Bullying in schools: doctors' responsibilities

To ignore bullying is to condemn children to misery now and perhaps also in adult life

Bullying is the intentional, unprovoked abuse of power by one or more children to inflict pain on or cause distress to another child on repeated occasions. It includes several different activities: hitting, pushing, spreading slanders, provoking, making threats, extortion, and robbery. A common, international phenomenon, it occurs to some extent in all schools.1 2 3 Whitney and Smith's study of more than 6000 pupils in 23 schools in Sheffield found that 27% of junior and middle school pupils and 10% of secondary school pupils said that they had been bullied sometimes or more often that term; 10% of junior and middle school pupils and 4% of secondary school pupils were being bullied at least once a week.3 Most had not told a teacher or anyone at home.

Bullying can be considered to be a form of child abuse: peer abuse.4 Like other forms of abuse, it is an abuse of power and is surrounded by fear, secrecy, and a misplaced loyalty to the perpetrator(s). Victims suffer adverse effects in the short and long term. Victims of regular bullying lack confidence, have lower self esteem, regard themselves as less competent,5 and have fewer close friends than children who are not bullied.2 5 Distress and preoccupation with their predicament may affect their concentration on their schoolwork. Bullying may be a contributory factor in why some children harm themselves or commit suicide, although this has not been systematically studied. When bullied children grow up they may be vulnerable to anxiety, depression, and loneliness (A H N Gillessen, annual convention of American Psychological Association, 1992)2 and may have difficulties with heterosexual relationships.6 Because bullying is usually unseen teachers, parents, and other adults often underestimate its prevalence and effects.

Children who are bullied may be reluctant to attend school and may absent themselves.7 They may be presented to doctors with a variety of symptoms, including fits, faints, vomiting, limb pains, paralysis, hyperventilation, visual symptoms, headaches, stomachaches, fugue states, and hysteria.8 No study has examined the mental health problems of children who are regularly bullied, although clinical experience suggests that bullying may contribute to the referrals of some children to child psychiatrists. Similarly, coping mechanisms and factors that promote resilience have yet to be described.

Bullies also deserve attention. They are learning to achieve dominance over others through the misuse of power. Bullying may be one component of a more general pattern of antisocial and rule breaking behaviour that shows considerable stability over time. As adults, bullies are more likely to have criminal convictions and be involved in serious, recidivist crime.2

Schools can adopt several approaches to deal with bullies.9 These include developing a policy for the school, tackling bullying through classroom and curriculum material, training playground supervisors, and working directly with bullies and victims. A clear account of the nature and implementation of these approaches is given in a recently published handbook, Tackling Bullying in your School.9

As bullying is so common all doctors dealing with children are likely to see some who are regularly victimised at school by their peers. This bullying may be an important factor in the development and maintenance of symptoms and should be considered in their management. If bullying is regarded as a form of abuse then professionals have a duty to detect it, take it seriously, and ensure that it is dealt with to reduce the child's suffering and minimise the potential long term effects. Olweus argues that it is a child's fundamental democratic right to attendschool without being bullied.2 As with other forms of abuse, children are unlikely to disclose it spontaneously as they feel ashamed and embarrassed and fear recriminations. Eventually they may believe that they deserve the bullying that they are subjected to.

Doctors should therefore ask directly about bullying. If children say that they are being bullied, they should be believed and reassured that they have done the right thing in telling. Parents should be informed and advised to take the matter up with the school (teachers or governors) directly. Children can be advised of simple measures to protect themselves—for example, ignoring name calling, making friends with a child who is not involved, and telling someone such as a teacher or playground supervisor.

Doctors and allied professionals need to know about bullying and what can be done. Research in Scandinavia2 and Britain10 has shown that intervention programmes in schools can successfully reduce bullying by up to half; they can also reduce truancy and antisocial behaviours in general and can increase pupils' satisfaction with school life. Two new books about bullying at school have been published recently.9 10 They summarise the Sheffield bullying project and provide the basis for the Department of Education's package for schools, Bullying: Don't suffer in Silence—An Anti-Bullying Pack for Schools.11 Organisations such as Kidscape run training courses and have information packs and advice leaflets for parents and teachers.12 To ignore bullying is to condemn children to further misery and may prejudice their academic achievements and adjustment in adult life.