Bullying (Abuse by Peers)

Bullying has always occurred and always will occur. When people are together there will be jostling for leadership and superiority, but 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.

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. This article will concentrate on bullying in children and most of this occurs in schools or is related to school.

Bullying is often seen as the physical oppression of the weak by a stronger, often older person but 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. Social exclusion, spiteful remarks,malicious rumours and damage to property or school work are just some of the techniques. Sending nasty messages by text on mobile phones is a recent innovation as is distributing pictures of someone being attacked or humiliated, sending the pictures by mobile. All this can be just as traumatic as physical attacks and it has driven some children to suicide.

It is estimated that 15 to 20% of school children are victims of bullying at some stage in their education. It is said that 30% are involved either as victims or perpetrators. National surveys of bullying in schools range from just over 11% in Denmark to nearly 50% in Ireland.¹ Such a wide range may be more indicative of differing criteria than differing social patterns. Bullying is not simply the occasional callous or cutting remark but a systematic and recurrent attempt to undermine the individual.

In a survey of 10 Scottish schools, half the children who had been bullied had told no one. Of those who had told, 47% had told a parent and 31% had told a teacher.

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, "Please don't send me 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 extra-curricular 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 like, "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 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.

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. This may be an alcoholic mother who drinks all day or who abuses 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.

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 the school must be involved.

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.

In the past some teachers may have taken the approach that bullying is just part of growing up or "We don't have any bullying in my school". The latter approach is akin to some national leaders who have refused to accept that their country has a problem with AIDS and as a result it has been neglected and is rife. There has been much publicity about bullying in recent years, and nowadays every school is required by law to have a policy on bullying and how to tackle it.

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 hopefully the "medical" problems that led to the consultation will be significantly improved or entirely gone.

• Make a list of what the child has said, including names and occasions so as to be specific. Unless names are named it is impossible to address the issue.
• Talk calmly to the child however emotional you may feel inside. Be logical, loving and understanding.
• Look at the whole situation from the child's perspective.
• Make an appointment to see the appropriate person at the school. This may be the form teacher or tutor. Someone who knows the child well is probably better than the head teacher. The head teacher may need to be approached if there is no satisfactory outcome.
• Let the school approach the other parents if that is necessary rather than doing it yourself. You must not approach the child yourself.

• Stay calm. Be rational and objective, not emotional.
• The teacher may not appreciate what is happening or may have heard conflicting accounts of an incident.
• The teacher may have noticed changes in behaviour or deterioration of performance at school but not have appreciated the cause.
• Be as specific as possible about what the child says has happened. If possible, give dates, places and names of other children involved.
• Take a note of what action the school intends to take.
• Ask if there is anything you can do to help your child or the school. Be the caring parent, working with the school to try to solve the problem. Do not play the part of the outraged parent, holding the school to blame and demanding that they sort it out. You get much better results from teachers by working with them rather than against them.
• Keep in contact with the school. Let them know if things improve or if problems continue.

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 is not the strong, confident person that may initially appear but a frail and insecure individual. Far from being confident and of high self-esteem, they may even have evidence of depression.² They are also more likely to struggling academically.³

Bullying tends to start in primary school and is less prevalent in more senior schools and classes. Perhaps this is because of increasing maturity. Those who suffer from bullying are also more likely to bully others.^4,5 About a third of bullies have been victims. A number of these will come from a home where domestic violence occurs and so bullying is part of the family tradition. It may be seen as a means of survival. We sometimes talk about a line of bullying in which the last in the chain kicks the dog.

Victims suffer great misery, underachieve and suffer poor health that may continue long after the bullying has ceased.⁶ The offenders are more likely to have delinquent behaviour and this may continue into adult life.⁷ Victims of bullying, especially if in an indirect form, often have suicidal ideation and this may be acted out.

The victims of bullying are not chosen at random and so perhaps some attention is also required as to why certain individuals tend to be victims and what they might do to rid themselves of this status, not just at school but throughout life. Those who are bullied at school are more likely to be victims in the workplace.⁸ Some anti-bullying projects select recurrent victims for special attention. There is obviously something about that person that makes him or her vulnerable and this needs to be addressed.

There is some evidence to suggest that both bullies and victims will have long-term increased risk of psychiatric conditions.⁹ These include development of an antisocial personality, substance abuse, depression and anxiety disorders. Bullies are also at risk for later criminality.

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.¹⁰ These can be curriculum changes, whole-school interventions or social skills teaching. Whole school approach is probably more effective than targeting individuals.¹ Also a multidisciplinary approach appears to be beneficial e.g. use of social workers.¹¹ 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. Hopefully, uncovering the inadequacy of the perpetrator will make him or her seem more an object of derision than 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 should be seen as someone in need of help as much as the victim.

Some areas have anti-bullying projects and schools can refer into the scheme. It may be possible to self-refer. If a GP has concerns and would like them to see and assess an individual they will almost certainly be happy to do so.

Prevention also requires changes to the media presentation of bullying. There are a number of media programmes which are based around bullying - even if it only consists of derogatory remarks from one person to another. The role of the internet in bullying must also be considered and methods to protect victims are required.

Thomas Hughes wrote Tom Brown's Schooldays which was published in 1857. Although both Tom Brown and the bully, Flashman were supposed to be fictitious characters, Thomas Hughes had attended Rugby school and much of the book was almost certainly autobiographical or strongly influenced by personal experience.

It was about 100 years after the publication of Tom Brown's Schooldays that George Macdonald Fraser lifted Flashman to be his antihero in a series of amusing books about the swaggering, cowardly and despicable character after he left Rugby School. Fraser saw Flashman as the object of contempt. Aristotle wrote that "laughter overcomes fear" and the fearsome bully has been the subject of much ridicule in comedy, highlighting his or her inner inadequacies. In Dad's Army, Arthur Lowe plays a swaggering incompetent Captain Mainwaring. Women with power and the need to bully are lampooned with Pauline Campbell-Jones as the re-start officer at the Job Centre in The League of Gentlemen and Marjorie Dawes as the terrifying leader of Fatfighters in Little Britain.

The school bully is certainly not neglected in The Simpsons. Nelson is rather larger than his peers but also rather more stupid. It is the underachievers at school who are portrayed as the bullies in the series and no one can watch the cartoons and feel that the bullies should be emulated or admired.