Bullying Basics for Emergency Providers Innova&ons in Emergency Care March 10, 2017 Beaumont, Royal Oak Marlene Seltzer, MD Director, The NoBLE Program Ø Defini&on of bullying and the roles youth play Ø  The different types of bullying Ø The impact exposure to bullying has on health Ø The role of healthcare providers 2
•  You are dispatched to an elementary school to see a 10 y/o male who is having difficulty breathing •  The boy appears extremely distressed •  He is tachypneic and tachycardic •  He tells you that he has a severe peanut allergy and 2 of his classmates who are always mean to him were threatening to smear peanut buTer on him 3
Bullying •  Unwanted aggressive behavior with intent to do harm •  Real or perceived power imbalance •  Behavior is repe&&ve (highly likely to be repeated) Gladden RM, Vivolo-­‐Kantor AM, Hamburger ME, Lumpkin CD. Bullying Surveillance Among Youths: Uniform Defini;ons for Public Health and Recommended Data Elements, Version 1.0. Atlanta, GA; Na&onal Center for Injury Preven&on and Control, Centers for Disease Control and Preven&on and U.S. Department of Educa&on; 2013. Roles •  Vic&m •  Bully •  Witness •  Bully-­‐vic&m Types of Bullying •  Physical •  Verbal •  Social (indirect, rela&onal) •  Cyber The Social Age 59% of youth < 10 yrs old use social media
52% ignored Facebook’s age limit of 13
21% of youth posted negative comments starting at 11
26% ‘hijacked’ another’s profile without permission
65% of 8-14 y/o involved in a cyber-bullying incident
The Social Age, Knowthenet.uk.org. 2014.
Risk Factors •  Appearance •  Obesity •  Disability •  LGBTQ youth •  Special health care needs/chronic diseases •  Learning disabili&es/ADHD •  Academic or other achievement -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐ •  Different •  Threat to social status Food Allergies Child and parental reports of bullying in a consecu;ve sample of children with food allergy •  31.5% of the children reported bullying specifically due to food allergies •  Bullying frequently including threats with foods, primarily by classmates Shemesh E, Annuziato RA, Ambrose MA, et al. Child and parental reports of bullying in a consecu&ve sample of children with food allergy. Pediatrics. 2013 Jan;131(1):e10-­‐7. doi: 10.1542/peds.
2012-­‐1180. Edgewater Elementary School Parents Want Student Home Schooled Over Peanut Allergy Is he being bullied and does that maDer? •  Being bullied has significant short and long term adverse consequences •  Mental and physical health •  Social rela&onships, economic status How do you know if he’s being bullied? Bullying: Ø Unwanted aggressive behavior with the intent to do harm Ø Real or perceived power imbalance Ø Behavior is repe&&ve (highly likely to be repeated) u Percep&on u Healthcare VicHm • 
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Depression Anxiety Loneliness Decreased self esteem Ea&ng disorders PTSD Suicidality Substance abuse Fa&gue Increased CRP • 
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Headaches Stomachaches Enuresis Change: sleeping/ea&ng Frequent URIs Dizziness MSK pain Obesity School avoidance Poor academic performance Poor long-term outcome: health, economic status, social relationships
Takizawa R, Danese A, Maughan B, Arseneault L. Bullying victimization in childhood predicts inflammation and obesity at mid-life: a five-decade birth cohort study. Psychol Med. 2015 May 20:1-11.
Kim YS, Leventhal B. Bullying and suicide. A review. Int J Adolesc Med Health. 2008 Apr-Jun;20(2):133-54
Gini G, Pozzoli T. Bullied children and psychosomatic problems: a meta-analysis. Pediatrics. 2013 Oct;132(4):720-9.
