Health Letter, August 2014
By Azza AbuDagga, Ph.D., M.H.A.
Most parents are aware how pervasive bullying is, but they may not know the lasting harms that can result from such behavior.
Bullying is the most common type of school violence. National survey results from the Centers for Disease Control and Prevention show that approximately one in every five American children experiences bullying on school property each year. In addition to the physical injuries (broken bones, lacerations, etc.) that can result from bullying, children may also experience a drop in their academic achievement; develop anxiety, depression, backaches, stomachaches, dizziness or irritability; or even attempt or commit suicide.
Though the short-term consequences of bullying are well-known, the long-term association between bullying during childhood and outcomes in early adulthood has received little attention. A recent study by researchers from Duke University in the U.S. and Warwick University in the U.K. provides new insights on how involvement in childhood bullying affects early adulthood outcomes, including health, risky or illegal behavior, wealth, and social relationships. The study was published online in the journal Psychological Science on Aug. 19, 2013.
What is bullying?
Bullying refers to any unwanted, repeated aggressive behavior against another person that is intentional and involves an imbalance of power. It can be physical (hitting or tripping), verbal (name-calling or teasing), or relational or social (spreading rumors or excluding someone from a group).[5 A child can be a perpetrator, a victim or both.
Bullying can occur at school and school events, during travel to and from school (for example, on a school bus), in the child’s neighborhood or in other settings. Bullying can also happen online: Cyberbullying can take place through e-mails, chat rooms, instant messages, websites, or videos or pictures posted on websites or sent through cell phones.
A number of factors can increase the risk of a child engaging in or experiencing bullying, including:
- Harsh parenting by caregivers.
- Defiant and disruptive behavior.
- Attitudes accepting of violence.
Factors associated with a higher likelihood of victimization include:
- Poor peer relationships.
- Low self-esteem.
- Perception by peers as different or quiet.
The long-term bullying outcomes study
The Psychological Science article reports findings from a study known as the Great Smoky Mountain study, which tracked more than 1,200 schoolchildren in 3 cohorts, ages 9, 11, and 13, in western North Carolina. Annual assessments were completed with each child and his or her primary caregiver until the child reached age 16 and then again with the child at ages 19 and 21. Participants were also assessed between ages 24 and 26.
At each assessment, the child and/or caregiver reported on whether the child had been bullied or teased or had bullied others in the three months prior to the interview. This information was used to categorize the children into four groups: those who identified as victims of bullying only, those who identified as bullies only, those who identified as both victims of bullying and bullies (bully-victims), and children not involved in bullying.
The study found that nearly a quarter of the child participants were victims only, 8 percent were bullies only, 6 percent were bully-victims and nearly two-thirds were not involved in bullying.
Child participants were evaluated in early adulthood on the following outcomes:
- Health: whether the participant reported being diagnosed with a serious illness, had been in a serious accident, had a sexually transmitted disease or was obese.
- Risky or illegal behavior: whether the participant had been charged with a felony; had contact with police; had been involved in physical fighting; had broken into a home, business or property; was often drunk; or used marijuana or other illegal substances.
- Financial and educational status: whether the participant lived below the poverty line, had no high school diploma or college education, had been dismissed from a job or had quit multiple jobs.
- Social relationships: whether the participant had violent relationships, had a poor relationship with his or her parents, had no best friend or confidant, or had problems making or keeping friends.
After adjusting for hardships during childhood (family socioeconomic status, family stability, family dysfunction and maltreatment) and psychiatric problems during childhood (depression, anxiety, disruptive behavior disorders and substance use disorders), the researchers found that of the three groups involved in bullying, those who had been bullies only were the only group not at increased risk of poorer outcomes in adulthood, compared with those who had not been involved in bullying.
On the other hand, the adjusted results showed that both victims only and bully-victims were at risk of poorer health, financial or educational status, and social relationship outcomes in early adulthood, compared with those who had not been involved in bullying.
Notably, of the three groups involved in childhood bullying, the bully-victim group was the only group that had a statistically significant association with risky or illegal behavior outcomes, compared with the group that was not involved in bullying.
The results of the study support the suspected long-term association between being a victim of bullying and negative outcomes in early adulthood. These results also suggest that the bully-victim group is perhaps the most vulnerable among all three groups involved in bullying behavior. This means that bully-victims may turn to bullying after being bullied themselves because they lack the emotional ability or support required to cope with it.
