13.8% (12.4–15.2%)

29.8% (27.6–32.1%)

45.7% (43.9–47.5%)

4.6% (4.0–5.2%)

2.6% (2.2–3.1%)

14.4% (13.1–15.9%)

23.9% (21.9–25.9%)

53.0% (51.1–54.8%)

6.1% (5.5–6.9%)

4.4% (4.0–4.9%)

14.1% (13.1–15.1%)

26.9% (25.5–28.4%)

49.2% (48.0–50.5%)

5.3% (4.9–5.8%)
Household Income

 0–99% FPL

 100–199%FPL

 200–399%FPL

 ≥ 400% FPL

18.3% (16.7–20.1%)

22.4% (20.6–24.3%)

28.6% (26.9–30.4%)

30.7% (29.1–32.3%)

17.3% (15.9–18.9%)

21.6% (20.0–23.3%)

29.6% (28.0–31.3%)

31.5% (30.0–33.0%)

17.8% (16.7–19.0%)

22.0% (20.8–23.3%)

29.1% (27.9–30.3%)

31.1% (30.0–32.2%)
Parent Highest

 Education†

 Less than high school

 High school/GED

 Some college

 College degree or more

14.9% (12.9–17.2%)

20.9% (19.3–22.6%)

19.5% (18.3–20.8%)

44.7% (42.8–46.6%)

9.0% (7.6–10.6%)

19.4% (17.9–21.1%)

22.5% (21.1–23.9%)

49.1% (47.4–50.9%)

12.0% (10.8–13.4%)

20.2% (19.1–21.3%)

20.9% (20.0–21.9%)

46.9% (45.5–48.2%)
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Note: † The highest education of any adult in the household, FPL = Federal Poverty Level,

The combined dataset (2019–2020) reported 24 chronic health conditions, whose prevalence was listed in the first column of Table 2. As seen in Table 2, allergies (24.9%), anxiety problems (14.0%), ADD/ADHD (11.5%), asthma (10.1%), and learning disability (9.1%) had the highest prevalence among the 12–17 year old adolescents. Cystic fibrosis (0.1%), Downs syndrome (0.1%), cerebral palsy (0.2%), Tourette syndrome (0.2%), and blood disorders (0.3%) had the lowest prevalence among the 24 chronic health conditions. Overall, 51.5% of the adolescents had no chronic health conditions, and 48.5% had at least one condition. Of those, about 21% had one and 27.5% had two or more conditions.

Table 2.

Prevalence of adolescents with chronic health conditions who bullied others or was bullied in the 12 months based on NSCH 2019–2020 data (12–17 years old)

Current chronic condition (% of the population) Perpetrator in the past 12 months (%) Victim in the past 12 months (%)

ADD or ADHD (11.5%)

Allergies (24.9%)

Anxiety problems (14.0%)

Arthritis (0.4%)

Asthma (10.1%)

Autism spectrum disorders (3.6%)

Behavioral or conduct problems (7.1%)

Blindness or visual impairment (2.2%)

Blood disorders (0.3%)

Cerebral palsy (0.2%)

Cystic fibrosis (0.1%)

Deafness or hearing problem (1.1%)

Depression (7.2%)

Developmental delay (5.2%)

Diabetes (0.7%)

Downs syndrome (0.1%)

Epilepsy or seizure disorder (0.7%)

Genetic or inherited condition (0.6%)

Heart conditions (1.2%)

Headache (frequent include migraine, 5.4%)

Intellectual disability (1.3%)

Learning disability (9.1%)

Speech or language disorder (3.1%)

Tourette syndrome (0.2%)

29.9% (26.7–33.3%)

17.1% (15.3–18.9%)

26.2% (23.2–29.4%)

25.0% (12.4–43.8%)

18.9% (15.3–23.1%)

22.1% (16.6–28.9%)

41.3% (37.0-45.8%)

17.1% (12.0-23.8%)

37.7% (18.0-62.7%)

9.9% (3.1–27.7%)

10.8% (2.4–38.1%)

16.9% (10.4–26.3%)

30.7% (26.3–35.4%)

24.2% (19.7–29.3%)

24.4% (14.7–37.6%)

10.6% (3.4–28.7%)

17.8% (10.0-29.7%)

13.0% (6.9–23.1%)

14.7% (9.9–21.2%)

