An Early Warning Sign for Violence

Psychiatric TimesPsychiatric Times Vol 18 No 9
Volume 18
Issue 9

Bullying and being bullied put adolescents at risk for developing violent behaviors. Depression and anxiety are two of the underlying issues related to this type of behavior. Recognizing the warning signs may help mental health care professionals prevent violence in the adolescent's life.

Over the past few years, the ripple of widely publicized school shootings has demonstrated that the nation's epidemic of youth violence has broadened in terms of age, geography and sex, to encompass all populations. The attention drawn by the media to these recent tragedies has thankfully also drawn attention to issues regarding the early identification of risk factors for violence and strategies for violence prevention.

We have now come to recognize that acts of bullying and revenge are associated with many of these violent incidents. Previously, issues related to bullying have not been a prominent part of the violence prevention agenda. An article by Nansel and colleagues (2001) confirmed that bullying is indeed a necessary component of a comprehensive violence prevention strategy for our children and youth. Further attention, effort and funding are required to provide antibullying interventions in U.S. schools, as well as other violence prevention approaches.

Nansel et al. found that, of their sample of over 15,000 children in the United States, 30% reported either moderate or frequent involvement in some aspect of bullying. Thirteen percent reported being a bully, 10.6% had been bullied, and 6.3% reported experiencing both bullying and being bullied. Demographic disparities were also noted in this study, with males significantly more involved in both aspects of bullying. No significant geographic variations in either aspect of bullying involvement were noted.

Nansel and colleagues' findings are consistent with prior research on bullying, most of which has been from studies conducted in Europe. There is a high degree of international variability, but studies have generally found bullying to be prevalent, ranging from 15% to 20% in most countries.

The study also demonstrated that bullying is associated with other indicators of maladjustment. Those involved in any aspect of bullying demonstrated poorer psychosocial adjustment than those youth who reported no involvement. Specifically, those who had been bullied demonstrated poorer social and emotional adjustment, had greater difficulty making friends, had poorer relationships with classmates, and experienced greater feelings of loneliness. Social isolation and lack of social skills were found to be associated with propensity for being bullied. Substance abuse was associated with children who reported bullying others. This group also showed poorer school adjustment in terms of academic achievement and perceived school climate, however, bullies reported ease of making friends, a finding that suggests bullies are not socially isolated. It is hypothesized that bullies develop friendships with others who are bullies, or who, at the least, endorse bullying.

Past research has also shown bullying to be associated with depression, low self-esteem and suicidal ideation (Kaltiala-Heino et al., 1999; Salmon et al., 1998). In young children, bullying has been associated with headaches, stomachaches, sad feelings, bed-wetting and sleep difficulties (Williams et al., 1996). The work of Olweus (1992) showed that bullying is associated with a fourfold increase in criminal behavior, including multiple convictions in 35% to 40% of bullies. The evidence that bullying must be addressed is overwhelming. The question is: What can we do about it?

First, we must recognize any involvement in bullying as a cautionary signal. As a behavior, it is a red flag that may coexist with a variety of other symptoms or risks. Given our understanding of what bullying is associated with, we must recognize that kids involved in bullying may also be exposed to family violence, by witnessing it, being abused themselves or both. As already discussed, there may be a host of mental health issues, such as underlying depression and anxiety. School dysfunction may also be related to learning disabilities among these children. It is essential that people who work with kids in settings where bullying behavior may be displayed understand these other symptoms so that appropriate mental health care services can be engaged.

In our review of the literature, we were unable to uncover any significant findings regarding successful strategies in the treatment of bullying. Nonetheless, the work of Olweus (1994) with school-based bullying prevention is extremely encouraging, reporting up to 50% reductions in reported bullying. We can, however, offer some suggestions, based on our knowledge of signs and symptoms associated with bullying.

Clinically, a comprehensive set of services is required. While therapeutic interventions need, in part, to focus on children's behaviors, it is even more important that mental health care professionals address the underlying issues. This may involve engaging the family in therapy if there are signs of family dysfunction. Appropriate therapy and medications are needed to address underlying depression and/or anxiety. Further, appropriate evaluations are required if school performance or conduct disorder become issues.

Most importantly, we must never lose sight of the fact that bullying is one of several coinciding warnings for involvement in violence. Involvement in bullying seems to be an indicator that something is wrong. Children who experience bullying, from either perspective (as the bullier or the bullied), need help. To better address violence prevention among our youth, it is paramount that we understand the key risk factors, their prevalence and how best to prevent them. Bullying is a crucial part of the cycle of violence and can be used to help address many of these issues. In addition, we must teach our children ways in which to be resilient and tools with which to counteract the epidemic of youth violence. Primary prevention of bullying involves elimination of risk factors and teaching children skills in order to promote more prosocial, interpersonal interactions.

We must also be cautious not to label children inappropriately and ensure that we undertake full evaluations to avoid drawing premature conclusions in order to promote responding appropriately and employing sound intervention strategies. We, as a society, have a tendency to blame children for the behaviors that they display, rather than attempting to understand what may underlay their actions. We must consider the role of environmental and social influences, most notably media. We must recognize that our own actions, and those of other adults, have a resounding effect on our children.

We must also not forget our roles, beyond those of clinicians. We have the capacity to act as effective advocates for our children. We must use this to counteract the violent messages portrayed in media, to oppose easy access to guns-particularly handguns-and to challenge the insufficiency of services available to children, including mental health care services, services to deal with domestic violence, afterschool programs and youth development activities. In sum, in our effort to stop the youth violence epidemic, we must be cognizant of our broader civic duties.

The epidemic of youth violence does not have a single-or simple-explanation. Bullying is one of several indications that there is a need for prevention and/or intervention. Certainly, a concerted effort to decrease bullying is necessary. However, we must also address issues associated with bullying as part of a comprehensive set of violence prevention strategies. It is only in this way that we will be successful in eradicating this epidemic.




Kaltiala-Heino R, Rimpelä M, Marttunen M et al. (1999), Bullying, depression, and suicidal ideation in Finnish adolescents: school survey. BMJ 319(7206):348-351 [see comment pp330-331].


Nansel TR, Overpeck M, Pilla RS et al. (2001), Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA 285(16):2094-2100 [see comment pp2131-2132].


Olweus D (1992), Bullying among schoolchildren: intervention and prevention. In: Aggression and Violence Throughout the Life Span, Peters RD, McMahon RJ, Quinsey VL, eds. London: Sage Publications, pp100-125.


Olweus D (1994), Bullying at school: long-term outcomes for the victims and an effective school-based intervention program. In: Aggressive Behavior: Current Perspectives (The Plenum Series in Social/Clinical Psychology), Huesmann LR, ed. New York: Plenum Press, pp97-130.


Salmon G, James A, Smith DM (1998), Bullying in schools: self reported anxiety, depression, and self esteem in secondary school children. BMJ 317(7163):924-925 [see comment].


Williams K, Chambers M, Logan S, Robinson D (1996), Association of common health symptoms with bullying in primary school children. BMJ 313(7048):17-19.

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