Wolke D, Copeland WE, Angold A, Costello EJ. Impact of Bullying in childhood on Health, Wealth, Crime, and Social Outcomes. Psychological Science 2013, doi 10.1177/0956797613481608
Effects of Early Childhood Adversity Toxic Stress •  Early experiences are built into our bodies •  Significant adversity can produce: –  Physiologic disrup&ons that undermine the development of the body’s stress response systems –  Affect the developing brain, cardiovascular system, immune system, and metabolic regulatory controls •  Physiologic disrup&ons can persist and lead to lifelong impairments in both physical and mental health Jack P. Shonkoff, Andrew S. Garner, et al. Pediatrics 2012;129;e232; originally published online December 26, 2011; DOI: 10.1542/peds.2011-­‐2663 Abuse by Peers vs. Adults – 
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2 cohorts, 2 countries, >5000 youth Physical/emo&onal/sexual/or severe maladap&ve paren&ng Peer abuse (bullying) Being bullied by peers worse long-­‐term adverse effects on young adults’ mental health –  Both > peer > adult –  Anxiety, depression, self harm, suicidality As youth get older, spend more &me with peers and those interac&ons take on increased importance Lereya ST, Copeland W, Costello J, Wolke D. Adult mental health consequences of peer bullying and maltreatment in childhood: two cohorts in two countries. Lancet Psychiatry. 2015;2(6) 524-531.
DOI: http://dx.doi.org/10.1016/S2215-0366(15)00165-0
Bully •  The pa&ent was transported to the ED with persistent SOB. •  What if during the course of ED his visit you find out that he is really the one who has been doing the bullying? Bully • 
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Depression Anxiety Suicidality Substance abuse Fa&gue • 
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Sleeping problems Back pain Headache Stomachache Delinquent/criminal behavior Ø  Children with mental health disorders 3x more likely to bully
Ø  Long-term: poor financial, social outcomes, risky illegal behavior
- risk did not persist after controlling for confounding factors
- behavior marker anti-social tendency, indicator vs. cause
Srabstein J, McCarter R, Shao C, Huang Z. Morbidities associated with bullying behaviors in adolescents. Int J Adolesc Med Health 2006;18:587-596.
Kim MJ, Catalano RF, Haggerty KP, Abbott RD. Bullying at elementary school and problem behaviour in young adulthood: a study of bullying, violence, and substance use from age 11 to age 21. Crim Behav Ment Health. 2011 Apr;21(2):136-44..
Wolke D, Copeland WE, Angold A, Costello EJ. Impact of Bullying in Childhood on Health, Wealth, Crime, and Social Outcomes. Psychological Science 2013;10:1958-70.
Benedict FT, Vivier PM, Gjelsvik A. Mental health and bullying in the United States among children aged 6 to 17 years. J Interpers Violence 2015; 30(5):782-95.
Farrington DP and Ttofi MM.. Bullying as a predictor of offending, violence and later life outcomes. Criminal Behav. Ment. Health, 2011;21: 90–98.
Falb K, McCauley H, Decker M, et al. School bullying perpetration other childhood risk factors predictors of adult intimate partner violence perpetration. Arch Pediatr Adolesc Med.2011;165(10):890-894.
The RelaHonship between Bullying and Suicide Bullying behavior and suicide-­‐
related behavior closely related Perpetrators and targets both at increased risk Any bullying involvement considered a stressor contribu&ng to feelings •  helplessness •  hopelessness raising the risk of suicide Bully-­‐VicHm •  Turns out he was bullying others last year and now he is being targeted •  Highest risk – mental health sequelae Ø depression, anxiety, substance abuse, suicidality •  Long-­‐term impact: health, economic, social rela&onships Haynie DL, Nansel T, Eitel P, et al. Bullies, vic&ms, and bully/vic&ms: dis&nct groups of at-­‐risk youth. J Early Adolesc 2001;21:29-­‐49. Klomek A.B., Marrocco F, Kleinman M, Schonfeld I, Gould M. Bullying, depression, and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry 2007;46:40-­‐49. Wolke D, Copeland WE, Angold A, Costello EJ. Impact of Bullying in Childhood on Health, Wealth, Crime, and Social Outcomes. Psychological Science 2013;10:1958-­‐70 Witness •  Or rather than having bullied, what if he is actually a witness to the bullying ? •  Depression, anxiety, substance abuse, suicidal idea&on – 
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Theory – cogni&ve dissonance Fear geqng a friend in trouble Fear aliena&on Fear retalia&on Do not ini&ally recognize behavior as bullying Believe that adults will not help Rivers I, Poteat V, Noret N, Ashurt N. Observing Bullying at School: The mental health implica&ons of witness status. Sch Psychol Q 2009;24:211-­‐223. Luster T, Small S, Lower R. The correlates of abuse and witnessing abuse among adolescents. J Interpers Violence 2002;17: 1323-­‐1340 Witness Ø  Afraid of becoming the next target Ø  Tries to avoid standing out Ø  Worried their friends make them vulnerable Ø  Watched a classmate get bullied arer trying to intervene Ø  Saw someone ‘destroyed’ by bullying -­‐ feels anxious, sad, hopeless Ø  Can’t concentrate, anxious Ø  Thinks about aligning with bully How oNen will you see paHents exposed to bullying? Starts in elementary school (22%), peaks in middle school
(26%), persists into high school (20%)
Bullying behavior exhibited in preschool/kindergarten
Persists in tertiary education, graduate schools, workplace
Limber SP, Olweus D, Luxenberg MA. Bullying in U.S. Schools 2014 Status report. Hazelden Foundation, 2015.
