“My daughter [age 10 years] has been bullied at school for the past 2 years by another girl in her class. This girl dominates my daughter’s lunchtime and recess, controlling where she sits and who she plays with. She uses scare tactics such as loud outbursts and physical threats. I know this girl has a history of being neglected and abused by her parents, but still. . . . My daughter is absolutely miserable. What should I do? Should I talk to the teachers—and if I should, what do you think I ought to say?”

Bullying is a subject that may surface during a child’s doctor visit. It may be tempting to consider this as solely a school problem and leave it in the teacher’s hands. However, many adverse health effects have been described as occurring with greater frequency in both bullies and their victims. Accidental and intentional injuries, substance abuse, mental and eating disorders, and increased risk of experiencing suicidal ideation and behavior are just some of the ill effects of bullying.^1,2 According to the United States Secret Service and Department of Education’s “Safe School Initiative” 2002 final report, 71% of perpetrators of targeted school shootings felt persecuted, bullied, threatened, attacked, or injured by others before they engaged in their deadly acts.³

Stress the importance of early intervention. In addition to having an interest in preventing the adverse health consequences of bullying, pediatricians can be uniquely helpful in reducing bullying. First, the pediatrician can advise a parent in a situation such as the one described above about the critical importance of early intervention. Some parents may be reluctant to intervene, feeling that their getting involved in something that is such a common childhood phenomenon constitutes overreaction or overprotection. However, it is important to debunk such “kids will be kids” myths, which downplay the serious nature of bullying.

The type of bullying can change over time (eg, teasing in elementary school can progress to cyber bullying in high school), can vary in severity, and may become more aggressive with increasing duration.⁴ It is reasonable to expect that when intervention is prompt and successful at stopping the bullying, potentially life-altering and life-threatening consequences may be averted. Teacher involvement in elementary school is especially important. Reductions in bullying are more likely to occur when anti-bullying actions are employed in early childhood.⁵ A review by Rigby and Slee⁵ revealed that teacher interventions are more effective in elementary school: they found that most 8-year-old students, but not 16-year-olds, reported that teacher interventions reduced bullying.
 

Steps to recommend to parents. A number of specific actions can be recommended to parents in most situations in which their child is a victim of bullying. Several of these are requests the parents can make of the school when they meet with their child’s teachers:
•That a meeting of the victim’s parents, teachers, and school administrators be held so that the details of the bullying can be outlined and the most at-risk times determined.
•That there be “restorative justice”—ie, that an effort be made to have the bully understand and apologize for the hurt caused by his or her actions; this may promote empathy and can provide some solace for the victim.⁶
•That continued surveillance of the problem be provided, 6 through solicitation of periodic updates from the victim and ongoing monitoring during school hours—especially at lunch and recess, when the bully has greater unsupervised access to the victim.
 

In addition, a pediatrician may often deem it wise to recommend counseling or cognitive-behavioral interventions for a child who is a victim of bullying. Such a child is likely to benefit from these interventions, which can improve self-esteem and social skills and may decrease the risk of being victimized in the future.⁶ Also, point out to parents the importance of providing positive reinforcement whenever a child who has been bullied asserts himself and acts in a self-protective manner.

What else can pediatricians do? Beyond counseling individual patients and their parents, pediatricians can offer to educate teachers, parents, and students about bullying at a school assembly. They can also lend their support to—or even initiate—efforts to implement anti-bullying programs in the local school or school system. Several such programs are in use. These vary in cost and in the extent of school-wide and communitywide involvement required.^5-7 Different situations will be best served by different programs. However, some important elements shared by most anti-bullying programs include:
•A review of the school’s anti-bullying policy, with an eye to ensuring that the rules of appropriate school behavior and the consequences of inappropriate behavior are made clear to all students.
•Encouragement of all students to be “helpful bystanders” and to inform teachers when they observe bullying; acting as a helpful bystander is touted as very honorable and altruistic and not belittled as “tattle-taling.”
•Interventions with students who bully as well as with those who are the victims of bullying.
In the scenario described above, counseling both for the student who bullied this girl and for her family would likely prove helpful. Prior exposure to victimization at home, such as occurred with this bullying child, has been shown to be associated with participation in bullying as either a victim or a bully.6 Pepler and colleagues⁴ describe bullying as a relationship problem that requires relationship solutions. Children who bully have learned that by being aggressive they can control situations in which the victim is involved. The aggressive behavior is reinforced because domination continually leads to a bully getting his own way. Interventions that emphasize the positive uses of power can prove helpful.