Objective To compare the prevalence and intensity of victimisation from bullying and the characteristics of the victim of bullying, comparing adolescents with and adolescents without chronic conditions (CC).
Design School survey.
Setting Postmandatory schools.
Participants A total of 7005 students (48% females) aged 16–20 years, distributed into adolescents with CC (728, 50% females) and controls (6277, 48% females). Chronic condition was defined as having a chronic disease and/or a physical disability.
Outcome measures Prevalence of bullying—intensity of bullying—and sociodemographic, biopsychosocial, familial, school and violence context characteristics of the victims of bullying.
Results The prevalence of bullying in our sample was 13.85%. Adolescents with CC were more likely to be victims of bullying (adjusted OR 1.53), and to be victims of two or three forms of bullying (adjusted OR 1.92). Victims of bullying with CC were more likely than non-victims to be depressed (RR 1.57), to have more physical symptoms (RR 1.61), to have a poorer relationship with their parents (RR 1.33), to have a poorer school climate (RR 1.60) and to have been victims of sexual abuse (RR 1.79) or other forms of violence (RR 1.80). Although these characteristics apply to victims in general, in most cases, they are less pronounced among victims without CC.
Conclusions CC seems to be a risk factor for victimisation from bullying. Therefore, as adolescents with CC are increasingly mainstreamed, schools should be encouraged to undertake preventive measures to avoid victimisation of such adolescents.
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Bullying is defined as an aggressive behaviour repeated over time with the intention to harm the victim and characterised by an imbalance of power between the bully and the victim.1,–,3 Bullying involvement (being a bully, a victim or both) has been widely studied, and prevalence vary with age and between countries.2 4 5 There is evidence that bullying has adverse effects on the victims' physical and psychosocial well-being, including school life.2 3 5
The phenomenon of bullying has been less studied among adolescents with chronic conditions (CCs). To our knowledge, only a few papers have addressed this problem, including all types of chronic diseases and disabilities, among representative samples.6 7 In fact, most research has focused either on physical disabilities3 8 or on specific diseases,9,–,11 using small clinical samples. Probably, for these reasons, there is no uniformity in the results: although most studies show that CC youths tend to be at increased risk of victimisation,3 4 7 some found no indication that children with a visible health problem were more likely to be victims.6 8 12
What is already known on this topic
Bullying is an aggressive behaviour repeated over time with the intention to harm the victim. The prevalence of bullying is greater among boys and decreases with age during adolescence. It is associated with poorer health status and psychological distress.
What this study adds
Adolescents with CCs are more likely than controls to be victims of bullying. When they are bullied, they are more likely to be victims of two or three different forms of bullying. Having a CC seems to potentiate the harmful effects of bullying.
Previous studies have shown an association between victimisation from bullying and several factors, such as sex and age,4 13 depression2 6 14 15 and suicidal ideation,15 low self-esteem,2 3 14,–,16 body dissatisfaction,16 17 being overweight16 18 19 or taller than average,16 poor health status or increased physical symptoms,6 18 low socioeconomic status (SES) and non-intact families.4 20 Low grades or unhappiness at school,5 14 15 having fewer friends14 or low-quality friendships3 and violent behaviours21 22 are also associated with bullying. Substance use seems to be linked with bullying, but the literature is not univocal about it.5 14
The objective of this study was to compare the prevalence and the intensity of victimisation from bullying together with the characteristics of the victims of bullying between adolescents with CC and their healthy counterparts in a representative Swiss national sample. We hypothesised that CC adolescents would be more likely to be victims of bullying than their peers because of their different appearance or behaviour (eg, checking blood glucose when diabetic, not attending physical education classes when disabled) and experience more intense bullying than victims without CC and that the characteristics of the victims would be different between adolescents with and adolescents without CC.
