What family physicians can do to combat bullying

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Applied Evidence

What family physicians can do to combat bullying

J Fam Pract. 2017 February;66(2):82-89

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References

1. Olweus D, Limber SP. Bullying in school: evaluation and dissemination of the Olweus Bullying Prevention Program. Am J Orthopsychiatry. 2010;80:124-134.

2. Lyznicki JM, McCaffree MA, Robinowitz CB, et al. Childhood bullying: implications for physicians. Am Fam Physician. 2004;70:1723-1730.

3. Temkin D. All 50 states now have a bullying law. Now what? The Huffington Post. April 27, 2015. Available at: http://www.huffingtonpost.com/deborah-temkin/all-50-states-now-have-a_b_7153114.html. Accessed January 5, 2017.

4. Anderson M, Kaufman J, Simon TR, et al. School-associated violent deaths in the United States, 1994-1999. JAMA. 2001;286:2695-2702.

5. Centers for Disease Control and Prevention. Injury prevention and control: Data and statistics (WISQARS). Ten leading causes of death and injury. Available at: https://www.cdc.gov/injury/wisqars/leadingcauses.html. Accessed January 5, 2017.

6. Nansel TR, Overpeck M, Pilla RS, et al. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285:2094-2100.

7. Committee on Injury, Violence, and Poison Prevention. Policy statement—Role of the pediatrician in youth violence prevention. Pediatrics. 2009;124:393-402.

8. Klein DA, Myhre KK, Ahrendt DM. Bullying among adolescents: a challenge in primary care. Am Fam Physician. 2013;88:87-92.

9. Lamb J, Pepler DJ, Craig W. Approach to bullying and victimization. Can Fam Physician. 2009;55:356-360.

10. Spector ND, Kelly SF. Pediatrician’s role in screening and treatment: bullying, prediabetes, oral health. Curr Opin Pediatr. 2006;18:661-670.

11. Gladden RM, Vivolo-Kantor AM, Hamburger ME, et al. Bullying surveillance among youths: uniform definitions for public health and recommended data elements. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention and US Department of Education; 2014. Available at: https://www.cdc.gov/violenceprevention/pdf/bullying-definitions-final-a.pdf. Accessed June 8, 2016.

12. Olweus D. Bullying at school: basic facts and effects of a school based intervention program. J Child Psychol Psychiatry. 1994;35:1171-1190.

13. Olweus D. Bully/victim problems in school: Facts and intervention. Eur J Psychol Educ. 1997;12:495-510.

14. Kowalski RM, Limber SP. Psychological, physical, and academic correlates of cyberbullying and traditional bullying. J Adolesc Health. 2013;53:S13-S20.

15. Craig W, Harel-Fisch Y, Fogel-Grinvald H, et al. A cross-national profile of bullying and victimization among adolescents in 40 countries. Int J Public Health. 2009;54(Suppl 2):216-224.

16. US Department of Education, National Center for Educational Statistics (2015). Student reports of bullying and cyberbullying: results from the 2013 School Crime Supplement to the National Victimization Survey. Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2015056. Accessed November 9, 2016.

17. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance - United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65:1-174.

18. Van Cleave J, Davis MM. Bullying and peer victimization among children with special health care needs. Pediatrics. 2006;118:e1212-e1219.

19. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weight-based teasing and emotional well-being among adolescents. Arch Pediatr Adolesc Med. 2003;157:733-738.

20. Hatzenbuehler ML. The social environment and suicide attempts in lesbian, gay, and bisexual youth. Pediatrics. 2011;127:896-903.

21. Song LY, Singer MI, Anglin TM. Violence exposure and emotional trauma as contributors to adolescents’ violent behaviors. Arch Pediatr Adolesc Med. 1998;152:531-536.

22. Singer MI, Anglin TM, Song LY, et al. Adolescents’ exposure to violence and associated symptoms of psychological trauma. JAMA. 1995;273:477-482.

