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Continuing Education Activity

Bullying is common in our society and has become a public health emergency. It is a form of repeated peer aggression which is intentional and involves a power differential between the bully and the victim. It is often subtle and hidden, profoundly affecting a substantial number of children. The information in the following activity will provide clinicians with tools for increased awareness and early recognition of bullying; this, in turn, is likely to result in the development of strategies for prevention and intervention with respect to this significant societal issue. This activity reviews the cause, pathophysiology, presentation of patients that are victims of bullying and the role of the interprofessional team in the evaluation and management of these patients.


  • Identify the etiology and epidemiology of bullying.
  • Discuss the presentation and signs and symptoms suggestive of bullying.
  • Outline strategies for the treatment and prevention of bullying.
  • Recognize that strategies for addressing bullying may be different for bullies and their victims.


Bullying is a very common, complex and potentially damaging form of violence among children and adolescents. Bullying is defined as unwanted, aggressive behavior, which involves a real or perceived social power imbalance. The behavior is repeated, or has the potential to be repeated, over time (therefore, the definition excludes occasional or minor incidents). These actions are purposeful and intended to hurt or make the victim uncomfortable.[1]

Bullying may manifest itself in many forms. It can be physical, verbal, relational, or cyber; it can be subtle and elusive. The most common form of bullying both for boys and girls is verbal bullying such as name-calling. Although bullying is more common in schools, it can occur anywhere.  It often occurs in unstructured areas such as playgrounds, cafeterias, hallways, and buses. In recent years, cyber-bullying has received increased attention, as electronic devices have become more common. Bullying through electronic means, although prevalent, ranks third after verbal bullying and physical bullying. In general, bullying is a common type of social experience that children refer to as “getting picked on.”


The etiology of bullying is complex and may depend on multiple issues including individual, social, and family issues. It is important to understanding these hidden causes that increase the risk of bullying.[2]


Although there are many causes of bullying, certain risk factors may attract bullies to their victims. 

  • Children who are different from their peers
  • Children who are weaker (than bullies)
  • Children who are socially isolated, less popular, and have few friends
  • May have underlying feelings of personal inadequacy


These children may have the following characteristics:

  • Increasingly aggressive behavior and can be easily frustrated
  • Tendency to blame others for their issues
  • Unable to accept responsibility for their actions
  • May be overly competitive and worry about their reputation or popularity
  • May have friends who bully others
  • May perceive hostile intent in the action of others
  • May have a desire for power or dominance

It is not necessary that a bully is stronger or bigger than their victim. The power imbalance can be due to many things including popularity, strength, or cognitive ability. Bullying behavior may be used to gain social status.[3]


According to the National Center for Educational Statistics (2013), 1 in 3 children (27.8%) report being bullied during the school year. Bullying is reported to be more prevalent among boys than girls. It occurs with greater frequency among middle school children. For boys, both physical and verbal bullying is common, whereas, for girls, verbal bullying and rumors are more common. African Americans youth report being bullied significantly less frequently than white or Hispanic youth.[4] Bullying peaks in early adolescence and then gradually declines as adolescence progresses, although recent research suggests that this is for more overt forms of bullying, whereas covert bullying continues through adolescence.


The issue of bullying in children is a complex problem that emerges from social, physical, institutional and community contexts, as well as the individual characteristics of the children who are bullied and victimized. A bullying interaction occurs not only because of individual characteristics of a particular child who is bullying, but also because of actions and attitudes of peers, teachers and school staff, and physical characteristics of that particular environment. Family dynamics, cultural factors, and even community response also play a role in the occurrence of the bullying interaction.

History and Physical

Certain signs may indicate that a child has been a victim of bullying, including:

  • Injuries or illness without a physical explanation
  • Lost or damaged belongings, such as books or clothes
  • Frequent somatic symptoms, changes in habits, and/or difficulty sleeping or frequent nightmares
  • Avoidance of school or social situations
  • Feelings of helplessness or decreased self-esteem
  • Hurting himself/herself or expressing suicidal intent


Bullying is a serious problem for both the bully and the victim. The first step is recognizing bullying as a problem for a child. It is also important to identify bullying interactions at an early stage.

Assessment of bullying: There are many tools available to assess bullying and determine the frequency and locations of bullying behavior. See the Centers for Disease Control and Prevention's compendium for measuring bullying, victimization, and bystander experience.

It may also be important to assess other risk and protective factors, such as depression, suicide risk, sources of internal and external resilience, to best determine the interventions and supports needed.

Treatment / Management

Since bullying is a very complex problem there is no “quick fix” to prevent or intervene with this issue.  It is important to understand the issues that are unique to the individual and the context in order to develop and implement interventions. Here we describe important elements for intervention to address this issue.

To stop bullying, remember prevention is the best intervention.