The researchers concluded that “being bullied is not a harmless rite of passage or an inevitable part of growing up.” They called for mitigating the involvement of bullying in the school environment to minimize human suffering.
Preventing and Dealing With Childhood Bullying
It is best to understand and prevent bullying before it starts. However, if bullying occurs, adults need to intervene and deal with it effectively. Below we offer actions to prevent bullying in schools and cyberbullying. We also offer tips for adults (including parents and teachers) to deal with bullied and bullying children.
Ways schools can prevent bullying 
- Improving supervision of students.
- Using school rules and behavior management techniques in the classroom and throughout the school to detect, address and provide consequences for bullying.
- Establishing and enforcing schoolwide anti-bullying policies.
- Promoting cooperation among various school professionals, school staff and parents.
Actions children can take to prevent cyberbullying
- Adjust the privacy settings on their social media accounts to keep personal information private and make sure anything they post on social networking websites (such as Facebook) is visible to individuals in their networks only. This way, only people known to the child can view what he or she posts.
- Think carefully before posting anything publicly.
- Never share very personal information (such as address or phone number) with strangers they meet online.
- Consult with an adult in case of any suspicious online activity or encounter.
Tips to help adults support children who are bullied 
- Listen and focus on the child: Learn what is going on and show you want to help.
- Assure the child that bullying is not his or her fault.
- Know that children who are bullied may struggle to talk about the bullying experience. Therefore, it may be helpful to ask for help from a counselor, psychologist or other mental health professional.
- Give advice about what to do. This may involve role-playing and thinking through how the child might react if bullying occurs.
- Involve others (such as teachers) to remedy the bullying behavior and protect the bullied child.
- Be consistent in supporting the bullied child and keep following up, because bullying may not end overnight.
Tips for adults dealing with children who are bullying others 
- Make sure the child knows what the problem behavior is; he or she needs to learn that bullying is wrong and harms others.
- Convey to the child that bullying will not be tolerated.
- Work with the child to understand some of the reasons he or she uses the bullying behavior. For example:
- Sometimes children bully to fit in. Such children can benefit from participating in positive activities, such as sports, which can enable children to take leadership roles and make friends without feeling the need to bully.
- Bully-victims often act out because of issues at home, abuse or stress, Such children may benefit from professional support, including counseling and mental health services.
- Involve the bullying child in activities to learn empathy, such as writing a letter apologizing to the child who was bullied or cleaning up, repairing or paying for any property damage.
- After the bullying issue is resolved, continue to help the child who bullied understand how his or her action affects others. For example, praise acts of kindness or talk about what it means to be a good friend.
 Iudici A, Faccio E. What program works with bullying in school setting? Personal, social, and clinical implications of traditional and innovative intervention programs. Procedia – Social and Behavioral Sciences. 2014;116(1):4425-4429. doi:10.1016/j.sbspro.2014.01.960.
 Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System: 2011 National Overview. https://www.citizen.org/sites/default/files/us_overview_yrbs.pdf.
 Wolke D, Copeland WE, Angold A, Costello, EJ. Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. Psychological Science. 2013;24(10):1958-1970. doi:10.1177/0956797613481608.
 Olweus D. Bullying at school: Basic facts and effects of a school based intervention program. Journal of Child Psychology and Psychiatry, 1994;35(7):1171-1190. doi:10.1111/j.1469-7610.1994.tb01229.x.
 Centers for Disease Control and Prevention. Understanding Bullying Fact Sheet 2013. https://www.citizen.org/sites/default/files/bullyingfactsheet2014-a.pdf.pdf. Accessed June 29, 2014.
 Centers for Disease Control and Prevention. Understanding Bullying Fact Sheet 2013. Available at: https://www.citizen.org/sites/default/files/bullyingfactsheet2014-a.pdf.pdf. Accessed June 29, 2014.
 Wolke D, Copeland WE, Angold A, Costello EJ. Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. Psychological Science. 2013;24(10):1958–1970. doi:10.1177/0956797613481608.
 Farrington DP, Ttofi MM. School-Based Programs to Reduce Bullying and Victimization. Systematic review for The Campbell Collaboration Crime and Justice Group. 2010. www.ncjrs.gov/pdffiles1/nij/grants/229377.pdf.
 StopBullying.gov. Support the Kids Involved. http://www.stopbullying.gov/respond/support-kids-involved/. Accessed June 30, 2014.