Bullying phenomenon among adolescents with mental health disorders

SUMMARY
Background: Bullying in the academic environment has become an important problem for mental heal specialists in the last decades, as research in this area has demonstrated the association between aggressive behavior and some psychosocial developmental disorder amongst children and adolescents. Th e interest in this matter has intensifi ed in order to have a better understanding of this phenomenon, to identify the possible predispositions, risk factors and intervention possibilities. Methods: Observational case-report study on a sample of 26 patients (13 females, 12 males, and 1 patient with gender dysphoria) admitted to Child and Adolescent Psychiatry Clinic in „Prof. Dr. Obregia” Clinical Psychiatry in Bucharest. Patients responded to a questionnaire which was divided into 3 sections: 1. Subject as Victim; 2. Subject as Perpetrator; 3. General Opinion on Bullying. We use diagrams to present our results on the fi rst part of the questionnaire. Results: Th e majority of the respondents (86.64%) reported that they were put in the position of victim of bullying the last year and approximately two thirds of them admitted to have been harassed at least once a day. Th e behavior happened predominantly in school and the perpetrators were mainly males. Th e way that the bully behavior manifested most often was by making fun of the victim and the most often consequence was sad disposition reported by the victim. 60% of the respondents reported that the school staff knew about the aggressive behaviors. Conclusions: Th ere are bullying victims amongst pediatric psychiatry patients. It is of great importance to implement programs that tackle this phenomenon in schools.
Key words: bullying, pediatric psychiatry, aggressive behavior, patient

INTRODUCTION In the last decades, due to its ubiquitous presence in both academic and outside academic environments, it became obvious that bullying among school children and adolescents has become a public health issue. In the confrontation with this complex phenomenon, the identification of risk and contributing factors as well as of their consequences is of major importance for conceiving adequate prevention and control strategies. Bullying stands at the cross-roads of many different research fields, hence the various hypotheses that aim at explaining it.
As a first step in the study of bullying it is necessary to have an accurate operationalization of the concept. Bullying is an aggressive behavior its components being classified as [1]:
1) Intention to harm others;
2) Persistence in time;
3) Inequality of power between the victim and the aggressor.
There is a distinction made between direct bullying behavior which requires an active and open behavior (physical or verbal attacks) and indirect bullying behavior where usually more than one person is involved (for e.g. ignoring or excluding somebody, gossip) [2]. The first form seems to be more frequent among boys with teasing, hitting, pushing, name calling, and threatening others being the main identified behaviors [3]. The latter form of bullying was assimilated as a relational form of bullying due to its main purpose of deteriorating one’s social image through constant exclusion from activities or group discussions, rumor spreading false personal rumors, embarrassing information [4]. It is more frequent in girls [3]. Cyber-bullying, namely the on-line aggressive behaviors, are of recent concern.
In 2010, Lenhart A and Co. reports that in the USA 93% of adolescents are active on the internet and 75% of them have a cellphone [5]. These figures support the occurrence potential of this type of aggression amongst the youth. The great variability between study methods in regard to the different definitions employed for bullying and duration of the study has hindered the assessment of the prevalence. The goal of establishing a static and exhaustive definition is far from being accomplished given the rapid technologic progress. A study of Kessel Schneider and Co. from 2012, estimates that prevalence for cyber-bullying lies in the interval between 9 and 40% of the school aged children, while this form of bullying is considered to be infrequent in comparison to other forms of the phenomenon [8].
What distinguishes cyber-bullying from other forms is the anonymity of the aggressor and the great number of people that can be targeted and reached by a single message [6, 7]. This makes the aggressors to not be aware of the responsibility of their actions. Bully-victims are described by their peers as physical inferior and with less social relations [9]. On the other hand, adolescent bullies are more likely to have conduct related problems, violent behaviors and to frequently engage in fights [10].
Predisposing factors were identified in relation to the development of aggressive behavior during the adolescence, among which the parental style and the interactional pattern in the family of origin. Other studies showed that poor parenting involvement, low parental warmth, feeble cohesion between family members, and single-parent households are factors that predispose adolescents to bullying.
In addition to the above mentioned factors, childhood experiences of aggression with physical, inadequate corrections, family violence and sibling harassment also play a role [11]. Objectives: The present study aims to investigate the presence of bullying amongst patients with psychiatric disorders, to determine the environment where it mostly occurs and to assess some of its consequences.

MATERIALS AND METHOD Observational case-report study on a sample of 26 patients (13 females, 12 males and 1 transgender) admitted to Child and Adolescent Psychiatry Clinic in „Prof. Dr. Obregia” Clinical Psychiatry in Bucharest. We determined as exclusion criteria the Intelligence Quotient lower than 70 and age under 9 or over 17.
The evaluation instrument was developed by the Center for Disease Control and Prevention as a Compendium of Assessment of Bullying/ victimization phenomenon. In our research it was used the D1 subsection of the questionnaire, which contains items for Bully Survey. Patients responded to a questionnaire which was divided into 3 sections: 1. Subject as Victim; 2. Subject as Perpetrator; 3. General Opinion on Bullying. We use diagrams to present our results on the first part of the questionnaire. The collected variables were qualitative nominal and ordinal. Absolute frequencies and percentage frequencies were computed. The graphic representation was through pie diagrams.

