Bullying: the need for an interagency response

Most readers will have experience of bullying either through their own schooldays or those of their children. But bullying may not necessarily be seen either as a social problem or one that has significant implications for health professionals. For many years bullying was the concern of teachers, educationalists, and educational psychologists. Current definitions, however, which highlight abuse, victimisation, and aggression, indicate why it requires the attention of all those who work with children. And recent research, including some in this week’s issue, shows psychological effects which should command the attention of doctors.

Over time perceptions have changed of what constitutes bullying, but it may include a range of activities including hitting, pushing, spreading slander, provoking, making threats, extortion, and robbery.¹ The commonest types of bullying reported by victims are name calling, followed by being hit, threatened, or having rumours spread about one.² Interestingly in a British investigation of teachers’ views on bullying, undertaken in the mid-1990s, many did not see teasing or social exclusion as bullying.² Although health professionals’ definitions or attitudes towards bullying are unknown, those of community paediatricians, general practitioners, and school nurses would be of particular interest.

Bullying is not confined to one type of institution (primary or secondary school), sector (public or private), or country or continent. There are published reports from Australia, Britain, Japan, Spain, and the United States, although early accounts came from Scandinavia. But findings from one country may not be transferable to another, as illustrated by prevalence rates which range from 5% to 35%. In the most extensive study of bullying in Britain to date 27% of junior and middle school pupils and 10% of secondary school pupils said that they had been bullied sometime or more often that term; 10% of junior and middle school pupils and 4% of secondary school pupils were bullied at least once a week.³ Moreover, when teachers’ reports are matched with those of children high levels of agreement are found.⁴

Victims’ characteristics include being anxious and unsure as well as having an insecure attachment pattern, being withdrawn, and behaving passively.⁵ Recent work suggests that children with learning disabilities and physical disabilities may also be vulnerable,⁶ although this conflicts with earlier studies.⁴ Young carers may be particularly prone to bulling, as reported by 71% of respondents in a recent survey for the Princess Royal Trust for Carers. Distinctions between bullies and those bullied nevertheless may not be clear cut since bullies may also be victims, as the study in this week’s issue by Forero et al (p 344).⁷

Recent social trends such as the rise in the incidence of violence in most industrial countries has led to increasing interest in school behaviour and prompted further research on childhood aggression and violence. For example, in the United States there have been eight school shooting incidents in the past two years. There is also greater awareness of the mental health problems of young people, estimated to be as high as 20% in some parts of Britain, where teenage rates of suicide give rise to alarm. Yet there is a paucity of research on bullying originating in child psychiatry.⁸

This may change as more evidence of the mental health effects of bullying emerges. Another study in this week’s issue by Kaltiala-Heino et al from Finland (p 348)⁹ adds to previous evidence that children who are involved in bullying may suffer psychological and physical distress in the short term.⁵ There are also likely to be long term effects. In a Swedish study boys who had been victimised had much higher levels of depression and a more negative view of themselves at the age of 23.⁴ Bullying may be associated too with later alcohol problems and family violence.⁹ Even more worryingly, there is evidence of intergenerational continuity of victimisation.⁵

Clearly, there are wide ranging reasons why mental health professionals should be concerned about bullying in school. But bullying is so common that all doctors having contact with children are likely to see some who are being bullied or are bullies.¹ As is well established, schoolchildren who present with somatic problems such as headaches, stomach ache, bedwetting, and sleeping difficulties may in fact be experiencing victimisation at school. It is not sufficient, however, for only doctors to be vigilant in clinical practice—especially since general practitioners may spend about 20% less time with adolescents in their surgeries than they do with other patients.¹⁰ Interagency collaboration is needed for bullying,¹¹ as more generally for children’s health needs.¹²

Current health service provision for schoolchildren may need to be reviewed. In Britain services for children are fragmented, and the school health service, which could play an important part in relation to bullying,⁶ is patchy, understaffed, and under threat. Preventative work above all else requires multidisciplinary input. Greater liaison and communication between all those who work with children and young people is required urgently if bullying, which is a social as well as individual problem, is to be tackled.

Papers pp 344 and 348