25.4% (19.2–32.7%)

22.4% (15.0–32.0%)

23.0% (19.7–26.7%)

20.2% (15.1–26.5%)

21.5% (10.4–39.2%)

58.7% (55.4–61.9%)

44.6% (42.2–47.1%)

62.5% (59.2–65.6%)

61.3% (46.8–74.1%)

47.5% (43.4–51.7%)

69.9% (63.4–75.7%)

66.6% (61.6–71.1%)

44.8% (35.7–54.3%)

62.4% (34.8–83.8%)

57.8% (41.6–72.5%)

32.6% (9.6–68.7%)

62.0% (50.2–72.4%)

65.3% (60.4–70.0%)

67.2% (61.6–72.4%)

48.6% (37.1–60.2%)

46.5% (28.4–65.6%)

51.5% (40.1–62.8%)

54.1% (39.7–67.9%)

50.5% (41.3–59.6%)

52.0% (45.5–58.4%)

58.6% (46.0-70.2%)

56.8% (52.4–61.1%)

63.0% (55.2–70.2%)

57.2% (39.2–73.4%)
At least one chronic health condition 22.1% (20.1–24.4%) 51.1% (48.0-54.4%)
No chronic health conditions 13.2% (11.7–15.2%) 33.1% (30.9–35.6%)
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Note: ADD = Attention Deficit Disorder, ADHD = Attention-Deficit Hyperactivity Disorder

As seen in Table 2, adolescents with each of the 24 chronic health conditions had significantly higher percentage of bullying victimization (ranging from 32.6 to 69.9%), than bullying perpetration (ranging from 9.9 to 41.3%) in the past 12 months. Adolescents with behavioral or conduct problems (41.3%), blood disorder (37.7%), depression (30.7%), ADD/ADHD (29.9%), and anxiety problems (26.2%) had the highest percentage of bullying perpetration in the past 12 months. Those with autism spectrum disorders (69.9%), developmental delay (67.2%), behavioral or conduct problems (66.6%), depression (65.3%), and speech or language disorder (63.0%) had the highest percentage of being victimized. Overall, there were significantly higher proportions of adolescents with chronic health conditions who were reported engaging in bullying perpetration (22.1%, 95%CI: 20.1–24.4% vs. 13.2%, 95%CI: 11.7–15.2%), and bullying victimization (51.1%, 95%CI: 48.0-54.4% vs. 33.1%, 95%CI: 30.9–35.6%), compared to peers without a chronic health condition (ps < 0.05).

Adolescents with chronic health conditions were more likely to engage in bullying perpetration and victimization than those with no conditions. As seen in Table 3, adjusting for participant sex, race, household income, the highest adult education, and the number of adverse childhood events, logistic regression models show that adolescents with two or more chronic health conditions had about three times more likely (aOR = 3.56, 95%CI = 3.13–4.06 vs. those with one condition aOR = 1.65, 95%CI = 1.42–1.92) to experience bullying victimization in the past 12 months, compared to those with no chronic condition. Similarly, adolescents with two or more chronic health conditions were almost three times more likely (aOR = 2.97, 95%CI = 2.50–3.54 vs. those with one condition aOR = 1.48, 95%CI = 1.18–1.85) to bully others in the past 12 months, compared to their peers with no chronic condition.

Table 3.

Adjusted odds ratios (OR†) of adolescents with chronic health conditions who bullied others or was bullied in the 12 months based on NSCH 2019–2020 data (12–17 years old, n = 29,285)

Current chronic condition status Bullied other in the past 12 months (OR, 95%CI) Was bullied in the past 12 months (OR, 95%CI)

None

Having one chronic condition

Having two or more chronic health conditions

1 (referent)

1.48 (1.18–1.85)*

2.97 (2.50–3.54)*

1 (referent)

1.65 (1.42–1.92)*

3.56 (3.13–4.06)*
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Note: †Logistic models adjusted for participant sex, race, household income level, highest adult education, and number of adverse childhood events. * p < .01