23. Glew GM, Fan MY, Katon W, et al. Bullying, psychosocial adjustment, and academic performance in elementary school. Arch Pediatr Adolesc Med. 2005;159:1026-1031.

24. Waseem M, Ryan M, Foster CB, et al. Assessment and management of bullied children in the emergency department. Pediatr Emerg Care. 2013;29:389-398.

25. US Department of Health and Human Services. stopbullying.gov. Available at: https//www.stopbullying.gov. Accessed January 5, 2017.

26. Shetgiri R, Lin H, Avila RM, et al. Parental characteristics associated with bullying perpetration in US children aged 10 to 17 years. Am J Public Health. 2012;102:2280-2286.

27. Hinduja S, Patchin JW. Social influences on cyberbullying behaviors among middle and high school students. J Youth Adolesc. 2013;42:711-722.

28. Borowsky IW, Mozayeny S, Stuenkel K, et al. Effects of a primary care-based intervention on violent behavior and injury in children. Pediatrics. 2004;114:e392-e399.

29. Olweus D. Bully/victim problems in school: Facts and intervention. Eur J Psychol Educ. 1997;12:495-510.

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31. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.

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Are community programs in place—or are they needed?

Many schools have robust, state-mandated programs in place to identify bullying and provide support for students who are victims of bullying. (See “NJ’s harassment and bullying protocol: A case in point.”) Explaining this to victims and their families may help them come forward and seek assistance. FPs who want to advocate for their patients should start with local schools to support such programs and link students at risk with school counselors.

SIDEBAR
NJ's harassment and bullying protocol: A case in pointThere is no federal law that specifically applies to bullying, but all 50 states have some type of anti-bullying legislation on the books, and 40 of those states have additional detailed policies in place addressing the subject.¹

New Jersey, for example, began enforcing one of the toughest harassment, intimidation, and bullying (HIB) protocols in the country back in September 2011² in the wake of the death of Rutgers University freshman Tyler Clementi, who committed suicide after his roommate allegedly shot a video of him with another man and posted it to the Internet.³ Among many other things, New Jersey’s legislation stipulates in its Anti-Bullying Bill of Rights⁴ that:

› Every school/district have plans in place that clearly define, prevent, prohibit, and promptly deal with acts of harassment, intimidation, or bullying, on school grounds, at school-sponsored functions, and on school buses.
› Plans must include a description of the type of behavior expected from each student and the consequences and remedial action for a person who commits an act of harassment, intimidation, or bullying. Student perpetrators may be suspended or expelled if convicted of any type of bullying, whether it be for teasing or something more severe.
› All school employees must act on any incidents of bullying reported to, or witnessed by, them and report such incidents on the same day to the school principal.
› Plans must include provisions and deadlines for investigating and resolving all matters in a timely fashion; investigations into allegations of bullying must be launched within one day.
› Every case of bullying must be reported to the state. Schools are graded by the state on their compliance with anti-bullying standards and policies and their handling of incidents.
› Schools must appoint safety teams made up of parents, teachers, and staff, and school personnel and students must receive extensive anti-bullying training.

1. US Department of Health and Human Services. Stopbullying.gov. Policies and laws. Available at: https://www.stopbullying.gov/laws/index.html.
Accessed January 5, 2017.
2. State of New Jersey Department of Education. An overview of amendments to laws on harassment, intimidation, and bullying. Available at: http://www.state.nj.us/education/students/safety/behavior/hib/overview.pdf. Accessed January 5, 2017.
3. Cohen A. Case study: Why New Jersey’s antibullying law should be a model for other states. Time. September 6, 2011. Available at: http://ideas.time.com/2011/09/06/why-new-jerseys-antibullying-law-should-be-a-model-for-other-states/. Accessed January 5, 2017.
4. New Jersey Legislature. Anti-bullying Bill of Rights Act. Available at: http://www.njleg.state.nj.us/2010/Bills/PL10/122.PDF. Accessed January 5, 2017.

