Journal of Adolescent Health 54 (2014) 618e620
www.jahonline.org
Letters to the editor
Cyberbullying and Psychological and Behavioral Health Problems
To the Editors:
We have read with great interest the recent editorial “Cyber-
bullying among adolescents: Implications for empirical research”
[1] by Justin W. Patchin and Sameer Hinduja in the Journal of
Adolescent Health. We think that they raise important issues, one
of which is using a consistent operationalization of cyberbullying
to advance the study of occurrence and correlates of this problem.
They also make a number of observations about our article
published in the Journal of Adolescent Health: “Longitudinal and
reciprocal relations of cyberbullying with depression, substance
use, and problematic Internet use among adolescents” [2]. We
agree with many of their comments; however, we think that it is
necessary to clarify some issues raised in their editorial.
First, it is pointed out that the relations found between
cyberbullying and other behavioral and health problems could
be simply spurious. In the strict sense, this claim is mainly
applicable to cross-sectional studies, in which it is not possible to
establish causeeeffect relationships between variables. Although
our longitudinal results do not imply causal relations between
the variables, findings contribute notably to the understanding of
temporal relationships among cyberbullying, depression, and
other psychological problems using a prospective design and
examining reciprocal relationships among them, which had been
not done to date. In addition, the results are theoretically and
empirically meaningful according to well-established theoretical
models (Stress Generation Model [3] and Problem Behavior
Theory [4]) and empirical evidence on traditional bullying (e.g.,
[5,6]). We agree with Patchin and Hinduja that the more time
points available to examine the relationships, the better. Future
research should progress in this direction.
Second, Patchin and Hinduja note that research studies on
bullying often “combine single experiences with multiple ones in
a way that makes it impossible to disaggregate the two” (p. 431).
We acknowledge that they make a reasonable point that studies
of bullying should include multiple instances of aggression.
When analyzing differences between “only victims” and “bully-
victims,” to create the groups we used a lenient criterion that
included “just once or twice” experiences of victimization. As
noted in the article, what is interesting in this approach is that
even using this lenient criterion, we found highly significant
differences among bully-victims, only victims, and noninvolved
adolescents. We think that this in itself is an important finding, as
it signals that even quite low-level involvement in cyberbullying
may be a risk factor for the health problems considered. Never-
theless any analytical decision brings some advantages and
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
http://dx.doi.org/10.1016/j.jadohealth.2014.02.003
disadvantages; in this case, we recognize the consideration made
by Patchin and Hinduja, and we agree it would have been more
consistent with traditional definitions of cyberbullying [7] to
include in these groups (“only victims” and “bully-victims”) just
adolescents with multiple experiences of cyberbullying.
Nonetheless, in the main analyses on the relations between
victimization and psychological and behavioral health problems, we
used a continuous variable that reflects the number of times that
each participant was a victim of cyberbullying. In this case, we did
not combine single experiences of victimization with multiple ones;
instead, our approach took into account the dimensionality and
variability of the construct. And what we get by analyzing cyber-
bullying as a continuous variable is that adolescents with multiple
experiences of cyberbullying (compared with those who have no
experience or just a few experiences) present a higher risk of psy-
chological and behavioral health problems. In other words, our
findings show a “doseeresponse” relationship between experiences
of victimization and several health problems in adolescence. Thus,
we maintain that these analyses are adequate, preserve the vari-
ability of the construct, and provide important information about
the relations of cyberbullying and the health problems analyzed.
Finally, the editorial pointed out that “students could have been
reporting the same incident(s) at Time 1 and Time 2, thereby
confounding the results and subsequent interpretation” (p. 432).
We do not agree with this statement. By controlling for the effect of
a specific variable at Time 1 on the same variable on Time 2 (i.e., the
inclusion of autoregressive paths), we analyzed the extent to which
the rest of Time 1 predictors accounts for the residual change in a
given Time 2 variable over time [8]. When we asked adolescents at
Time 2 for their experiences of cyberbulling “ever,” they are also
reporting more recent experiences (i.e., during the last 6 months).
This, in turn, allows examining the variables that predict this re-
sidual increment of cyberbullying from Time 1 to Time 2.
In conclusion, we agree with Patchin and Hinduja that research
in this field must further refine conceptual and methodological
issues. A range of such issues are debated in two recent collections
[9,10]. Research in cyberbullying has gathered pace very rapidly
in the last few years, and discussion of these issues serves an
important purpose in improving research and ultimately helping
those involved in cyberbullying behaviors.
Manuel Gámez-Guadix, Ph.D.
University of Deusto
Bilbao, Spain
 Letters / Journal of Adolescent Health 54 (2014) 618e620
Peter K. Smith, Ph.D.
Goldsmiths
University of London
London, United Kingdom
Izaskun Orue, Ph.D.