Data were drawn from the Swiss Multicenter Adolescent Survey on Health 2002 (SMASH02) database. This cross-sectional study was carried out through a self-administered anonymous questionnaire among a representative national sample of 7548 adolescents aged 16–20 years who were attending a postmandatory school. In Switzerland, mandatory school ends at age 16 years. Then, about one-third of adolescents enter high school (which prepares students for university), about two-thirds are enrolled as apprentices by companies for professional training (with class at a vocational school 1 or 2 days per week) and about 10% interrupt or delay their education and therefore were not included in this study. The methodology of the survey has been described elsewhere.23 The study's protocol was approved by the ethics committee of the University of Lausanne's Medical School.
From the initial 7548 individuals (48% girls) included in SMASH02, we excluded altogether 543 individuals (49% girls): 295 with non-responses to having a chronic disease and/or disability, 17 with non-responses to bullying and 231 with non-responses to explanatory variables. We compared included and excluded individuals for age, sex and academic track. There were differences for academic track only (more apprentices among excluded individuals; data not shown). Therefore, we controlled all analyses for academic track to reduce this possible bias. Our final sample included 7005 adolescents (48% girls).
The CC group included 728 adolescents (50% girls) who reported a chronic disease (a disease that lasts at least 6 months and may need regular care) and/or a physical disability (an injury that affects the body integrity and limits its functioning). The prevalence of CC (10.4%) matches that found in the literature.24 25 To assure the homogeneity of the CC group, we performed preliminary analysis comparing the three possible subgroups (chronic disease, disability and both) for sex, age, academic track and bullying. There were no significant differences among the three subgroups (data not shown). The non-CC group included 6277 adolescents (48% girls).
Bullying was assessed by the question “During the last year, have others…” (A) “made fun of you or insulted you?”, (B) “attacked or ill-treated you?” or (C) “excluded you intentionally or prevented you from participating?”, representing three forms of bullying, respectively teasing, physical aggression and social exclusion, according to Solberg and Olweus'2 description. Each item had four possible answers: “never”, “once or twice”, “about once a week” and “more often”. Of these three questions, we created a variable called Bullying, with two categories. The victim category comprised individuals who experienced at least one form of bullying approximately once a week or more (n=908, 45% girls). All the others were considered non-victims (n=6097, 49% girls).
In a second step, we measured the intensity of bullying by examining how many of the three forms of bullying were experienced. This variable initially had four categories: none and one, two and three forms of bullying. Because of very small proportions (0.27%) in the fourth category, we combined the last two into “two to three forms of bullying”.
Finally, to analyse the characteristics of the victims, we divided the sample into four groups based on whether adolescents were victims of bullying and whether they had a CC: victim-CC (n=140), victim–non-CC (n=768), non–victim-CC' (n=588) and non-victim–non-CC (control group, n=5509).
The sociodemographic factors included sex, age (16–20 years), academic track (student/apprentice) and SES. Parents' education was used as a proxy for SES and was dichotomised into “low education of both parents” (mandatory school or less) and “high education of at least one parent (beyond mandatory schooling)”.
The biopsychosocial factor overweight was assessed with body mass index (calculated from self-reported data on weight and height) using the age cut-offs described by Cole et al.26 Self-assessed puberty was categorised into advanced/on time/delayed, compared with that of adolescents of similar age. We also examined adolescents' health perception (good/poor) and body dissatisfaction (yes/no). Depression was measured with the Depressive Tendencies Scale, a validated instrument27 28 graduated from 1 (low) to 4 (high) based on eight items. In this study, Cronbach α was 0.89. Suicidality was expressed as having attempted suicide in the last year (yes/no). Physical symptoms consisted of having had frequent headaches, stomach-aches and/or sleeping problems in the last year. We also assessed daily smoking (yes/no), drunkenness (any episode in the last month), cannabis use (any use in the last month), difficulties to make friends (yes/no) and having a friend to talk to (yes/no). Finally, peer relationships was graduated from 1 (good) to 4 (poor), using the Inventory of Parent and Peer Attachment29 (four items; Cronbach α 0.89).
Family factors comprised family structure (non-intact/intact family) and parent–adolescent relationship. The quality of the parent–adolescent relationship was scaled from 1 (good) to 4 (poor), using five items from the Inventory of Parent and Peer Attachment29 plus an item about adolescents' perception on how much their parents trusted them (Cronbach α 0.85).
