Patient professional reference
Bullying has always occurred and always will occur. When people are together there will be jostling for leadership and superiority. However, bullying is not about leadership. It is an abuse of power. It is about belittling and humiliating weaker people to give satisfaction to the abuser. In some groups of animals, if one is weak or injured the others will attack it. Bullying has much in common with this, including the willingness of others to join in.
We tend to think of bullying as being something from school and probably it is more prevalent in the immature environment of school but it can occur in the workplace, in the home, with the official who likes to wield power and anywhere where there is interaction between people. Bullying has come to public attention in recent years because of campaigns and it may be tempting to think that it is more prevalent than it was. A problem does not have to be recognised to exist and many victims of bullying suffer in silence, afraid even to complain. Hence, it is impossible to tell if it is really more prevalent or just more recognised than before.
The advent of the internet and social media added cyberbullying to the options available to bullies, further contributing to the problem. With ever increasingly young children using social media, and with increasing evidence of the potential harm cyberbullying can have, this has been an important issue to address in recent years.
Bullying in the workplace is a significant problem, with lives that are a misery and days lost from work by people who cannot face another day of victimisation being just part of the price that is paid. Even healthcare is not immune, with bullying of inexperienced staff by more senior staff and intimidation of staff by patients or their families.
The nature of bullying
Bullying is often seen as the physical oppression of the weak by a stronger, often older person; however, bullying does not have to be physical. Girls are less likely than boys to be physical but they can be extremely vicious and spiteful in the things that they do. Cyberbullying adds another level. All this can be just as traumatic as physical attacks and it has driven some children to suicide.
Types of bullying
Bullying can take many forms.
Examples of bullying include:
- Physical assault.
- Name calling.
- Social bullying - social exclusion, spreading rumours about a person.
- Damage to property or school work.
This is harmful behaviour to others online or via tablets and smartphones. The bully may use social media networks, messaging apps or gaming sites. Children, adolescents or adults may be bullied in this way. It may involve:
- Sending/posting of offensive or insulting messages.
- Posting false information about a person.
- Posting pictures to ridicule a person.
- Distributing pictures or videos of someone being attacked or humiliated.
- Impersonating another person.
- Excluding a person from a group.
- Cyberstalking - using the internet to stalk or harass an individual.
- Trolling. This is posting offensive or inflammatory messages to provoke people or cause disruption. Trolling is not always bullying but may be in some instances.
- Aggression - verbal or electronic.
- Persistent humiliation, ridicule or criticism in front of others.
- Picking on one individual.
- Malicious rumours.
- Unjustifiably changing areas of responsibility and relegating people to demeaning or inappropriate tasks. Undermining a competent individual.
- Deliberate exclusion of an individual from discussions or decisions.
- Denying training or promotion opportunities without justification.
There are wide ranges in reports as to the incidence of bullying, which may be more indicative of differing criteria than differing patterns. Around one in three children report that they have been bullied at some point, with 10-14% experiencing bullying which goes on for six months or more.
Statistics from a Ditch the Label 2016 survey suggest, for young people aged 12-20:
- 1.5 million young people have been bullied in the past year (50%).
- Twice as many boys as girls bully.
- 14% of young people admit to bullying somebody.
The National Society for the Prevention of Cruelty to Children (NSPCC) estimates:
- From April 2014-March 2015 there were 26,000 counselling sessions with children related to bullying.
- Over half of lesbian, gay or bisexual young people experience homophobic bullying.
- More than 16,000 young people are absent from school due to bullying.
A 2013 Ditch the Label survey on cyberbullying found:
- 7 out of 10 young people had experienced cyberbullying.
- Facebook® was the most common social network site for bullying.
The UK Department of Education advises that most young people have been involved in cyberbullying in some way, as a perpetrator, victim or bystander.
A report from the Advisory, Conciliation and Arbitration Service (ACAS) states:
- The ACAS helpline gets 20,000 calls per year related to bullying or harassment.
- The impact on the economy of absenteeism and lost productivity due to bullying or harassment is estimated at £13.75 billion per year.
- Prevalence is rising. Managers reported bullying or harassment issues in 11% of workplaces in 2011, compared to 7% in 1998.
There are a number of ways that the bullied child may present. The child may possibly be brought to the doctor with the complaint that he or she is being bullied. A more common presentation is with various symptoms, hypochondriasis and behavioural changes from which the doctor must discover that bullying is the root cause.
- There may be complaints of tummy aches, headaches and reasons to be off school. Physical signs that may otherwise be expected, such as pyrexia or cervical lymphadenopathy, are absent. These features are common in term time but absent at weekends and in holidays. The doctor may feel that the child is not so much ill as pleading that they don't want to be sent to school.
- There may be a decline in the standard of school work and achievement and this may be brought to the consultation. There may be a sudden loss of interest in extracurricular activities.
- There may be stammering and general loss of self-confidence.
- There may be stealing, especially if the bullying includes extortion or the child may be trying to buy popularity.
- There may be sleep disturbance, crying before going to sleep, or nightmares. Very young children may suffer regression with thumb sucking or nocturnal enuresis.