  • Assist child and family in providing a supportive and safe environment
  • Provide assurance to the child that bullying is not his or her fault
  • Work with school and other agencies as applicable to protect the victim
  • Defuse or de-escalate an acute situation

Addressing bullying is a multi-step process.[5]

  • Teach children not to bully; discourage bullying
  • Improve supervision in commonly under-supervised areas such as playground, cafeteria, hallway and bus
  • Bullying prevention strategies should be clear and visible to other children
  • Educate children about consequences of bullying and letting him/her know that bullying is wrong and a serious act.
  • Apply consistent disciplinary consequences (e.g., removal of privileges, reparation).   
  • Enforce penalties such as requiring community service as “payback” for unacceptable behavior

Be aware that punishment based strategies (suspension and expulsion) should be reserved for severe disruptive and aggressive behavior. These may not be the most effective strategies.

Engaging the Victim

  • Empathetic listening to the child; trying to understand child’s view
  • Provide emotional support to child and family
  • Obtain permission for a discussion with school officials
  • Discuss when to contact parents; consider parents as partners
  • Psycho-educational counseling
  • Long-term support and intervention

Engaging Bullies

Explore the basis of bully’s behavior: it is also important not to label them as a bully.

  • Listen to their perspective. Remain non-confrontational; share concern for the victim, ask for suggestions for improvement.
  • Set the boundaries between acceptable and unacceptable behavior; communicate that this behavior is unacceptable
  • Children may quit bullying when they become aware of the hurt they have caused and learn alternative ways of coping

Team approach: Many researchers believe that bullying is a group process and therefore interventions against bullying should be targeted at the peer-group level rather than at individual bullies and victims. Research has shown that the most successful programs are those that use multi-level interventions.[6]  

  • Involve parents; determine the best time and most effective method of involving parents
  • Family therapy is one effective method of reducing anger and improving interpersonal relationships
  • Encourage schools to develop an anti-bullying policy that should be included in the student code of conduct
  • Pediatricians should consider screening children for their potential involvement in bullying activities and encourage youth to prevent and intervene with bullying in safe ways (even as bystanders)

Bullying is a learned behavior that may be preventable. School-based interventions have shown a significant reduction in bullying by up to 20%.  These interventions included the following[7]:

  • Changes in the school and classroom climate to increase awareness about bullying
  • Increase teacher and parent involvement
  • Improved supervision
  • Setting clear rules against bullying
  • Providing support and protection for bullied children 

Differential Diagnosis

  • Antiphospholipid syndrome and pregnancy
  • Atherosclerosis
  • Frostbite
  • Giant cell arteritis
  • Gout imaging
  • Imaging in polyarteritis nodosa
  • Raynaud syndrome
  • Scleroderma
  • Systemic lupus erythematosus
  • Type 1 diabetes mellitus
  • Type 2 diabetes mellitus

Pearls and Other Issues

Bullying is not primarily a law enforcement issue, but because of its ramification, all fifty states in the United States have developed school anti-bullying legislation or policies. Bullying may also appear in the criminal code of a state, or may relate to other crimes, such as aggravated harassment or stalking, and may apply to juveniles.

Enhancing Healthcare Team Outcomes

Bullying is a serious societal problem, often very difficult to diagnose. The entire interprofessional team must be aware of signs and symptoms. Often a child will open up to a nurse that opens the communication to the entire team. Usually, social workers, nurses, and clinicians need to work together to assist the child or adolescent. Usually, parents and sometimes school officials will need to become involved. The best outcome is achieved with an interprofessional team. [Level V]

Article Details

Article Author

Muhammad Waseem

Article Editor:

Amanda B. Nickerson


8/7/2022 9:16:15 AM

PubMed Link:




Olweus D, Bullying at school: basic facts and effects of a school based intervention program. Journal of child psychology and psychiatry, and allied disciplines. 1994 Oct     [PubMed PMID: 7806605]


Garcia-Continente X,Pérez-Giménez A,Espelt A,Nebot Adell M, Bullying among schoolchildren: differences between victims and aggressors. Gaceta sanitaria. 2013 Jul-Aug     [PubMed PMID: 23416025]


Waseem M,Ryan M,Foster CB,Peterson J, Assessment and management of bullied children in the emergency department. Pediatric emergency care. 2013 Mar     [PubMed PMID: 23462401]


Nansel TR,Overpeck M,Pilla RS,Ruan WJ,Simons-Morton B,Scheidt P, Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001 Apr 25     [PubMed PMID: 11311098]


Frisén A,Jonsson AK,Persson C, Adolescents' perception of bullying: who is the victim? Who is the bully? What can be done to stop bullying? Adolescence. 2007 Winter     [PubMed PMID: 18229509]


Framing public policy and prevention of chronic violence in American youths., Dodge KA,, The American psychologist, 2008 Oct     [PubMed PMID: 18855489]


Salmivalli C,Kaukiainen A,Voeten M, Anti-bullying intervention: implementation and outcome. The British journal of educational psychology. 2005 Sep     [PubMed PMID: 16238877]