Bullying in Children: Public Health Implications and Prevention Strategies

The WHO has classified childhood bullying as a major public health problem1 and has been known for decades to increase the risk of poor health, social and educational outcomes in childhood and adolescence.2

The dynamics within such relationships are consolidated by repeated and sustained episodes of bullying: bullies accumulate compound power while victims are stripped of what is theirs and become increasingly less able to defend themselves and increasingly vulnerable to psychological distress. .4 However, only in the last decade have prospective studies been published revealing the far-reaching effects of childhood bullying that extend into adulthood.

There is now substantial evidence that bullying in childhood or adolescence has a causal relationship with the development of mental disorders, health problems beyond the first years of life, including depression, anxiety and suicidality. .5

As such, addressing the global public health problem of childhood bullying has received increasing international attention and is vital to the achievement of Sustainable Development Goal 4.6 The impact of the COVID-19 pandemic on health and education has focused even more attention on bullying in its digital form, so-called "cyberbullying", the prevalence of which is feared to be increasing.7

Participants in child bullying assume one of three roles:

1. the victim
2. the harasser (or aggressor)
3. the bully-victim (who is both the perpetrator and the victim of bullying).5

Victims and bullies belong to the same peer group (peer bullying) or the same family unit (sibling bullying),8 although bullying often occurs in multiple settings simultaneously, such as at school (peer bullying) and in the home (sibling bullying), representing a pervasive ecology of bullying that permeates the child’s life.

There are three main types of bullying briefly described in Table 1. While traditional bullying has been recognized and studied for many decades9 and is often accepted as an inevitable aspect of a normal childhood,3 cyberbullying represents a relatively new phenomenon in which child bullying now occurs through digital modalities.

Widespread adoption of electronic devices has reached near-complete saturation among adolescents in high-income countries, with users checking their devices hundreds of times and for hours a day.10 While providing beneficial access to information and support Socially, this large and increasing online exposure of young people makes them vulnerable to exploitation, gambling and grooming by criminals and sexual abusers, as well as cyberbullying.11

Due to the increased potential for large audiences, anonymous attacks, and the permanence of posted messages, along with lower levels of direct feedback, reduced time and space limits, and decreased adult supervision, it is feared that the Cyberbullying may represent a greater threat to the health of children and adolescents than traditional forms of bullying.12

Two large-scale international surveys regularly conducted by WHO, the Global School Student Health Survey (GSHS) 13 and the Health Behavior in School-aged Children (HBSC) study, 14 provide data from 144 countries and territories across all regions. of the world.

These data identify specific factors that strongly influence the type, frequency and severity of bullying experienced by children and adolescents globally. These factors, briefly described in Table 2, suggest that children who are perceived as “different” in some way are at greater risk for victimization.

A 2019 report from the United Nations Educational, Scientific and Cultural Organization (UNESCO) 15 examined the global prevalence of bullying in childhood and adolescence using data from the GSHS and HBSC studies along with additional data from the “ Progress in International Reading Literacy Study”16 and the “Program for the Assessment of International Students.”17

It was found that almost one in three (32%) children worldwide have been bullied on one or more days in the previous month, and that 1 in 13 (7.3%) have been bullied on six or more days during the same period.15 However, there is substantial regional variation in the prevalence of bullying around the world, ranging from 22.8% of victimized children in Central America, to 25.0% and 31.7% in Europe and North America, respectively 48.2% in sub-Saharan Africa.

There is also significant geographic variation in the type of harassment reported, with direct physical and sexual harassment predominating in low- and middle-income countries, and indirect harassment being the most common type in high-income regions. However, bullying is a significant public health problem of truly global importance.