- There may be unexplained cuts and bruises or damage to possessions or clothes.
- The parent may have noted a change in routine with regard to travel to school, or a reluctance to travel alone.
- The child may be clinically depressed.
The features listed above may not be volunteered and so direct inquiry may be required. If the diagnosis is uncertain ask the child questions such as:
- 'Do you like your school?'
- 'Do you have any friends?'
- 'Is there anyone whom you don't like or who doesn't like you?'
- 'Is there anyone who makes your life rather difficult?'
The reply to the second of those questions may demonstrate a child who is socially ostracised.
Children may be reluctant to admit that they are being bullied. They may not wish to admit to this weakness and failure. They may fear that it will upset their parents or make others think less of them. They may also fear that action will be taken that will be counterproductive and the bullying will become worse.
Adults may also present complaining of bullying in the workplace or even at home as a part of domestic violence. Adults may present with the consequences of being bullied - stress, anxiety, insomnia, and depression, or they may be requesting a fit/sick note to help them deal with the situation.
There are other reasons for school phobia and school refusal.
- The child may simply be struggling academically. These children usually say that they find the lessons boring, as if they are too simple for their superior brain. They may also be disruptive in class. They tend not to have the air of oppression that is more typical of those who are bullied.
- Sometimes children are reluctant to go to school because they are worried about the one they leave at home. For example, a physically or mentally unwell parent, or one who has problems with misuse of alcohol or drugs.
- Sometimes it is not their peers who are constantly belittling and humiliating children but their teachers.
- The child may be the victim of abuse by someone rather older, and possibly the victim of sexual abuse. The perpetrators do not wait in the woods wearing dirty raincoats but are usually previously known to the child and trusted by the family. The child who is bullied may also be more susceptible to grooming because of low self-esteem. 'My little princess' and 'This is our special secret' are some of the phrases used to make the child feel special. See the separate Safeguarding Children - How to Recognise Abuse or a Child at Risk article for more information.
A GP's role is to support and to help empower the victim (or perpetrator) to resolve the situation. This involves listening, empathy, giving advice and information and treating any physical or psychological sequelae.
Children and adolescents
Having made the diagnosis, the more difficult problem is how to manage it. This must be done in consultation with the child, who may well be afraid that a 'bull in a china shop' approach will only make the bullies more vicious. Reassure the child that the right thing is to share the information. Denial will not make it go away but is the bully's best friend. These fears must be explained to the parents too, who may be governed more by emotion than by reason. If the parents confront the bully directly this will be counterproductive and could get them into trouble. A rational approach is required and, where the bullying is taking place in or around school, the school must be involved. Where non-school-related cyberbullying has taken place, it may be appropriate to notify the police. In less serious cases, parents may be able to take control by changing the child's mobile number and re-educating on safe use of social media.
There has been much publicity about bullying in recent years and, nowadays, by law, all state (not private) schools must have a behaviour policy in place that includes measures to prevent all forms of bullying among pupils.Schools must also follow anti-discrimination law. This means staff must act to prevent discrimination, harassment and victimisation within the school.
The child may be relieved that at last something is being done and it will all be better tomorrow. The reality is that it will take rather longer. It is not the role of the doctor to sort out the bullying but the doctor does have a responsibility to ascertain that the child and parents are made aware of the direction that they should take. A follow-up appointment, probably in about a month, should be offered to ascertain that all is going according to plan and, it is hoped, that "medical" problems which led to the consultation will be significantly improved or entirely gone. Most schools will be able to offer appropriate counselling if there are ongoing psychological problems. In some cases a referral to the local Children and Adolescent Mental Health Services (CAMHS) may be needed, or advice about local youth counselling options. There have been cases of children and teenagers committing suicide following bullying or cyberbullying, so this is an issue which must be taken seriously.[11, 12]
Again, the GP should offer advice on how to resolve the situation.
For victims of workplace bullying, advise discussion with their manager or Human Resources (HR) department. If neither is possible, they could also discuss matters with their trade union representative, or with ACAS, who have a helpline. Discuss their long-term plans and wishes with regard to ongoing employment; encourage them to find a way to achieve these. Sometimes a fit note or sick note may be appropriate, either to alert the workplace to the impact on health of the situation, or to achieve a change in working environment. People may be too affected by stress to continue working and a sick note may be necessary while the situation is resolved.
For those who are victims of domestic violence, see the separate article Domestic Violence for further information about the resources available.
Ideally, if the situation is resolved there may be no need for further medical involvement. However, often it is not as simple as this. Referral may be needed for psychological therapy, such as counselling or cognitive behavioural therapy (CBT). Medication may be needed for symptoms of anxiety, depression or insomnia.
It is very easy to be so engrossed with the victim as to forget the bully and why he or she acts in that way. How should the bully be managed? Punishment is unlikely to be an effective means of making the bully realise his or her shortcomings. The bully is also someone in need of help. Victim empathy is often employed in prevention of re-offending courses used in the prison and probation services. Getting the bully to appreciate what it must be like to be on the other end may be useful. The bully may not be the strong, confident person that may initially appear but a frail and insecure individual. In some cases there may be low self-esteem or depression. They are also more likely to be struggling academically.