RESULTS
We will present the results of the first section of the questionnaire.
To the question „Have you been bullied in school this year?”,84,62% of the respondents answered affirmative (Figure 1).

When asked about the frequency of the bullying behaviors 46,15% of the subjects answered that it
happened at least once a day, while 30,77% declare that it happened at least once a month. 7,69% declared a frequency of at least once a month (Figure 2).

With regard to the place where the aggression took place, the majority of the patients answered that it happened in school, in the classroom. The other 27,27% declared that it happened after they left from school or before they got there, near their house or near their school (Figure 3).

Of all the ways of bullying that were approached and assessed in this study (name-calling, making fun of someone, threatening, rejection from being part of the group, direct physical attack), the one that occurred most often was the making fun of someone. This particular way of bullying was experienced by all the patients who declared that they have been bullied in the last year. 26,92% report that this behavior always happens and 23,08% report that is often happened. The next most frequent way of bullying was rejection (30,77% report that it often happened) (Figure 4).

When asked about the categories of the perpetrators, including gender of perpetrators, 86,36% were reported to be males. 4,55% were females and 9,09% of the perpetrators were considered to be poplar persons with more friends (Figure 5).

As consequences of the bullying behavior experienced by the victims we evaluated the following: difficulties in making friends, sad disposition, learning difficulties, school absenteeism, family problems. The most common was sad disposition. 38,46% reported that they always felt sad and 11,54% said that they often felt sad (Figure 6).

When asked if the school staff knew about the aggressive behavior that happened in the school, 60% responded affirmatively. 36% said that the school staff didn’t know and 4% declared that they don’t know (Figure 7).

DISCUSSION
Scientific literature has emphasized in the last years the importance of the bullying problem in schools, as a problem of public health. In the present study we assessed the bullying behaviors experienced by children with psychiatric disorders admitted to the Child and Adolescent Psychiatry Clinic. Firstly, we observed that the majority of the patients report that they were victims of bullying in the last year (84, 62%) and this mostly occurred in the classroom. A study conducted in the United States, on a group of 15686 students, that investigated the bullying prevalence, concluded that 29,9% of children reported a moderate or frequent implication in bullying – 13% as perpetrators, 10,6% as victims and 6,3% as both [12]. Another study concluded that besides the subjects that actively take part in bullying behaviors, there are also the by-standers who should also be taken into consideration when determining the prevalence [13]. In the sample that we assessed in this study, most of the participants reported sad disposition as a consequence of the bullying. 80, 77% of the children felt sad, to various intensities. Numerous studies surveyed the impact that bullying has from the psychological point of view and they issued the conclusion that children and adolescents who are targets of peer victimization are more likely to develop maladaptive psychosocial symptoms. Bullying victims, whether is direct or indirect bullying, are more likely to develop internalization symptoms, including depressive episodes, loneliness, low self-esteem, anxiety and low quality of life and these associations are usually reported in young adulthood [12,14]. As a particularity, it has been observed that males who are victims of direct, overt peer victimization have a higher risk to do develop internalization symptoms [14]. Some studies have linked suicidal thoughts and attempts to bullying [15]. Furthermore, it is increasingly recognized that victims of peer victimization often experience a series of psychosomatic symptoms such as headaches, back pains, abdominal pain, skin problems, sleeping disorders, enuresis or dizziness [16]. A meta-analysis from 2009 has investigated this association by gathering data from 11 studies which determined the prevalence of somatic symptoms of children and adolescents aged 7 to 16 who were bullying victims. This study concluded that targets of peer victimization in schools have a significantly higher risk of developing psychosomatic symptoms than their colleagues who did not have such experiences [17].

In our sample 86,36% of the perpetrators were males and just 4,55% females. The scientific literature offers limited data on the matter of gender differences when it comes to bullying. Research on this matter focused on the way the perpetrators act depending on their gender and indicate that males and females report similar frequency of relational victimization (indirect bullying), but males are more likely to be victims [18]. Regarding females, it seems that relational victimization is more common. An explanation for this fact could be that girls are more involved and treasure social relationships more than boys, so they consider that limiting social goals for other girls cause more harm [19]. Moreover, girls consider relational victimization to be more painful than boys do [20].

CONCLUSIONS It becomes more and more clear that the problem of peer victimization in schools does not only resume to the short-term implications and consequences, but the psychosocial long-term consequences are of great importance.
Therefore, bullying can be considered a matter with mental health implications, as it interferes with the healthy psychosocial development of children and adolescents. In this study we emphasized that patients who are hospitalized in a Child and Adolescent Psychiatry Clinic often experience peer victimization at school, given the fact that 84,62 of them identified aggressive behavior directed at them in the last year. Furthermore, 46% of them reported a frequency of more than once a day. In most of the cases bullying happened in school (73% of the cases). Most of the respondents identified the perpetrator to be male and in 4,55% of the cases the perpetrator was a female. Sad disposition reported in our sample corresponds with data presented in the scientific literature which identifies associations between internalizing symptoms and bullying. 80,77 of the patients felt sadness in this context. Targets of bullying are often children that have limited resources. It is of crucial importance that these behaviors are identified and stopped through implementing specific prevention programs in school.

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