Discussion

The primary purpose of this study was to examine the prevalence of adolescents with chronic health conditions experiencing bullying perpetration and victimization. Consistent with previous research (Gage et al., 2021; Haegele et al., 2021; Rose & Gage, 2017), adolescents with chronic health conditions in this analysis experienced significantly higher rates of bullying victimization and engaged in significantly higher rates of bullying perpetration than those without chronic health conditions. Notably, victimization (51.1%) and perpetration (22.1%) rates among those with chronic health conditions in this analysis were slightly elevated from previously published rates of 44.5% and 12.63% for victimization and perpetration for adolescents receiving special education services from the 2016 NSCH dataset (Haegele et al., 2021). These elevated figures are of critical concern due to the deleterious outcomes associated with bullying engagement, and reinforce the calls by Rose and colleagues (2011) for more funding, research, and interventions allocations, particularly in school-based contexts, to alleviate this significant concern. One school-based context, extracurricular activities, may have particular value here, given that prior work has demonstrated that engagement in extracurricular activities can have a mitigating effect on bullying involvement for adolescents with chronic health conditions (Haegele et al., 2020).

Bullying Victimization by Group

A major contribution of this analysis is that it helps to identify specific groups of adolescents with chronic health conditions that have comparably higher prevalence of engaging in bullying perpetration or victimization. For example, approximately 2 in 3 adolescents who were identified autism spectrum disorder, behavioral or conduct problems, depression, developmental delays and speech and language disorders were identified as experiencing bullying victimization. Interestingly, these identified groups may each fall into the category of those whose behavioral differences may make them outwardly or conspicuously different from other children (Jackson et al., 2019) that might make them an obvious target for bullies. Of this group, adolescents with autism spectrum disorder demonstrated the highest rate of bullying victimization, at nearly 70%. The disproportionate rate of bullying victimization among adolescents with autism spectrum disorder has received a substantial degree of attention in the literature (Humphrey & Hebron, 2015). According to Kin and colleagues (2000) those with autism spectrum disorder have been described as being the ‘perfect victim’ (p. 6) for bullying because the typical profile of those who are victims of bullying reads remarkably similar to the social experiences of adolescents with autism spectrum disorder (Humphrey & Hebron, 2015; Schroeder et al., 2014). According to Humphrey and Hebron (2015), high rates of bullying victimization among adolescents with autism spectrum disorder may be related to a combination of factors, including an incongruence between the behaviors of adolescents with autism spectrum disorder and those socially expected by peers. The fact that autism spectrum disorder is a hidden or non-obvious disability makes understanding behavioral particularities difficult for peers to understand, and the existence of non-teacher adult support that reduces social interactions and increases social distance between adolescents with autism spectrum disorder and peers. With that, we echo calls from prior work for acknowledging that adolescents with autism spectrum disorder are at an elevated risk for bullying victimization, and for the requirement for individualized and tailored interventions to meet their unique needs (Humphrey & Hebron, 2015).

Bullying Perpetration by Group

This study also identifies groups who are at a particularly elevated risk for engaging in bullying perpetration. In this analysis, adolescents with behavioral or conduct problems (41.3%), blood disorders (37.7%), depression (30.7%), and ADD or ADHD (29.9%) reported the highest rates of bullying perpetration in our sample. It should be noted, prior to further discussion, that researchers have cautioned against identifying adolescents with behavioral or conduct problems as bullying perpetrators, as they may be engaging in behaviors that are a manifestation of their disability and these behaviors may not equate to contemporary definitions of bullying (Rose & Espelage, 2012). Interestingly, most of the ‘at risk’ groups with high rates of perpetration were also identified as experiencing particularly elevated rates of bullying victimization, which may reflect the fluid nature of the bully-victim dynamic (Rose et al., 2015). Referred to as ‘bully-victims’, studies have identified that bullying perpetration behaviors can emerge after adolescents have been victimized from bullying many times, in an attempt to regain a sense of social power (Goldback et al., 2018; Rose et al., 2015). The notion of ‘cycle of violence’ is relevant here, which suggest that exposure to violence incites violence in the victim, hence victims of bullying becoming bullies themselves (Falla et al., 2022). Of further concern, ‘bully-victims’ are known to purposefully target other adolescents who appear weaker or to have less social capital than they do, further affecting marginalized populations, like other adolescents with chronic health conditions. Problematically, ‘bully-victims’ have been identified as experiencing higher vulnerability toward deleterious psychological and physiological health and academic outcomes associated with bullying (Mark et al., 2019; Rose et al., 2015), and as such are most in need of intervention development and implementation.

