5 Jeff M. Kretschmar, Ph.D. Research Assistant Professor Begun Center for Violence Prevention Research and Education Mandel School of Applied Social Sciences Case Western Reserve University Fredrick Butcher, Ph.D. Begun Center for Violence Prevention Research and Education Mandel School of Applied Social Sciences Case Western Reserve University Daniel J. Flannery, Ph.D. Begun Center for Violence Prevention Research and Education Mandel School of Applied Social Sciences Case Western Reserve University
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality Despite increased awareness and attention, bullying remains a significant concern for children, parents, and school personnel. Bullying has been found to affect a multitude of outcomes for both the victims and perpetrators of bullying.bullies are more likely to exhibit negative or antisocial behavior including truancy and substance abuse and are at greater risk for psychiatric disorders (Coie & Dodge 1998; Kumpulainen, Rasanen, & Puura, 2001; Smith et al., 1999). Victims of bullying often suffer from low self-esteem (Hodges & Perry, 1999; O Moore & Kirkham, 2001; Olweus, 1993b) and poor mental (Callaghan & Joseph, 1995; Klomek, Marrocco, Kleinman, Schonofeld & Could, 2007; Kumpulainen, Rasanen, & Puura, 2001), and physical (Gini & Pozzoli, 2009; Rigby, 1998, 2003; Williams et al., 1996) health outcomes. Because of its prevalence and relationship to mental and physical health outcomes, researchers have described bullying as a significant public health concern (Haynie et al., 2001; Solberg & Olweus, 2003; Srabstein & Leventhal, 2010). The focus of this chapter is to review the current literature on bullying, its relationship to mental health outcomes, and explore the connection between bullying, mental health, and suicide. We first define bullying, provide a description of the various types of bullying, identify the characteristics of those involved in the bullying behaviors, and discuss current estimates of bullying in schools. We then turn our attention to the relationship between bullying, both as perpetrator and victim, and mental health outcomes and risk for suicide. As part of this discussion, we summarize the literature on one of the most recent areas of bullying research: cyberbullying. While this is a relatively new area of research, we discuss what we know about cyberbullying and its relation to both mental health problems and suicide. We end the chapter with a review of the effectiveness of school bullying prevention programs. Although specifics of the definition can vary, bullying is typically defined as a type of aggression in which the behavior is intended to harm or bother, the behavior is repeated over time, and there exists an imbalance of power with the more powerful per- 59
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach son attacking the less powerful person (Nansel et al., 2001; Olweus, 1993a, 1999).The aggressive behavior can take several forms, including physical, (e.g. slapping, hitting) verbal (e.g. making threats), or relational (e.g. rejecting, spreading rumors). In addition, the balance of power that exists in bullying can be physical (e.g. height, body build) or psychological (e.g. social status, popularity). Wang, Iannotti, and Nansel (2009) refer to physical and verbal bullying as direct forms of bullying, and identify relational bullying as indirect bullying. Boys have been found to be more likely to engage in direct forms of bullying while girls are more likely to be involved in indirect bullying (Bjorkqvist, 1994; Owens, Shute, & Slee, 2000). More recently, the definition of bullying has been expanded to include bullying that occurs through personal computers or cell phones. This new type of bullying has been referred to as cyber bullying, internet harassment, or internet bullying. When describing this type of bullying, we use the term cyber bullying and will return to the issue later in this chapter. Those involved in bullying behaviors are identified as bullies, victims, and bully-victims. Bullies report engaging in bullying behavior against others while victims report being the focus of such behavior. Bully-victims report both bullying others and being bullied. In addition, there are often bystanders to the bullying behavior and those who report no involvement with bullying either as a victim, perpetrator, or bystander. Nansel et al. (2001) surveyed over 15,000 students in grades 6-10 and found that 13% were identified as bullies, 11% were identified as victims, and 6% were identified as bully-victims. Overall, researchers have found that boys are more likely to engage in bullying behavior than girls, especially physical and verbal bullying (Baldry & Farrington, 2000; Bosworth, Espelage, & Simon, 1999; Rivers & Smith, 1994; Robers, Zhang & Truman, 2012; Sharp & Smith, 1991). Bullies have been found to demonstrate aggressiveness and hostility toward peers and demonstrate poorer psycho-social functioning than students not involved in bullying. Bullies tend to perceive their families as less cohe- 60
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality sive and less organized and experience more hostility in the home (Bowers, Smith, & Binney, 1992; Oliver, Oaks, & Hoover, 1994; Rigby, 1994; Stevens, De Bourdeaudhuij, & Van Oost, 2002). Harachi, Catalano, and Hawkins (1999) found higher rates of bullying among boys who received physical punishment from their parents.bullies have been found to score lower on measures of behavior conduct (Austin & Joseph, 1996) and higher on measures of externalizing behaviors and hyperactivity (Kumpulainen et al., 1998). Bullies report liking school less and are less popular with teachers than their non-bully peers (Rigby & Slee, 1991; Slee & Rigby, 1993). Haynie et al. (2001) found that students who engaged in bullying reported being less likely to use non-violent strategies for conflict resolution and had more accepting views toward deviance and deviant peers. There are also several long-term negative consequences of bullying. Bullies have been found to be more likely to engage in delinquency, adult crime, and substance abuse (Haynie et al., 2001; Loeber & Dishion, 1983). Olweus (1993b) found that bullies who were identified by age 8 were significantly more likely to be convicted of crimes as young adults and to have a serious criminal record by age 30. In his