There is likely to be a reason or background for bullying behaviour. People who have been bullied or mistreated themselves are more likely to bully others. It may be an attention-seeking behaviour, in which case there is probably a reason why attention is needed. In the workplace, bullying may result from someone being put in a position of authority without training in leadership skills.
Victims suffer great misery, underachieve and experience poor health which may continue long after the bullying has ceased. In childhood and adolescence, a history of having been bullied has been shown to increase the risk of:
- Physical symptoms: abdominal pain, headache, back pain, tiredness, dizziness, insomnia, nightmares.
- Inferior academic achievement.
- School absenteeism.
- Anxiety disorders.
- Borderline personality disorder symptoms.
- Psychotic episodes.
- Suicidal ideation and suicide.Cyberbullying was found to increase the risk of suicidal ideation more than traditional bullying in one meta-analysis.
Into adulthood, long-term effects of being bullied in childhood include an increased risk of:
- Anxiety disorders.
- Psychotic symptoms.
- Suicidal ideation and suicidal behaviour.
- Having lower academic qualifications.
- Having difficulty keeping a job.
- Having lower income.
- Having relationship problems and difficulty making friends or finding a long-term partner.
- Having poor general health.
The offenders are more likely to have delinquent behaviour and this may continue into adult life. They may be more likely to be involved in crime and illicit drug use. However, this has been less extensively studied and other factors may also account for this.
Bullying in the workplace can lead to:
- Stress-related symptoms.
- Anxiety and panic attacks.
- Post-traumatic stress disorder (PTSD).
- Loss of self-esteem.
- Physical problems: increased blood pressure, symptoms of irritable bowel syndrome, peptic ulcers, skin disease.
- Lower productivity at work.
- Absenteeism at work with implications for future employability.
- Suicidal ideation and behaviour.
Various approaches have been used to try to prevent bullying from becoming endemic. The authoritarian approach of 'We don't have any of that sort of thing in this school' is more likely to hide the problem than to solve it. An atmosphere of openness and ability to talk about it is far more helpful. Prevention programmes in schools do work. These can be curriculum changes, whole-school interventions or social skills' teaching. Whole-school approach is probably more effective than targeting individuals. Also a multidisciplinary approach appears to be beneficial. Sometimes teachers have asked children to write essays about bullying so that they have to think about it and see it from the side of both the perpetrator and the victim. It is hoped that, in uncovering the inadequacy of the perpetrator, he or she will be made to seem more an object of derision than one of admiration. Understanding the way that the victim feels and the devastating impact may produce such an empathy that no one would really wish to inflict that on another.
A culture must be established in which a person who wishes to bully another is seen as weak and inadequate, someone to be despised, not feared and certainly not respected. The bully, in the same way as the victim, should be seen as someone in need of help
Schools have an enormous role to play in the prevention of cyberbullying. Early education for children about the risks of the internet and social media is now routine practice. Parents also have a responsibility to keep children safe from cyberbullying by education and monitoring of their children's use of online and social media sites. Parents should be involved in teaching children and adolescents about privacy settings, communicating with strangers online and about not posting comments or information which could harm themselves or others.
Preventing bullying in the workplace is largely a management role. It involves promoting a safe work environment where there is respect between individuals, suitable training for leadership roles, promoting communication and putting in place systems to allow for prompt resolution of bullying issues which arise. Employers are responsible for preventing bullying and harassment within the workplace.
Further reading and references
Bullying at school; GOV.UK
Bullying: General Advice; bullying.co.uk
Stopping bullying and harassment at work; British Medical Association (BMA)
Wolke D, Lereya ST; Long-term effects of bullying. Arch Dis Child. 2015 Sep100(9):879-85. doi: 10.1136/archdischild-2014-306667. Epub 2015 Feb 10.
Annual Bullying Survey 2016: Bullying statistics in the UK; Ditch the Label, 2016
Bullying and cyberbullying: Facts and Statistics; The National Society for the Prevention of Cruelty to Children (NSPCC)
Cyberbullying report; Ditch the Label, 2013
Advice for parents and carers on cyberbullying; Dept of Education, GOV.UK, November 2014
Seeking better solutions: tackling bullying and ill-treatment in Britain's workplaces; The Advisory, Conciliation and Arbitration Service (Acas) Policy Discussion paper, November 2015
Shireen F, Janapana H, Rehmatullah S, et al; Trauma experience of youngsters and Teens: A key issue in suicidal behavior among victims of bullying? Pak J Med Sci. 2014 Jan30(1):206-10. doi: 10.12669/pjms.301.4072.
van Geel M, Vedder P, Tanilon J; Relationship between peer victimization, cyberbullying, and suicide in children and adolescents: a meta-analysis. JAMA Pediatr. 2014 May168(5):435-42. doi: 10.1001/jamapediatrics.2013.4143.
Vreeman RC, Carroll AE; A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007 Jan161(1):78-88.
Bullying and harassment at work: a guide for employees; Advisory, Conciliation and Arbitration Service (ACAS)
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