Encouragingly, there has been a decrease in the prevalence of bullying in half (50.0%) of countries since 2002, while 31.4% have seen no significant change over this time period.15 However, 18.6% of countries have witnessed an increase in child bullying, mainly between members of one sex or the other, although among both girls and boys in North Africa, Sub-Saharan Africa, Myanmar, the Philippines and the United Arab Emirates. fifteen

Since its emergence, cyberbullying has received considerable attention from the media, which claims that the near-ubiquitous adoption of social media among teenagers has induced a wave of online victimization and triggered multiple high-profile suicides among teenagers. after being harassed online.18 19

However, a recent meta-analysis suggests that cyberbullying is much less common than bullying in its traditional forms, with online victimization rates less than half those offline.20

The study also found relatively strong correlations between bullying in its traditional form and cyber variety, suggesting that victims of online bullying can also be bullied offline, and that these different forms of victimization reflect alternative methods of representing bullying. same behavior of the perpetrator.

Recent evidence from England also indicates a difference between the sexes, with 1 in 20 female adolescents and 1 in 50 male adolescents reporting being victims of cyberbullying in the previous 2 months.21

There is a wide range of possible consequences of childhood bullying, determined by multiple factors, including the frequency, severity and type of bullying, the role of the participant (victim, bully, or bully-victim), and the timing of observations. the consequences (during childhood, adolescence or adulthood).

The consequences can be grouped into three broad categories:

1. Educational consequences during childhood and adolescence.
2. Consequences for health during childhood and adolescence.
3. All the consequences during adulthood.

Children who are frequently bullied are more likely to feel like an outsider at school,17 while indirect bullying specifically has been shown to have a negative effect on socialization and feelings of acceptance among children in schools.22

Consequently, a child’s sense of belonging to school increases as bullying decreases.22 Additionally, being bullied can affect continued participation in driving. Compared to those who are not bullied, children who are frequently bullied are almost twice as likely to regularly miss school and are more likely to want to leave school after completing secondary education.16

Children who are bullied have lower test scores than those who are not bullied. For example, in 15 Latin American countries, the test scores of bullied children were 2.1% lower in math and 2.5% lower in reading than children who were not bullied 22 or rarely bullied, Mean learning achievement scores were 2.7% lower in children bullied monthly and 7.5% lower in children bullied weekly, indicating a dose-response relationship. These findings are consistent globally in both low- and high-income countries.17

Numerous meta-analyses, 2 23-26 longitudinal studies5 27 28 and cross-sectional studies29-31 have demonstrated strong relationships between childhood bullying and physical, mental and social health outcomes in victims, bullies and bully-victims. The physical health outcomes reported are mostly psychosomatic in nature.

Most studies focused on impacts on victims, although adverse effects on bullies and victims of bullies are also recognized. Many studies identified a dose-response relationship between the frequency and intensity of bullying experienced and the severity of reported negative health consequences.

While there is significant regional variation, the association between childhood bullying and suicidal ideation and behavior is recognized globally.32 Alarmingly, childhood bullying victimization is associated with a risk of mental health problems similar to those experienced children in public or substitute care.33

Victimization in sibling bullying is associated with substantial emotional problems in childhood, including low esteem, depression, and self-harm,8 and increases the risk of further victimization through peer bullying. Overall, adverse mental health outcomes due to childhood bullying appear to have a more severe impact on victims of bullying, followed by victims and bullies.34

Nine out of 10 teens who report being victimized by cyberbullying are also victims of bullying in its traditional forms,35 meaning cyberbullying creates very few additional victims,36 but it is another weapon in the bully’s arsenal and has not replaced traditional methods.37

Cyberbullying victimization appears to be an independent risk factor for mental health problems only in girls and is not associated with suicidal ideation in either gender. 38 As such, traditional bullying remains the leading type of bullying associated with poor mental health outcomes in children and adolescents.21

A recent meta-analysis39 and many other prospective longitudinal studies40, 41 using large population-based community samples analyzed using quantitative methods suggest that childhood bullying can lead to three main negative outcomes in adulthood for victims, bullies, and bullies. stalkers: psychopathology, suicidal tendencies and criminality.

