Commentary: Guiding a Public Health Approach to Bullying

Tragic events have served to focus the nation on possible profound and damaging effects of bullying on victims, on bystanders and on the school and community environments. Although a reliance on self-report and issues of definition and survey structure are concerns (Sawyer, Bradshaw & O’Brennan, 2008), recent analyses of national representative samples estimate about 30% of adolescents are involved in bullying with about half as victims (Wang, Ianotti & Nansel, 2009). The report by Wang et al. (2010) uses latent class analyses of a nationally representative sample of youth who completed the Health Behavior in School-aged Children (HBSC) study to identify a group of adolescents (All Types) who appear likely to be victimized by all types of bullying, including cyberbullying. The strong support for the relation between this type of victimization and a variety of psychological and physical sequelae suggest that intervening carefully at an individual level may be a useful strategy; however, such a strategy needs to be applied cautiously to avoid possible negative consequences and represents only one component of a comprehensive approach to this underestimated public health crisis.

Patterns of Victimization

The All Types group reported higher levels of depression and use of medications for sleep and nervousness, in keeping with other work identifying anxiety and low-self esteem as factors that may increase vulnerability to bullying (Egan & Perry, 1998). This work suggests an intervention strategy of providing such at-risk groups with techniques to use to avoid teasing and harassment (Berry & Hunt, 2009). However, efforts to impart these strategies may create a risk of further victimization (Wessler, 2003). Bullying usually involves a perceived power differential; youth who are bullied often are too frightened to utilize strategies. Moreover, if, after implementing strategies promoted by teachers or parents, harassment continues, victims may believe that the bullying is their fault and/or that they have failed an important adult in their lives. To avoid negative consequences, such interventions need to be used cautiously and should be coupled with a universal approach to teach all students the skills (problem-solving, decision-making, risk avoidance) to deter and interrupt bullying and to promote acceptance of all individuals. School-wide interventions also address the negative impact of witnessing bullying. Recent work suggest that 60% of teens observe bullying in school at least once a day, and witnessing predicts risks to mental health over and above that of direct involved in bullying behavior as either a perpetrator or a victim and irrespective of whether students are or are not victims themselves (Rivers, Poteat, Noret, & Ashurst, 2009).

A caution in focusing on the All Types group is the need for more data on relative risk for negative impact. More frequent exposure to one type of bullying may result in greater effects than a broad range of bullying behaviors. Alternatively, the impact of a single act of bullying committed by several students may be highly correlated with impact.

Cyber-bullying

Almost 20% of adolescents in the Wang et al. (2010) study reported experiencing cyber-bullying and the experience was independently associated with increased social anxiety. The growing use of cyber-bullying will demand that we develop new responses as well as adapt and extend responses that have proven successful in addressing more traditional forms of bullying. Cyber-bullying often occurs out of school, restricting school-based interventions. Educators are unsure of their authority to intervene; only about one-third of states offer guidance about whether schools may intervene in bullying involving electronic communication. Also, cyber-bullying relates differently to variables that guide intervention, and data are needed in order to avoid unintended consequences. For instance, enhanced peer support, often understood as an important factor in victimization, may not have the same influence in cyber-bullying (Wang et al., 2009). Also, parent monitoring, a frequent component of bullying prevention, may likely be detrimental, if, in trying to protect their children, families restrict use of the Internet.

Impact on Physical and Emotional Health

The Wang et al. (2010) study and other work supports the link between bullying and physical as well as psychological outcomes, highlighting the need to engage health providers to identify and intervene with youth (American Academy of Pediatrics, 2009). Besides emotional issues, such as anxiety and depression, other sequelae of bullying such as common physical complaints, reduced scholastic competence, and school absenteeism, are often reported first to medical professionals. Strategies such as regular screening for bullying involvement, anticipatory advice and appropriate referral are essential ways that medical staff can contribute to addressing the problem. However, increasing the capacity of medical staff to successfully implement such strategies requires new approaches to address the attitudinal, organizational, and training barriers that impede engaging diverse families, initiating treatment, and collaborating with educational, mental health and other involved systems (Wissow et al., 2008).

Public Health Approach

The scope and impact of bullying demands a coherent, integrated and comprehensive public health approach, following several guiding principles (Miles, Espiritu, Horen, Sebian & Waetzig, 2010). First, the Wang et al. (2010) paper and other recent work are examples of the type of population-level research necessary to provide appropriate data to drive effective intervention decisions and strategies. Second, a public health approach should strive to create environments that support optimal mental health and the building of skills that enhance resilience. Working with those children most at risk for victimization or bullying may be important; however, intervening at that level may be pointless if more community-wide supports are not in place. Informed development of interventions that empower all students with the skills and behaviors to promote positive behaviors and protect themselves is needed to help prevent bullying and increase the possibility of bystander intervention. Evaluation of such whole-school interventions is rare and has shown only modest success (Olewus, 1993; Smith, Ananiadou & Cowie, 2003), however. More broadly, a public health approach includes a strong emphasis on larger social factors that might influence outcomes. Such macro-determinants have been little considered, although, recent work has shown the strong effect of economic inequality on both bullying (Elgar, Craig, Boyce, Morgan, & Vella-Zarb, 2009) and victimization (Due et al., 2009).

A public health approach should balance promotion and prevention. An emphasis on building skills to reduce and prevent bullying in those youth with identified individual and social risk profiles has been a staple of interventions in the Europe and the USA. However, programs to promote social–emotional development may be an important strategy as well. For example, early parenting behaviors such as cognitive stimulation and emotional support have been shown to confer resilience against the future development of bullying behaviors. Finally, a successful public health approach requires coordination across a broad range of systems and sectors to create policy and program strategies to protect young people. For example, the precipitous rise in cyber-bullying will require sensitive screening for such activity in a variety of settings; development of effective campaigns using accessible social media coupled with parent–teacher efforts to raise awareness and strategies to intervene; relevant business involvement (e.g., Facebook); and careful integration of law enforcement, legal and school policy to implement strategies both to combat both on site and off site harassment. A comprehensive and coordinated strategy informed by knowledge of bullying determinants is needed to engage multiple sectors.

Funding

This commentary was supported by grants from the Substance Abuse and Mental Health Administration (SM056495) and the National Institute of Mental Health (P20MH082743).

Conflicts of interest: None declared.