Bullying is common in our society and has become a public health emergency.

It is a form of repeated
peer aggression which is intentional and involves a power differential between the bully and the victim. It
is often subtle and hidden, profoundly affecting a substantial number of children. The information in the
following activity will provide clinicians with tools for increased awareness and early recognition of
bullying; this, in turn, is likely to result in the development of strategies for prevention and intervention
with respect to this significant societal issue. This activity reviews the cause, pathophysiology,
presentation of patients that are victims of bullying and the role of the interprofessional team in the
evaluation and management of these patients.

Objectives:

 Identify the etiology and epidemiology of bullying.

 Discuss the presentation and signs and symptoms suggestive of bullying.
 Outline strategies for the treatment and prevention of bullying.
 Recognize that strategies for addressing bullying may be different for bullies and their victims.

Introduction
Bullying is a very common, complex and potentially damaging form of violence among children and
adolescents. Bullying is defined as unwanted, aggressive behavior, which involves a real or perceived
social power imbalance. The behavior is repeated, or has the potential to be repeated, over time (therefore,
the definition excludes occasional or minor incidents). These actions are purposeful and intended to hurt
or make the victim uncomfortable.[1]

Bullying may manifest itself in many forms. It can be physical, verbal, relational, or cyber; it can be subtle
and elusive. The most common form of bullying both for boys and girls is verbal bullying such as name-
calling. Although bullying is more common in schools, it can occur anywhere.  It often occurs in
unstructured areas such as playgrounds, cafeterias, hallways, and buses. In recent years, cyber-bullying
has received increased attention, as electronic devices have become more common. Bullying through
electronic means, although prevalent, ranks third after verbal bullying and physical bullying. In general,
bullying is a common type of social experience that children refer to as “getting picked on.”

Etiology
The etiology of bullying is complex and may depend on multiple issues including individual, social, and
family issues. It is important to understanding these hidden causes that increase the risk of bullying.[2]

Victims

Although there are many causes of bullying, certain risk factors may attract bullies to their victims. 

 Children who are different from their peers

  Children who are weaker (than bullies)
 Children who are socially isolated, less popular, and have few friends
 May have underlying feelings of personal inadequacy

Bullies

These children may have the following characteristics:

 Increasingly aggressive behavior and can be easily frustrated

 Tendency to blame others for their issues
 Unable to accept responsibility for their actions
 May be overly competitive and worry about their reputation or popularity
 May have friends who bully others
 May perceive hostile intent in the action of others
 May have a desire for power or dominance

It is not necessary that a bully is stronger or bigger than their victim. The power imbalance can be due to
many things including popularity, strength, or cognitive ability. Bullying behavior may be used to gain
social status.[3]

Epidemiology
According to the National Center for Educational Statistics (2013), 1 in 3 children (27.8%) report
being bullied during the school year. Bullying is reported to be more prevalent among boys than girls. It
occurs with greater frequency among middle school children. For boys, both physical and verbal bullying
is common, whereas, for girls, verbal bullying and rumors are more common. African Americans youth
report being bullied significantly less frequently than white or Hispanic youth.[4] Bullying peaks in early
adolescence and then gradually declines as adolescence progresses, although recent research suggests that
this is for more overt forms of bullying, whereas covert bullying continues through adolescence.

Pathophysiology
The issue of bullying in children is a complex problem that emerges from social, physical, institutional
and community contexts, as well as the individual characteristics of the children who are bullied and
victimized. A bullying interaction occurs not only because of individual characteristics of a particular
child who is bullying, but also because of actions and attitudes of peers, teachers and school staff, and
physical characteristics of that particular environment. Family dynamics, cultural factors, and even
community response also play a role in the occurrence of the bullying interaction.

History and Physical

Certain signs may indicate that a child has been a victim of bullying, including:

 Injuries or illness without a physical explanation

 Lost or damaged belongings, such as books or clothes
 Frequent somatic symptoms, changes in habits, and/or difficulty sleeping or frequent nightmares
 Avoidance of school or social situations
 Feelings of helplessness or decreased self-esteem
 Hurting himself/herself or expressing suicidal intent

Evaluation
Bullying is a serious problem for both the bully and the victim. The first step is recognizing bullying as a
problem for a child. It is also important to identify bullying interactions at an early stage.

Assessment of bullying: There are many tools available to assess bullying and determine the frequency
and locations of bullying behavior. See the Centers for Disease Control and Prevention's compendium for
measuring bullying, victimization, and bystander experience.

It may also be important to assess other risk and protective factors, such as depression, suicide risk,
sources of internal and external resilience, to best determine the interventions and supports needed.

Treatment / Management
Since bullying is a very complex problem there is no “quick fix” to prevent or intervene with this issue.  It
is important to understand the issues that are unique to the individual and the context in order to develop
and implement interventions. Here we describe important elements for intervention to address this issue.

To stop bullying, remember prevention is the best intervention.

 Assist child and family in providing a supportive and safe environment

 Provide assurance to the child that bullying is not his or her fault
 Work with school and other agencies as applicable to protect the victim
 Defuse or de-escalate an acute situation