Bullying and Number of Chronic Health Conditions

A secondary purpose of this study was to examine associations between the number of chronic health conditions and bullying victimization and perpetration. In this analysis, adolescents with two or more chronic health conditions were 3.56 times as likely to be bullying victims and 2.97 times as likely to be bullying perpetrators than those with no chronic health condition. The odds ratios were significantly higher for adolescents with one chronic health condition than those have none as well, controlling participants ethnicity, sex, household income, and number of adverse childhood experiences. These findings support and provide updated data aligned with Jackson and colleagues (2019) assertions that there are multiplicative effects to having more than one chronic health condition with regard to experiences with bullying victimization and perpetration. Additionally, those who experienced multiple chronic health conditions and were engaged in bullying behaviors were more likely to experience additional health-related difficulties (unrelated to their primary diagnoses) than those who experience just one chronic health condition who were engaged in bullying victimization or perpetration.

Study Strengths and Limitations

This analysis includes a number of strengths, including the use of a nationally representative sample of children with and without chronic health conditions and the exploration of the prevalence rates of bullying victimization and perpetration among 24 chronic health conditions. In contrast to studies that use smaller, convenience samples, the utilization of a representative sample enhances the generalizability of our findings. To our knowledge, this is the most comprehensive evaluation of bullying victimization and perpetration among adolescents with chronic health conditions available using recent national data. Despite the inherent strengths of this study, limitations should also be considered when interpreting our results. First, the extent to which parents are aware of bullying experiences of their children is unknown and may be a limitation. As such, the use of parental reports of bullying victimization and perpetration may underestimate the prevalence of these behaviors (Shemesh et al., 2013). In addition, parents were not provided with a definition of bullying during survey procedures, and the bullying variables associated with the NSCH do not distinguish between various severity or types (e.g., physical, social, verbal, cyber) of bullying. As such, the severity and types of bullying experienced by adolescents with chronic health conditions cannot be known from analyses of this, or similar, datasets. While this analysis can help identify groups with need for special attention for research, funding, and interventions, further studies are needed to understand the particularities of bullying experiences among those with chronic health conditions to help with the development and implementation of programs to ameliorate bullying issues. Finally, this analysis used pooled data from 2019 to 2020, and bullying rates during this time may have been influenced by the COVID-19 pandemic and related school closures. With that, some may argue that bullying victimization and perpetration rates should have seen a unique decrease during this time, and that perhaps these figures do not reflect true prevalence rates. This assertion is interesting, though, given our figures were slightly elevated from previous iterations of the NSCH (Haegele et al., 2021). To further understand if figures during this time were a one-time change, future studies may elect to compare bullying perpetration and victimization rates before, during, and after the COVID-19 pandemic. However, we would suggest that this comparison is outside of the scope of the current study.

Conclusion

In conclusion, this analysis demonstrated that, consistent with previous research, adolescents with chronic health conditions experience higher rates of bullying victimization and perpetration than those without chronic health conditions (Gage et al., 2021; Haegele et al., 2021; Rose & Gage, 2017). Among those with chronic health conditions, several groups were identified as engaging in high rates of bullying as both a victim and perpetrator, supporting assertions about the dynamic and fluid nature of the bullying experience. In addition, the multiplicative effect of having more than one chronic health condition was supported, where those with one or more chronic health conditions experience significantly higher odds of experiencing bullying victimization and engaging in bullying perpetration than those without. This analysis has helped to identify a number of groups of adolescents with chronic health conditions who are in need of targeted and specific research and interventions to help reduce bullying victimization and perpetration rates.

Key Messages

  • Bullying behaviors have gained attention as a significant public health issue due to its high prevalence among adolescents and associated deleterious health outcomes.

  • Bullying victimization and perpetration rates among those with chronic health conditions were significantly higher than those without chronic health conditions.

  • Two-thirds of adolescents with autism spectrum disorder, behavioral or conduct problems, and developmental delays experienced bullying victimization.

  • Those with two or more chronic health conditions were over 3.5 times as likely to be bullying victims than those with no chronic health conditions.

Acknowledgements

No grants of financial support were involved in the completion of this study.

Funding

The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations

Conflict of Interest

The Authors declare that there is no conflict of interest.

Ethics

The National Center for Health Statistics Research Ethics Review Board and the National Opinion Research Center Institutional Review Board approved all the study procedures.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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