University of Deusto
Bilbao, Spain
Esther Calvete, Ph.D.
University of Deusto
Bilbao, Spain
References
[1] Patchin JW, Hinduja S. Cyberbullying among adolescents: Implications for
empirical research. J Adolesc Health 2013;53:431e2.
[2] Gámez-Guadix M, Orue I, Smith PK, Calvete E. Longitudinal and recip-
rocal relations of cyberbullying with depression, substance use, and
A Child Rights and Equity-Based Framework to Advance Policy and Practice
Related to Adolescent Consent to Vaccines
To the Editors:
Ensuring minors can legally consent to vaccines, as dis-
cussed in the recent position paper on adolescent consent for
vaccination [1], is critically important. However, the paper’s sole
focus on ethical and legal arguments will constrain our capacity
to advance such enlightened public policies. The principles of
child rights and equity provide a complementary approach to
analyze and revise policies and practice. As rights-bearers,
children have the right to access vaccines that will optimize
their survival and development. As duty-bearers, physicians
and advocates are responsible to ensure those rights are
fulfilled.
The United Nations Convention on the Rights of the Child
(CRC) [2] provides the framework to support a child rights and
equity-based approach to advance policy and practice related to
youth consent to vaccines. In particular, the CRC:
 Article 2 defines obligations to protect children from
discrimination.
 Article 3 requires that all societal decisions consider their best
interests.
 Article 6 obligates the State to ensure a child’s optimal survival
and development.
 Articles 12/13 ensure rights to express opinions freely.
 Article 16 ensures the child’s right to privacy.
 Article 17 ensures children have access to information.
 Article 24 ensures the child’s right to the highest standard of
health and healthcare.
Despite the United States’ failure to ratify the CRC, it is
nevertheless as relevant to American children as to other chil-
dren across the globe.
Human papilloma virus vaccine provides an example of the
paradox of contemporary vaccine policy and adolescent consent
619
problematic Internet use among adolescents. J Adolesc Health 2013;53:
446e52.
[3] Gibb BE, Hanley AJ. Depression and interpersonal stress generation in
children: Prospective impact on relational versus overt victimization. Int J
Cogn Ther 2010;3:358e67.
[4] Jessor R. Risk behavior in adolescence: A psychosocial framework for un-
derstanding and action. J Adolesc Health 1991;12:597e605.
[5] Kaltiala-Heino R, Fröjd S, Marttunen M. Involvement in bullying and
depression in a 2-year follow-up in middle adolescence. Eur Child Adolesc
Psychiatry 2010;19:45e55.
[6] Tharp-Taylor S, Haviland A, D’Amico EJ. Victimization from mental and
physical bullying and substance use in early adolescence. Addict Behaviors
2009;34:561e7.
[7] Smith PK, Mahdavi J, Carvalho M, et al. Cyberbullying: Its nature and
impact in secondary school pupils. J Child Psychol Psychiatry 2008;49:
376e85.
[8] Little T. Longitudinal structural equation modelling. New York: Guilford;
2013.
[9] Bauman S, Walker J, Cross D. Principles of cyberbullying research:
Definition, methods, and measures. New York & London: Routledge;
2013.
[10] Smith PK, Steffgen G. Cyberbullying through the new media: Findings from
an International network. Hove: Psychology Press; 2013.
laws. Current policy fulfills the rights of minors to seek diagnosis
and treatment of sexually transmitted infections independently
but does not fulfill their right to prevention.
Fulfilling adolescents’ rights does not subvert parental rights
or responsibilities. Child rights principles emphasize the role
of parents as primary caregivers and protectors of the rights of
their children. Ideally these should be informed joint decisions.
Increasing a child’s autonomy according to their evolving capac-
ities is not a threat to parental authority but an opportunity for
communication between the parent and child.
Applying rights and equity-based principles to address adoles-
cents’ rights to consent to immunization will expand our capacity
for advocacy. Physicians can begin by (1) establishing rights-
respecting practices; (2) posting a children’s rights charter;
(3) routinely obtaining children’s assent to immunization; (4)
developing vaccine information sheets that reflect children’s
evolving capacities; and (5) implementing rights and equity-based
approaches and policies that secure the ability of adolescents to
consent to vaccines.
Rita Nathawad, M.D.
Jeffrey Goldhagen, M.D., M.P.H.
Division of Community and Societal Pediatrics
Department of Pediatrics, University of Florida
Jacksonville, Florida
References
[1] Society for Adolescent Health and Medicine, English A, Ford CA, Kahn JA,
et al. Adolescent consent for vaccination: A position paper of the Society for
Adolescent Health and Medicine. J Adolesc Health 2013;53:550e3.
[2] UN GA Res 44/25. Convention on the rights of the child. Available at:
http://www.un.org/documents/ga/res/44/a44r025.htm. Accessed December
24, 2013.