National Center for Education Statistics, U.S. Dept. of Education. Indicators of School Crime and Safety: 2014
http://www.stopbullying.gov/image-gallery/what-you-need-to-know-infographic.pdf
Barker ED, Bolvin M, Brendgen M, et al. Predictive validity and early predictors of peer-victimization trajectories in preschool. Arch Gen Psychiatry, 2008
Oct;6(10)1185-92
Bullying/Cyberbullying Prevalence •  Youth Risk Behavior Surveillance 2015
–  high school students, during the previous 12 months
–  20% bullied on school property (25% F, 16% M) –  16% bullied electronically (22% F, 10% M) •  Cyberbullying Research Center
–  >15,000 middle/high school students (2007-2016)
–  average (lifetime) victim 28%
–  average (lifetime) bully 16%
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Bullying in Michigan •  MI YRBS 2015 -­‐ high school students –  26% students reported being bullied on school property –  19% reported being bullied electronically Ø Bullying peaks in middle school Ø Youth exposed in any role are at risk Percentages -­‐ only a fracHon of those whose health is at risk Centers for Disease Control and Prevention. Youth Risk Behavior Survey Data—United States, 2015. MMWR, Surveillance Summaries 2016;65
(6). Available from http://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/ss6506_updated.pdf.
Bullying as part of the differenHal • 
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Depression Anxiety Suicide Substance abuse PTSD Irritability Sadness Fearfulness Loneliness Decreased self-­‐esteem Self harm Injuries • 
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Changes in ea&ng, sleeping paTern Headaches Abdominal pain Fa&gue Ea&ng disorders MSK Pain Enuresis More frequent URIs Dizziness School avoidance, poor performance •  Delinquent behavior DifferenHal vs. Screening •  Screening •  Pre-­‐clinical state as well as clinical •  Goal •  Sensi&ve topics •  Asking Screening for Disease. Boston School of Public Health. Available at hTp://sphweb.bumc.bu.edu/otlt/MPH-­‐Modules/EP/EP713_Screening/EP713_Screening_print.html Brown JD, Wissow LS. Discussion of sensi&ve health topics with youth during primary care visits: rela&onship to youth percep&ons of care.J Adolesc Health. 2009 Jan;44(1):48-­‐54. Asking •  Behaviors –  Physical, verbal, social, cyber –  Do your classmates ever spread rumors or purposely excluding others? Do they fight or take/destroy people’s stuff? Say mean things or post them on line? •  All roles –  Has that ever happened to you? –  Have you ever seen that happen/done that to someone else? •  General –  How do your classmates treat each other –  Do you feel safe at school, do you like school 27
Screening|Educate Opportunity to educate •  No one deserves to be mistreated •  It is OK ask an adult for help or to report what you see •  It is important to help others — and to get an adult if you don’t feel safe helping by yourself •  Hanging around and watching a fight or bullying makes it look like you support what is happening •  Suppor&ng vic&ms privately and in small ways can s&ll make a difference •  Discuss ways to report bullying if they see or experience it What if the answer is YES? SEERS •  Safety assessment •  Evaluate •  Educate •  Refer •  Support Resources •  NoBLE bullying hotline (Common Ground) •  Crisis Text line •  Na&onal Suicide Preven&on Lifeline www.michigan.gov/ok2say
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The Bully Project Pacer’s Na&onal Bullying Preven&on Center Stopbullying.gov Interna&onal Bullying Preven&on Associa&on Cyberbullying Research Center Michigan ATorney General’s Cybersafety Ini&a&ve •  Global Health Ini&a&ve for the Preven&on of Bullying •  NoBLE QuesHons? Marlene Seltzer, MD
[email protected]
www.Beaumont.edu/urnoble
www.facebook.com/urnoble
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