The school factor school climate was measured with a scale from 1 (good) to 4 (poor) based on five items used in earlier studies30 31 (Cronbach α 0.61). Other factors considered were school grades (good/poor) and skipping school (at least once a week).
Violence context factors “having suffered sexual abuse (yes/no)”; “having been a victim of violence in the last year” scaled from 1 (low) to 4 (high) based on three items about experiencing physical violence, racketeering or theft (Cronbach α 0.62); “being afraid to be beaten by parents” (yes/no) and “carrying a weapon in the last year” (yes/no).
In a first step, we compared the sociodemographic characteristics of the CC and non-CC groups. Results are given as prevalence with 95% CI or medians and p values (table 1). Then, we computed the prevalence and the unadjusted and adjusted odds ratios (ORs) of bullying globally and for each form of bullying (teasing, aggression and exclusion). The intensity of bullying between CC and non-CC adolescents was also analysed (table 2). Finally, we compared the distribution of the independent factors described previously between the victim-of-bullying and non-victim groups (table 3).
Standard procedures for automatic variable selection in regressions such as backward and stepwise selection are known to produce unstable and non-reproducible results.32 Thus, we selected important explanatory factors to the relation between CC and bullying using a bootstrap procedure. Ten thousand bootstrap samples were generated, and a backward selection procedure was applied on each of them, starting from a model including all the independent factors described previously. Explanatory factors retained in at least 60% of the replications were included33 in a multinomial regression. We compared the victim-CC and victim-non-CC groups with the non-victim–non-CC (control) group. Besides the explanatory factors retained from the bootstrap procedure, we also controlled for age and academic track because these are significant confounders. Results are given as risk ratio (RR) with 95% CI, using the control group as the reference category (table 4).
We used STATA V.9.2 for most analyses because it allows computing coefficient estimates and variances, taking into account the sampling weights, clustering and stratification procedure. χ2 tests were used for categorical data, and the Mann–Whitney test was used for numerical data because the variables did not follow a normal distribution. MATLAB V.7 was used for the bootstrap variable selection procedures.
Overall, CC adolescents were significantly older and less likely to have a low SES than non-CC adolescents (table 1).
The overall prevalence of bullying in our sample was 13.85% (teasing 12.53%; physical aggression 2.12%; social exclusion 1.59%), and this was significantly higher among CC adolescents (18.61%) than among the controls (13.32%; p<0.01). Even when controlling for possible confounders, CC youths remained significantly more likely to be victims of bullying, teasing and social exclusion and to experience one or more forms of bullying. Bullying in the form of physical aggression, though slightly higher, did not reach significance (table 2).
The bivariate analysis showed that most explanatory variables were significantly more frequent among victims of bullying. The only factors not reaching significance were daily smoking, cannabis use and skipping school (table 3).
The multinomial regression revealed that both victim groups were significantly more likely to have a poor health perception and physical symptoms, to have a high level of depression, to have difficulties to make friends, to be dissatisfied with their body, to experience high levels of violence and to have been sexually abused. These characteristics were more pronounced in the victim-CC group than among the victim–non-CC, except for difficulties to make friends and being a victim of violence (table 4).
In this study, almost one of seven adolescents report having been bullied, and the prevalence increases to almost one of five among CC youths, indicating that adolescents with chronic illnesses are more likely than their peers to be victims of bullying. This might be because of a difference in physical appearance or behaviour induced by their condition or its management. CC adolescents also appear to experience more than one form of peer victimisation, which can be interpreted as more intense bullying. These findings confirm our first and second hypotheses. Nevertheless, it is interesting to note that there is no difference between groups regarding physical exclusion.