If programs are lacking in your community, there is much you can do to educate yourself about successful programs and advise local community organizations and schools about them. Among the most successful and well-studied interventions for thwarting the bullying epidemic have been school-based community ones. The most studied of these is the Olweus Bullying Prevention Program (OBPP), which is based on 4 principles:^1,29

Adults both at home and at school should take a positive and encouraging interest in students.
Unacceptable behavior should have strict and well-known limits.
Sanctions should be applied consistently and should be non-hostile in nature.
Adults both at home and in the educational environment should act as authorities.

In short, the program focuses on greater awareness and involvement on the part of adults, and employing measures at the school level (eg, surveys, better supervision during break and lunch times), the class level (eg, rules against bullying, regular class meetings with students), and the individual level (eg, serious talks with bullies, victims, parents of involved students).

Research has shown that the OBPP reduces bullying behaviors by as much as 50%, reduces vandalism and truancy, and reduces the number of new victims.¹²Limits to the more widespread implementation of the OBPP have consisted mainly of the inability to appropriately train adults, including teachers and other school personnel in educational settings. Despite these limitations, the OBPP has been praised and endorsed by numerous groups, including the US Department of Justice.³⁰

Encourage children who are bullied to stay safe by standing near adults or groups of peers when bullies are present.Other non-curricular, school-based programs exist, such as the School-Wide Positive Behavioral Interventions and Supports (SWPBIS). This program is a school-wide prevention strategy aimed at: 1) reducing behavior problems that lead to office discipline referrals and suspensions, and 2) changing perceptions of school safety. (For more information, see https://www.crimesolutions.gov/ProgramDetails.aspx?ID=385 and https://www.pbis.org/school/swpbis-for-beginners.)³¹

The research-based Second Step: Student Success Through Prevention (SS-SSTP) Middle School Program (http://www.cfchildren.org/second-step/middle-school)³² focuses on the often difficult middle school years. The program helps schools teach and model essential communication, coping, and decision-making skills to help adolescents navigate around common pitfalls such as peer pressure, substance abuse, and bullying (both in-person and online). The program aims to reduce aggression and provide support for a more inclusive environment that helps students stay in school, make good choices, and experience social and academic success.

The Positive Action Program (https://www.positiveaction.net/research/primer),³³ which is predicated on the notion that we feel good about ourselves when we do positive things, features scripted lessons and kits of materials (eg, posters, games, worksheets, puzzles) appropriate for each grade level.

CASE › Stacey’s visit to her FP’s office has presented several clues that she may be a victim of bullying. Her mild persistent asthma appears to no longer be as well controlled as it was in the past. Direct questioning has revealed that 2 girls at school have been making fun of Stacey when she uses her inhaled corticosteroid in the morning before class, so she has stopped using it. These same students are on her cheerleading team, so she quit the team to avoid them. Her school-related anxiety is so great that she no longer pays attention in math class and is constantly worried that something is being posted about her online.

Stacy’s FP responds to this information with a multifaceted approach. In the exam room, he screens Stacy for depression. While she is negative and denies any suicidal ideation, Stacy is clearly having anxiety, so the FP refers Stacey to a counselor at a local mental health clinic. With Stacy’s permission, the FP discusses the issue with her mother and they decide together with Stacy that she should talk to a teacher at school about the ongoing bullying. Because this was not the first time that the FP has heard this from a child in the community, the FP plans to attend an upcoming school board meeting to advocate for an evidence-based bullying prevention program to help curb the ongoing problem facing his patients.

CORRESPONDENCE
Robert McClowry, MD, Department of Family and Community Medicine, Jefferson Family Medicine Associates, 833 Chestnut East, 3rd Floor, Suite 301, Philadelphia, PA, 19107-4414; Robert.McClowry@Jefferson.edu.