Bullying Victimization (Being Bullied) Among Adolescents Referred for Urgent Psychiatric Consultation: Prevalence and Association With Suicidality

Abstract

Objective:

To examine the prevalence of bullying victimization among adolescents referred for urgent psychiatric consultation, to study the association between bullying victimization and suicidality, and to examine the relation between different types of bullying and suicidality.

Method:

A retrospective chart review was conducted for all adolescents referred to a hospital-based urgent consultation clinic. Our study sample consisted of adolescents with a history of bullying victimization. The Research Ethics Board of Queen’s University provided approval. Data analysis was conducted using SPSS (IBM SPSS Inc, Armonk, NY). Chi-square tests were used for sex, suicidal ideation, history of physical and sexual abuse, and time and type of bullying, and an independent sample t test was used for age.

Results:

The prevalence of bullying victimization was 48.5% (182 of 375). There was a significant association between being bullied and suicidal ideation (P = 0.01), and between sex and suicidal ideation (P ≤ 0.001). Victims of cyberbullying reported more suicidal ideation than those who experienced physical or verbal bullying (P = 0.04).

Conclusions:

Bullying victimization, especially cyberbullying, is associated with increased risk of suicidal ideation among adolescents referred for psychiatric risk assessment. The detailed history of the type and duration of bullying experienced by the victims should be considered when conducting a psychiatric risk assessment.

Bullying and victimization is a universal public health concern that affects a significant proportion of adolescents.¹ Bullying is characterized by repeated aggressive behaviour with the intention to harm the victim, and an imbalance in power between the bullies and their victims, making it difficult for the victims to defend themselves.^2–4 Bullying may be direct or indirect aggression, it may be verbal, physical, psychosocial, emotional, or cyber bullying.^5–7 In the last decade, research has shown that about 10% to 30% of children and adolescents are recurrently involved in school bullying, either as victims, bullies, or bully-victims.^8,9 Factors that confer risk for bullying victimization include being female, low socioeconomic status, belonging to a minority group, being overweight, having a learning disability, and having poor social skills.¹⁰ There is growing evidence that bullying victimization may have numerous negative, long-term mental health consequences, including anger, sadness, anxiety, depression, self-harm, and suicidal ideation and attempts.^7,8 Further, both bullies and victims are overrepresented among those seen by mental health professionals. One study found that about 24% of victims, 42% of bullies, and 44% of bully-victims had contact with mental health professionals, compared with 13% of control subjects.¹¹

There have been very few studies on the association between bullying victimization and psychiatric disorders in clinical populations. A Finnish study¹² investigated the association between bullying, suicide attempts, and self-mutilation among 508 adolescents, aged 12 to 17 years, who were admitted to inpatient psychiatric units. The results showed that 61 boys and 115 girls were victims of bullying. Self-harm was present in 21 boys and 74 girls, and 78 girls and 26 boys had made a suicide attempt. After adjusting for age, family factors, and psychiatric disorders, there was a higher risk of suicide attempts in girls who were bullied or who bullied others.¹² The authors recommended psychiatric evaluation of bullying behaviour, as this may be an early marker of psychiatric disorders.¹² A Norwegian cross-sectional study¹³ of 685 patients aged 13 to 18 years used an electronic questionnaire that showed that 19% reported being bullied often or very often, and 51% reported being bullied from time to time. There was an association between being a victim of bullying and having a mood disorder.

Clinical Implications

• History of bullying victimization would be helpful when assessing adolescents for risk of suicide.

• Specific questions about cyberbullying are merited when conducting an assessment for risk of suicide.

Limitations

• Standard questionnaires for bullying were not used.

• There is no information on whether both bullying and being a bullying victim coexisted.

Our study examined the prevalence of bullying victimization (being bullied) and its association with suicidality in adolescents referred to a hospital-based outpatient psychiatric urgent consultation clinic.

Method

The sample for our study was drawn from the 12-month database of an outpatient urgent consultation clinic. This clinic provides expedited assessment of adolescents referred by emergency department (ED) physicians, school boards (counsellors), pediatricians, family physicians, and community mental health agencies—if they deem the patient urgent rather than emergent (able to wait 24 to 48 hours for assessment). Informed consent had been given by the parents and youth to have their information included in research studies that did not identify them individually. From this database, we extracted youth who had been bullied and entered their details in a separate file. Each chart was then reviewed by the research assistant to extract data for the variables under study, which included sex, age, time period of being bullied (past or present), type of bullying (verbal, physical, and [or] emotional) and history of sexual, physical, or emotional abuse. Confidentiality was maintained by password-protected files.

Data were entered in Microsoft Excel 2010 format, and SPSS (IBM SPSS Inc, Armonk, NY) was used for analyzing the data. Chi-square tests were used for sex, suicidal ideation, history of physical and sexual abuse, time and type of bullying, and an independent sample t test was used for age.

This study was approved by the Research and Ethics Board of Queen’s University.

Results

During the 12-month study period, 375 patients were assessed in the clinic, and 182 (108 females and 74 males) of those reported a current and (or) past history of being bullied, yielding a prevalence of 48.5%. Their average age was 14.4 years. Table 1 shows the sociodemographic distribution of study variables.

Table 1.