There is a strong dose-response relationship between the frequency of peer victimization in childhood and adolescence and the risk of adversity in adulthood.39 For example, frequently bullied adolescents are twice as likely to develop depression in early adulthood compared to their non-victimized peers, and is observed in both men and women.41

Surprisingly, the effects of this dose-response relationship appear to persist until at least 50 years of age.33

The impact of childhood bullying victimization on mental health outcomes in adulthood is staggering. Approximately 29% of the burden of depression in adulthood could be attributed to peer victimization in adolescence, 41 and bullying victimization by peers is thought to have a more impactful negative effect on adolescents. adult mental health than adult abuse, including sexual and physical abuse.42

Finally, these consequences go beyond the health sphere, since childhood bullying victimization is associated with a lack of social relationships, economic difficulties, and a poor perceived quality of life at the age of 50.33

Until not long ago, being bullied was considered a normal rite of passage through which children simply had to persevere.3 However, the size and scale of its impact on childhood health, and later on the health of adulthood , are now clearly understood and make it a major public health problem requiring urgent attention.1

While parental and peer support is known to protect against victimization, regardless of global location, cultural norms, or socioeconomic status, 43 structured programs have been implemented at scale to prevent victimization and its associated problems.

School-based interventions have been shown to significantly reduce bullying behavior in children and adolescents. School-wide approaches that incorporate multiple disciplines and high levels of staff involvement provide the greatest potential for successful outcomes, while targeted, curriculum-based social skills training are less effective methods that may even worsen victimization. 44

The most widely adopted approach is the Olweus Bullying Prevention Program (OBPP), a comprehensive, school-wide program designed to reduce bullying and achieve better peer relationships among school-age children.9 However, despite Despite its wide global acceptance, meta-analyses of studies examining the effectiveness of OBPP have shown mixed results in different cultures.45,47

Cooperative learning, in which teachers increase opportunities for positive peer interaction through carefully structured group learning activities in schools, is an alternative approach to bullying prevention that has recently gained traction and has been shown to significantly reduces bullying and its associated emotional problems while improving student engagement and educational performance.48

Also located within the educational environment, school-based health centers became popular in the US in the 1990s and provide medical, mental health, behavioral, dental, and vision care for children directly in schools, and have had some positive impacts in mitigating the prevalence and impact of bullying.49

In the UK, school nurses act as links between primary care and education systems and are often the first to identify victims of bullying, although their numbers in the UK have fallen by 30% among 2010 and 2019.50

Due to the link between sibling and peer bullying, there have been calls for bullying prevention interventions to be developed and made available to start in the home, and for GPs and paediatricians to routinely ask about sibling bullying. .8

While countless cyberbullying prevention programs, both online and offline, are marketed to educational institutions, only a small proportion have been rigorously evaluated.51 Furthermore, since cyberbullying rarely induces negative impacts on children’s health Independently, interventions to address these must also target traditional forms of bullying to have a meaningful impact.

Addressing the global public health problem of bullying in childhood and adolescence is vital to achieving the Sustainable Development Goals. In recognition of this, UNESCO recently launched its first International Day Against Violence and Bullying in Schools, an annual event that aims to raise global awareness of the scale of the problem, the severity and the need for collaborative action.52

Significant progress on this issue is urgently needed to increase mental well-being and reduce the burden of mental illness in both children and adults globally.

GPs should be prepared to consider bullying as a potential contributing factor in children’s presentations of non-specific physical and mental health complaints.

While GPs recognize their responsibility to deal with disclosures of childhood bullying and its associated health consequences, they often feel unable to do so adequately due to the limitations of time-pressured primary care consultations and the uncertainty surrounding the specialized services to which these children can go. 53

In both primary and secondary care, there is a lack of clear management and referral pathways for health professionals dealing with child bullying. Local, national, and online anti-bullying organizations, such as Ditch the Label54 and Anti-Bullying Alliance,55 provide free counseling for children affected by bullying, and their parents, teachers, and health professionals, along with free training in certified line for anyone who works with children.

School nurses continue to act as a link between primary care and educational systems56 and should be essential for the multidisciplinary management of childhood bullying. Finally, if bullying is considered to contribute to childhood depression, child and adolescent mental health services, together with primary care physicians and education professionals, should work collaboratively to promote effective anti-bullying approaches. harassment.57

Table 1. Typical characteristics of the main types of childhood bullying