From The Carlat Child Psychiatry Report, September 2018, Depression in Children and Adolescents

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Bullying | Depression | Free Articles | Suicidality

What can you do when one of your patients reports being bullied? Research has shown that being bullied increases the risk of depression, anxiety, and suicidality in children. In this article, we’ll give you some tips for how to ask about bullying, how to assess its impact, and how to help your patients and their families deal with the problem.

How bullying affects children and adolescents
Bullying is unfortunately common. About 30% of school-aged children and teens report being bullied, and 70% report seeing bullying (https://nces.ed.gov/pubs2013/2013329.pdf). Kids who are bullied are more likely to have psychiatric problems than other children. A prospective, 15-year study of 2,120 children in Quebec (Geoffroy M et al, CMAJ 2018;190(2):E37–E43) found that children who suffered severe and chronic bullying had 2.5 times the risk of depression and 3.5 times the risk of both anxiety disorders and suicidality than controls.

The relationship between bullying and suicidality is complex—not the direct “bullicide” often cited in media. Experiences of rejection and exclusion and feelings of isolation and despair contribute to suicidal thinking. Those who become suicidal tend to have multiple risk factors, such as family turmoil, poor grades, and peer difficulties. Children who are both victims and bullies are at the highest risk for suicidal thinking and behavior. Social media bullying doubles the risk of self-harm or suicidal behavior (John A, J Med Internet Res 2018;20(4):e129).

How to assess for bullying
Children and teens are often embarrassed to bring up the topic of bullying, so it’s important to routinely ask about it during evaluations. Younger children may not understand what the word means, so you might ask, “Has anyone hurt you? Have they yelled at you or called you bad names?” When you see injuries, ask, “Was this an accident or on purpose?” Sometimes bullied children take a different way home or avoid certain places, such as the library or the bathroom. Such behavior may paradoxically lead to adult punishment for avoidance behavior or for wetting or soiling. Ask, “How come you are not using the bathroom at school?” Children who are having trouble sleeping may be worried or having nightmares; in these cases, ask, “Is something scaring you?”

For older children, you don’t need to be as cautious about phrasing—you can use the word “bullying,” then have the patient elaborate on what that means—but in these older kids, be sure to also ask about cyber or social media bullying.

As in all abuse situations, accept the child’s or teen’s report as the true reality. While some kids misperceive situations (eg, kids with externalizing disorders may see neutral expressions as critical), most of the time this is not the case. Either way, our job is to complete the psychiatric assessment. Look especially for depression, anxiety, and suicidality, and seek collateral data by assessing the perspectives of parents, teachers, and peers to hone in on an accurate set of diagnoses. Parents can have an important role in this process. In particular, they can ask their teens: “Who’s texting you? Why are you turning the phone away? What don’t you want me to see?”

What to do for the patient who reports bullying
Treat the syndromes that you find, using psychotherapy or medications for depression and anxiety, and consider referring your patient for trauma-focused cognitive behavioral therapy (TFCBT), a well-researched therapy for trauma of many types. Address other contributing factors, particularly conditions that set the child apart from others (eg, ADHD and autism spectrum disorder), with treatments like social skills training. Use medications as you usually would for psychiatric conditions, but avoid benzodiazepines, since recent research indicates that these might worsen PTSD.

Advise parents that their child requires care and protection. Many parents might encourage their child to strike back; however, this is shown to lead to more bullying difficulties. There are better approaches. Carol Gray is a well-known educator who has written extensively on managing bullying. I recommend using her evidence-informed technique of coaching the child to use one well-practiced, neutrally delivered verbal response, such as, “I’m not staying for this,” then turning and walking away from a bully and going to a trusted adult. There is excellent research showing that children and teens who witness bullying have a very good chance of stopping the bullying if they speak up forcefully, telling the bully, “Stop it!” This research demonstrates that when bystanders speak up, most of the time bullies back down.

What if your patient reports bullying but doesn’t want you to tell the parents? This is one of those times when motivational interviewing can help: Ask the child about the advantages vs disadvantages of keeping such a secret. Some children worry that they are “tattling” on the bully and thus might incite reprisals. Help the child move toward a more balanced view, hopefully one that allows you to act with the child to inform parents and authorities in a manner that is safe and productive.

Advocating at school
Child psychiatrists can have a powerful impact on schools in addressing bullying. Get parental consent and call the principal to talk about the situation. It is a rare event for schools to hear from an outside, interested professional, and your advice will carry weight. Here are some talking points that you might consider.

Encourage good supervision. The most important intervention at a school is to provide better, more engaged, and often more structured supervision during lunch, recess, and other times and places when children and teens are likely to have conflict.

Make sure there are safe people to go to. Children need to have relationships with adults whom they trust, and who can actually advocate for and protect them at school.

Discourage having the child face the bully to “work it out.” Many schools believe that such meetings are helpful for both parties, affording them the experience of working out their problems. In my experience, the meetings are rarely helpful. They tend to result in perfunctory and meaningless apologies at best, and often the bullying continues. This may also disincentivize the victim from reporting subsequent bullying.

Make sure the school is addressing the needs of all the children involved, including perpetrators (often a group) and bystanders. In rare instances, a school change may seem necessary, despite losing contact with friends and disrupting the child’s education. Weigh the option carefully.

CCPR Verdict: Always ask about bullying as part of your routine assessment and advocate with schools to address it.