Sociodemographic factors and distribution of study variables of patients who were bullied (total n = 182)

Factors	n	%
Sex
Male	74	40.7
Female	108	59.3
History of abuse
Physical	8	4.4
Sexual	14	7.7
Emotional	10	5.5
Physical and emotional	11	6.0
Physical and sexual	3	1.6
Sexual and emotional	1	0.5
All	4	2.2
None	130	71.4

There was a statistically significant association between sex and being bullied (χ² = 135.01, df = 2, P < 0.001) (Table 2). The odds of females being bullied was 1.8 times higher than males (OR 1.8, 95% CI 1.6 to 2.9). We did not find an association between age and being bullied (t = 2.86, df = 200, P = 0.09). Suicidal ideation, threats, or plan was reported by 123 of the 182 patients and 26 reported self-harming behaviours. There was a statistically significant association between history of being bullied and suicidal ideation (χ² = 5.81, df = 1, P = 0.01). The odds of being bullied in patients who were suicidal were 2 times higher than those who were not (OR 2, 95% CI 1.5 to 3.2) (Table 3 shows the distribution by type of bullying). Patients who were cyberbullied reported more suicidal ideation, compared with those who were verbally bullied (χ² = 4.09, df = 1, P = 0.04) (Table 3). Suicidal ideation was 3.6 times higher in those who experienced cyberbullying (OR 3.6, 95% CI 1.3 to 10.9). However, there was no statistically significant difference between being both physically and verbally bullied and being cyberbullied (χ² = 2.34, df = 2, P = 0.12) (Table 2). There was no significant difference in suicidality between those with a past or present history of being bullied (χ² = 0.2, df = 1, P = 0.3) and no association between being bullied and history of abuse (Table 2).

Table 2.

Results of chi-square tests for sex, suicidal ideation (SI), type, and time of bullying

Risk factor	χ2a	P	OR
Female sex and bullying	135	<0.001	1.8
Bullying and SI	5.8	0.01	2.0
Cyberbullying and SI	4.1	0.04	3.6
Physical and verbal bullying and SI	2.3	0.12	n/a
Current bullying and SI	0.2	0.3	n/a

^adf = 1

n/a = not applicable

Table 3.

Bullying and suicidality among psychiatric urgent consultation patients (total n = 182)

Factor	n	%
Suicidal ideation	123	67.6
Self-harming behaviour	26	14.3
Types of bullying
Verbal	55	30.2
Physical	2	1.1
Cyber	9	4.9
Verbal and physical	27	14.8
Verbal and cyber	12	6.6
All	11	6.0
Nonspecified	66	36.3
Time of bullying
Current	76	41.8
Past	41	22.5
Both	65	35.7

Discussion

Our study aimed to examine the prevalence of bullying victimization and its relation with suicidal ideation among adolescents seen in an outpatient psychiatric clinic for risk assessment. Unlike other studies involving adolescents and bullying victimization, ours was a prospective study that measured victimization in a population of adolescent patients referred for urgent psychiatric assessment. Our prevalence rate (48.53%) was much higher than in the general population, and higher than that reported for other mental health clinics and inpatient populations.¹⁴ This finding is explicable based on the demographics of our population and the referral patterns in our region.¹⁸ There are a disproportionate number of prisons in our region; we have a large proportion of single-parent families on social assistance and children with multiple biopsychosocial vulnerabilities. The local school boards, community mental health agencies, pediatricians, and ED physicians have had training for appropriate use of the urgent clinic in triaging high-risk patients. In examining the relation between suicidality and being bullied, our results replicate those from previous studies; there is a higher prevalence of suicidal ideation and self-harm behaviours among bullied patients.^2,5,15 In our study, females were overrepresented, similar to previous studies^16,17; this is explicable based on existing information that females are more likely to express their distress, either directly or indirectly, to friends and family and are more willing to seek mental health help. Males are less likely to do so and may only present to the ED having made a suicide attempt, leading to admission to the hospital, rather than to an urgent consultation referral.^16,18–20

The type of bullying experienced by participants was also consistent with reports from victims of bullying in other studies.^1,15 Verbal aggression was the most common among victims, and physical aggression (for example, hitting, pushing, and kicking) was a less common occurrence. This result may be partly explicable based on the zero tolerance policy for physical aggression in schools. Congruent with prior research,⁷ involvement in cyberbullying was found to be less frequent than other forms of bullying. However, significant links were found between being cyberbullied and suicidal ideation. Further, students who are cyberbullied are less likely to report and seek help than those who are bullied by more traditional means, decreasing their levels of social support and putting them at a greater risk of suicidal ideation.⁷

ED staff would be well advised to ask whether the youth is being threatened or demeaned on social media, such as Facebook, emails, and (or) texting. Unlike traditional forms of bullying, cyberbullying has characteristics that make it much more pernicious than traditional bullying, such as the victim may continue to receive emails, Facebook or Twitter messages, or text messages regardless of time and place; and the possibility of widespread dissemination of demeaning or threatening material to a large audience of peers. Further, cyberbullies feel protected and have a sense of invisibility and anonymity. This feeling of invisibility can also allow bullies to be less aware of the consequences of their actions, and without such direct feedback, the bullies may have less empathy or remorse, and also less opportunity for bystander (teacher, parent, or peer) intervention.²⁰ The introduction of social networks (MySpace, Facebook, Twitter, and Instagram) has provided new forums for relational conflict.¹⁷ Awareness of the risks inherent in the increased access to the Internet and other technologies, and the possible increased risk of cyberbullying, is important for health care professionals.

Conclusion

Bullying victimization is a potential risk factor for suicidal behaviour among youth. In recent years, cyberbullying has led to suicides among females. Thus a detailed history of the extent and type of bullying should form an integral part of a suicide risk assessment in youth.

Strengths and Limitations

The strength of our study lies in its prospective design, and it is one of a very few studies on outpatient clinic populations. A limitation is that we did not use any specific bullying questionnaire, and data were derived from history only. We have no information on whether the victims were bullies themselves, as there is evidence to suggest that bullying and being bullied can be present in the same person.

Future Directions

A larger outpatient prospective study on bullying victimization with structured questionnaires for both youth and parents, and special attention to the growing problem of cyberbullying would add to existing knowledge.