Is bullying in children and adolescents a modifiable risk factor for mental illness?

Scott and colleagues (2014) discuss the importance of bullying as a risk factor for serious mental illness and propose a public health intervention to target bullying in Australian schools at a population level. Their article is timely: ‘bullying’ – the modern shape-shifter – has transformed itself into a cyber-entity that invades and lives in the psyche of modern children and adolescents.

Traditional bullying typically involved a bully (usually a more powerful individual) or bullies, who confronted the victim face to face with the intention of manipulation and intimidation. Whether at school or in the community, bullying occurred in a time-limited fashion. Home remained a place of sanctuary where the child/adolescent might recover from the challenges of the day. Modern bullying has no boundaries. Cyber-bullying – an increasing form – has no respect for boundaries between home and school, night and day, public and private. It continues constantly and ubiquitously through online applications such as text messaging and social-networking. These are so diverse and ever-changing that parents, often cyber-naïve, have little chance of keeping their children safe. Legal systems are likewise ill prepared. In July 2013 the American state of Florida enacted a cyber-bullying law that is likely to become a model for laws in other states. The problem has yet to be addressed in Australia, at either the state or federal level, although harassment or threats are covered by the 2004 Commonwealth Crimes Legislation Amendment ((Telecommunications Offences and Other Measures) Act (No.2)).

Some perpetrators of cyber-bullying are known to their victims; others are ‘trolls’ specialising in sowing discord online; they may even be the recipients themselves (a form of self-harassment or self-harm). Efforts to address bullying are complicated by non-existent or nascent legal frameworks for intervention and by the logistical difficulties in tracking the originators of anonymous messages. The proliferation of photo-sharing applications – allowing children and adolescents to exchange pictures of themselves, called ‘selfies’ – raises the stakes by creating electronic, immediately and widely distributable images, which, when sexually explicit, raise questions about the production and distribution of pornography.

In preparing this commentary, we carried out an audit of 30 consecutive presentations to our Emergency Department in 2013 and found that 50% of cases involved technology as part of the presenting history. To give a flavour of the problem, we offer a clinical vignette, a typical case that presents to our emergency department on a daily basis:

Ellen, a 13-year-old girl in year 8, lived with her mother and younger brother. Ellen’s parents were separated; she felt rejected by her father and was sensitive to rejection by others. Primary school was a refuge for Ellen, but life in high school was more complicated. Her two closest friends started smoking and acting ‘cool’ and were angered by Ellen’s refusal to follow suit. Ellen’s mother attempted to monitor Ellen’s social-networking account (as Ellen’s ‘friend’), but much of the communication – e.g. ‘YABYABYAB’ ‘FOC’ ‘WTF?’ (see www.urbandictionary.com/) – occurred via social steganography, a coded language used to keep out outsiders (Boyd and Marwick, 2011). In addition, Ellen had set up dual accounts, resulting in two parallel worlds, one using language her mother didn’t understand, and the other which her mother didn’t know existed. The break up of Ellen’s friendships was played out in the first of these two cyber-worlds. Day and night, Ellen was subjected to venomous texts, though she gave as good as she got. Ellen’s health deteriorated: her sleep was disturbed, she ruminated constantly, she was overwhelmed with feelings of rejection, and daily on the way to school she experienced panic attacks and felt she wanted to die. So Ellen retreated into her other cyber-world, where she talked to a 16-year-old boy named Sam, whom she had never met. Ellen didn’t question his veracity; it was enough that they ‘connected’. Sam said that he, like Ellen, had been rejected by his father and felt depressed. He told Ellen about cutting and sent her pictures of his cuts. Ellen began to cut too, wearing long sleeves so her mother would not see. Over time the ‘selfies’ became increasingly sexualised. Sam circulated them amongst his friends. Ellen then began to receive daily anonymous communications that she was a slut, bitch, cow, and f***ster, that she was no good and should kill herself. Ellen’s mother noticed that Ellen was moody and withdrawn and tried, unsuccessfully, to woo her out of her bedroom. Was all Ellen’s adolescence going to be like this? The situation came into focus when Ellen posted that she would end her life, took an overdose, and, after a friend contacted Ellen’s mother, was brought into the Emergency Department.

Ellen’s story, an amalgam of repeated tales told in our Emergency Department, highlights the complexity of bullying today. Cyber-bullying violates many social norms and potentially includes criminal behaviour, such as harassment, stalking, pornography, and incitement of individuals to harm or kill themselves. As highlighted by Scott and colleagues, a national anti-bullying intervention focused on measuring the prevalence of bulling via available infrastructure – the National Assessment Program for Literacy and Numeracy (NAPLAN) – could function to increase awareness and galvanize students who are aware of bullying to intervene by bringing it to the attention of parents and school staff. Making the presence of bullying explicit, rather than secret, is a powerful intervention in its own right. However, school-based interventions are no more than a first step. They would need to be supported by public awareness campaigns delivered by the Australian government and by collaborations with therapeutic organisations such as headspace. In addition, the increasingly multi-dimensional and diverse forms of bullying require legislative action and close collaboration with child protection agencies, the police and the judicial system.

Scott and colleagues build upon the long-standing ‘standard’ conception of bullying as something like a physical act that can be easily defined, identified and then reported (e.g., by another student, in the school setting). However, the continuing evolution of cyber-bullying will raise ongoing questions concerning definition and identification. Since the information and messages involved in cyber-bullying may be shared within existing social networks, members of those networks who report cyber-bullying may find themselves the next victims. The cost of reporting may be very high indeed. It remains an open question whether the intervention suggested by Scott and colleagues will serve as a useful foundation for addressing the new world of bullying, but it is surely a good start.

See Viewpoint by Scott et al., 2014, 48(3): 209–212