Description

• “Aggressive behavior or intentional harm-doing by peers that is carried out repeatedly and involves an imbalance of power, either actual or perceived, between the victim and the bully” (1)
• Bullying behaviors begin in elementary school, peak during middle school, and begin to subside as children progress through high school.
• Bullying can occur outside of peer groups such as adult-on-child bullying.
• Bullying is more common in children, although frequent in workplaces, and other adult-only environments.
• Commonly a pediatric or early adult issue, but cyberbullying can occur anywhere, at any age, such as at work or in college between students or student bullying of professors on anonymous course evaluations
• Media has linked bullying to dramatic, horrific, aggressive behavior; torture; and suicide, but most bullying is repeated microaggressions.
• Bullying can be either direct, such as physical or verbal aggression, or indirect, such as insults, threats, name calling, spreading rumors, or encouraging exclusion from a peer group.
• Subtypes: “Alpha” bullies tend to be popular, socially dominant, with less comorbid psychopathology in contrast to “delta” bullies—more dysregulated, less socially skilled, more associated behavioral problems.
• Bystanders present in >85% of episodes; a minority actively helps victims (10–25%). As many as half of peers passively watch; 1 in 5 actively supports bullies.
• Hazing is a form of bullying.
• Bully victims are those who are both bullies and victimized during their lives.
• Bullying is estimated to cause children to miss approximately 160,000 days of school each year (2).

Epidemiology

Incidence
20% of high school youth reported being bullied on school property in the prior 12 months.

Prevalence
25% of high schoolers admit to being a bully at some point in their lives, and 17% of middle schoolers say they have bullied someone at school.

Etiology and Pathophysiology

• Bullies’ motivations are to dominate victims, increase their own social status, and instill fear in potential victims.
• Their modus operandi is to abuse their victims, either physically or (more commonly) psychologically/verbally.

Genetics

• Bullying and victimization has not been linked to genetic influences.
• In monozygotic twins, genetically identical and living in the same household but discordant for bullying experiences; emotional problems increase over time only in those bullied (3).

Risk Factors

• For victims:
  • Often unassertive, easily emotionally upset, and as having poor emotional or social understanding
  • More likely to have psychosomatic, emotional, or peer problems or social anxiety, low peer acceptance
  • More likely to come from families with structures other than two biologic parents
  • Greater female correlation with depression
  • School bullying is a risk factor for suicide.
  • Males are more likely to stand up to bullies.
  • Targets may be perceived as different due to physical or mental disability, race/ethnicity, spoken language, socioeconomic class, gender expression, or sexual preference.
  • Being bullied for sexual orientation has a higher association with depression and suicidality than bullying for other reasons.
• For bullies:
  • Males are more likely to bully; physical bullying is more common in boys, whereas bullying among girls is more likely to be relational or verbal.
  • Frequent smoking, alcohol
  • Low prosocial behavior (limited empathy, other callous emotional traits such as shame)
  • Not associated with different ethnic, racial, or socioeconomic status
• For those who are both bully and victim:
  • Higher rates of severe psychiatric illness
  • Aggressive, easily angered, low on popularity, frequently bullied by their siblings, and come from families with lower socioeconomic status

General Prevention

• Schools, physicians, coaches, supervising adults should understand when youth behavior is unacceptable and be trained on how to intervene.
• Antibullying legislature exists in 49 states; has been shown to decrease bullying incidence
• Screen for bullying risk factors at primary care visits.
• Monitor for sudden change in behavior (depression, suicidal ideation), truancy, somatic symptoms without clear cause.

Commonly Associated Conditions

• Cyberbullies are more likely than not to be prior bullying victims.
• Behavioral health comorbidities
• Bully victims are more likely to bring guns to school and engage in school violence.
• Victims report more depressive symptoms; bullies report more problems with substance use and antisocial traits.
• Sexual harassment is a common form of bullying as adolescents transition to high school; can lead to different sequelae than nonsexualized bullying because sexual predation has a greater focus on gender, power, and cultural roles of males and females