Identifying and Addressing Bullying

Bullying is a significant and pervasive yet preventable public health problem with detrimental consequences for children's physical and mental well-being. Bullying is a repeated and deliberate pattern of aggressive or hurtful behavior targeting individuals perceived as less powerful. The CDC's formal and somewhat unwieldy definition is "any unwanted aggressive behavior by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated."[CDC. Fast Facts: Preventing Bullying] In Australia, the National Center Against Bullying defines bullying as an "ongoing and deliberate misuse of power in relationships through repeated verbal, physical or social behavior that intends to cause physical, social, or psychological harm." This activity focuses on children and youth younger than 18 and does not address adult or workplace bullying.

Historically, bullying has been seen as a "rite of passage" in childhood, and even today, there often is a tacit acceptance of bullying behavior. Many healthcare professionals struggle to accept bullying as a public health issue. An increased awareness of the long-term consequences on physical and mental health necessitates a shift in these attitudes.[Campbell, Kristin. Bullying and Victimization. AAP] Populations at greater risk are those perceived as "different," including racial, religious, and ethnic minorities, immigrants, refugees, individuals with notable physical features or disabilities, and younger or more vulnerable children. Bullying episodes are usually unprovoked and deliberate, and bullies often seek visibility and prestige through their actions.

Healthcare professionals play a vital role in preventing and identifying bullying and assisting with mitigating its mental and physical health consequences. This overview provides clinicians with the knowledge and tools to increase their awareness of bullying, enabling early recognition and effective intervention. Bullying is a problem that affects victims, perpetrators, and bystanders, and this overview equips clinicians with the skills to improve the lives of affected youth.

Bullying can happen anywhere, although it is most common in and around schools. Bullying usually occurs in relatively unstructured situations and minimally supervised areas such as playgrounds, cafeterias, hallways, bus stops, and buses. Bullying manifests in various forms, such as physical, verbal, social/relational, and cyberbullying, each having unique characteristics. Verbal bullying, including name-calling and taunting, is the most frequent.

Cyberbullying has received much attention in the past few years, as children and teens now have easy access to digital devices and social media sites. Cyberbullying manifests as text messages, social media posts, emails, online forums, and other platforms, and the risk increases considerably with the duration of a child's online activity. The term was first coined in the 1990s but has only become a significant concern in the 21st century as rates have risen, especially during the COVID-19 pandemic when electronic media use soared during lockdowns. Name-calling occurs most frequently, but 15% of youth bullied online describe being scared. Teens also report receiving unsolicited and explicit images meant to intimidate them.[Vogels, Emily. Teens and Cyberbullying 2022]

Artificial intelligence (AI) has complicated this issue. The Wall Street Journal wrote about a group of high school boys who used an online tool powered by AI to create nude photographs of female classmates, which they spread electronically. Although this might have been an isolated event, these fake nude likenesses will persist in cyberspace indefinitely and are likely to cause irreparable adverse effects.[WSJ. Nov 4-5, 2023, p1] Despite these growing concerns, only 11% of teens talk with their parents or caregivers about their cyberbullying experiences.[Security.org. Cyberbullying] Identifying this form of bullying is challenging because the episodes may be less repetitive than typical verbal or physical bullying. In many instances, perpetrators remain anonymous, allowing them to engage in behavior they might not display face-to-face with their victims. Because online content is easily preserved and disseminated, cyberbullying results in ongoing suffering, especially when hurtful messages "go viral." Cyberbullying differs from traditional bullying as it does not rely on physical proximity or a specific location and can occur at any time of day or night. Traditional bullying at school usually does not extend to the home setting, but victims of cyberbullying may feel they cannot escape since their electronic devices are turned on 24/7. Like traditional bullying, cyberbullying can cause profound adverse psychological effects.

Relational or social bullying occurs when the aggressor manipulates social relationships to harm or control the victim. Unlike physical and verbal bullying, which involve direct acts of aggression, relational bullying is more subtle. The aggressors often rely on tactics such as spreading rumors, excluding victims from social groups, and manipulating social dynamics to damage reputations or relationships. In social bullying, the bully aims to isolate, hurt, or control the victim emotionally, which can result in psychological and emotional sequelae. Social bullying is no longer restricted to the schoolyard but frequently takes the form of cyberbullying.

Clinicians play a crucial role in identifying bullying and treating the children it impacts. They screen patients for risk factors, educate families about coping skills, and advocate in their communities and local schools. School anti-bullying measures can help prevent bullying and empower youth to intervene when they are bystanders. This overview describes how clinicians can address bullying in an outpatient setting to improve child well-being and reduce its physical, psychological, social, and educational harms.