The greatest difference between forms of bullying experienced by CC and healthy adolescents lies in social exclusion. In this study, the CC adolescents are almost three times as likely as the healthy peers to experience exclusion. Previous research has shown a more limited social integration of adolescents with CC,34 35 who were more likely to have fewer friends and lower levels of friend support. Helgeson et al35 suggest that the self-care needed to manage illnesses like diabetes might restrict social activities and interfere with the development of close relationships with peers, and in turn, negative social interactions might lead to poorer management of the disease. Besides, there is evidence that good-quality friendships are a protective factor against bullying,36 making this situation of social exclusion a vicious circle.
However, the CC victims in this study are slightly less likely than other victims to have difficulties to make friends and to be exposed to high levels of violence. Physical illness might represent a protective factor against victimisation, as it might be socially more acceptable to bully those with psychological fragility than those with physical problems, who are less capable of defending themselves.6 12 Bullied CC adolescents might induce more compassion than psychologically weak youths, thus making peers act more friendly with them. There is also evidence that young people targeted by bullies for other reasons than physical differences are mainly those with poor social interactions and submissive behaviours,3 12 which independently from bullying, may lead to difficulties to make friends.
Our findings also show that victims, regardless of their health status, are overall more likely to present with a greater amount of somatic and psychological conditions, more troubled relationships with parents and a poorer school climate and are surrounded by greater violence context, including sexual abuse. The victims thus display quite similar characteristics, whether or not they have a CC, and the coexistence of such features in the context of bullying is supported in the literature.6 14 16 21 However, these features are more pronounced among CC victims than non-CC ones and seem to indicate that having a CC can potentiate the effects of bullying. A possible explanation is the higher prevalence of body dissatisfaction and depression induced by the presence of CC37 that might add to the occurrence of such conditions in association with bullying. Similarly, the poorer health perception and higher amount of physical symptoms observed among CC victims can be interpreted as expressions of the underlying health condition.
The main strength of our study is that, to our knowledge, this is the only study comparing bullying between adolescents with and adolescents without CC, using a nationally representative sample and examining features of overall somatic and psychosocial health between victims with illness and healthy victims.
However, this study has some limitations. First, the cross-sectional setting allows no causality considerations. A second limitation is a possible response bias due to self-reported data, although anonymous self-administered questionnaires have been shown to be quite reliable.38 39 Third, no information about the severity of the condition was obtained from the questionnaire. However, the fact that we controlled for health perception should minimise this bias. Fourth, we have no data on youth not integrated in the school system, and further research is needed on that specific group of adolescents. Finally, the questionnaire gives no information about the perpetrators of bullying, allowing no analysis of this side of the problem in our sample.
In conclusion, bullying is probably more prevalent than supposed, especially among adolescents with CC. They are not only more likely to be victims than their peers, but they also experience more intense bullying than victims without CC. Besides, having a CC seems to potentiate the effects of bullying. From that point of view, it is important that health practitioners do not forget to discuss the issue of bullying when dealing with young people with chronic illnesses. Furthermore, there is currently a positive trend towards promoting the integration of CC youths into mainstream schools to improve their socialisation. To ensure the success of such procedures, they should be applied cautiously, and in view of a relative intolerance of children to those who are different, some attendant measures should be planned to prevent victimisation of CC youths in schools.
The survey was performed within a multicentre multidisciplinary group from the Institute of Social and Preventive Medicine, University of Lausanne (F Narring, MD, MSc (principal investigator); V Addor, RN, MPH; C Diserens, MA; A Jeannin, MA; G van Melle, PhD, and P-A Michaud, MD); the Institute for Psychology, University of Bern (F Alsaker, PhD; A Bütikofer, MA, and A Tschumper, MD) and the Sezione Sanitaria, Dipartimento della sanità e della socialità, Canton Ticino (L Inderwildi Bonivento, MA).
Funding The SMASH02 survey was carried out with the financial support of the Swiss Federal Office of Public Health (contract 00.001721/2.24.02.-81) and the participating cantons.
Competing interests None.
Ethics approval This study was conducted with the approval of the Institute of Social and Preventive Medicine, University of Lausanne. The study's protocol was approved by the ethics committee of the University of Lausanne's Medical School.
Provenance and peer review Not commissioned; externally peer reviewed.
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