longitudinal research, Farrington (1993) found that children identified as bullies at age 14 were more likely to have children who became bullies. Victims of bullying report elevated levels of depression and anxiety, lower levels of self-esteem, and are typically more sensitive and quiet than their non-bullied peers (Craig, 1998; Haynie et al., 2001; Olweus, 1995, 1996; Rigby & Slee, 1991). Bullying victims, especially boys, tend to be physically weaker and have less favorable attitudes toward violence than their peers (Olweus, 1996). Victims tend to be more socially isolated than non-victims. Slee and Rigby (1993) found that victims were more likely to be introverted while Junger-Tas and Van Kesteren (1999) found that just over half of their sample who reported having no friends were bullied compared to 11% who said they had more than five friends. Kumpulainen et al. (1998) found that bullying victims exhibited elevated psychosomatic symptoms and greater problems with internalizing behaviors than non-victims. Victims of bullying, especially girls, report being concerned about social ostracism or negative evaluation by their peers (Slee, 1995). Recent re- 61
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach search has found that lesbian, gay, bi-sexual, and transgendered (LGBT) children and students enrolled in special education classes may be particularly vulnerable to bullies (Advocates for Children, Inc. 2005; Birkett, Espelage, & Koenig, 2009; Ploderl & Fartacek, 2007; Rose, Espelage, & Monda-Amaya, 2009; Rose, Monda-Amaya, & Espelage, 2010). In a longitudinal study, Olweus (1993b) followed two groups of boys who had or had not been victims of bullying during sixth through ninth grades. At age 23, while the victims of bullying had normalized in many ways, they still suffered from higher depression and lower self-esteem than non-victims. Farrington (1993) used a proxy measure of bullying victimization and found that probable victims of bullying were significantly more likely to have children who were victims of bullying. The final category of children directly involved in bullying behavior is the bully-victim, or those who both engage in bullying others and who are also victims of bullying. Craig (1998) found that bully-victims exhibit higher levels of both physical and verbal aggression than their peers. Compared to bullies, bully-victims scored higher on measures of externalizing behaviors and hyperactivity (Kumpulainen et al., 1998). Austin and Joseph (1996) found bully-victims were more likely to display lower scholastic competence, social acceptance, and self-worth. Compared to victims, bully-victims demonstrate more internalizing and externalizing problems and fewer prosocial behaviors (Arseneault et al., 2006; Stevens, De Bourdeaudhuij & Van Oost, 2002). Bully-victims come from families with low cohesion, but not as low as families of bullies (Bowers, Smith, & Binney, 1992; Bowers, Smith, & Binney, 1994). Bully-victims belong to families who are characterized by inconsistent discipline and parental monitoring (Schwartz, Dodge, Pettit & Bates, 1997; Smith, Bowers, Binney & Cowie, 1993). In an investigation of elementary school students, Burk et al. (2011) found that over 60% of students identified as bully-victims in 1 st grade were subsequently identified as bully-victims two or three additional times over their elementary school career, suggesting the stability of this classification. In addition, chronic bully-victims exhibited 62
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality greater externalizing and hyperactivity symptoms and lower academic competence (Burk et al., 2011). Due to somewhat different definitions and ways in which researchers measure or assess bullying, prevalence rates of school bullying vary fairly widely. Internationally, bullying victimization rates have been found to be as low as 6% for girls in Sweden and as high as 41% for boys in Lithuania (Due et al., 2005). Estimates for bullying victimization for US students typically range between 10% and 30% (Due et al., 2005; Nansel et al., 2001; Dinkes, Cataldi, Grace & Baum, 2006; Robers et al., 2012). In a nationally representative sample of grades 6 through 10, Wang, Iannotti, and Nansel (2009) found that in the previous two months, 13.3% reported engaging in physically bullying, 37.4% engaged in verbally bullying, and 27.2% admitted to relational bullying. Victimization rates in the previous two months included 12.8% for physical bullying, 36.5% for verbal bullying, and 41% for relational bullying. Overall, including bullies, victims, and bully-victims, 20.8% of the students reported being involved in physical bullying, 53.6% in verbal bullying, and 51.4% in relational bullying. Results from the 2011 Youth Risk Behavior Surveillance System (YRBS) for students in grades 9-12 indicated that nationwide, 20.1% of students reported being bullied on school property in the 12 months prior to the survey, largely unchanged from data collected as part of the 2009 YRBS (19.9%).Females (22.0%) and whites (22.9%) were more likely to report being bullied than males (18.2%) or black (11.7%) or Hispanic (17.6%) students. Ninth graders reported the highest rates of being bullied on school property (24.2%). In a recent nationally representative sample of students, parents, and school personnel, Robers et al. (2012) reported that 28% of 12 to 18 year old students reported having been bullied at school during the school year and that verbal bullying was most common. Consistent with previous research, the authors found males were more likely to be the victims of physical bullying and females were more likely to report expe- 63
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach riencing relational bullying. Reports of bullying victimization decreased in each successive grade level, going from 39% in 6 th grade down to 20% in 12 th grade. We examined our own data from a school-based violence prevention program called Peace Builders to explore the prevalence of bullying behaviors in an ethnically diverse sample of elementary and middle school students (for a thorough review of the characteristics of the sample and data collection methods, see Embry, Flannery, Vazsonyi, Powell & Atha, 1996; Flannery et al., 2003). Bullies, victims, and bully-victims were identified based on item-level data indicative of physical and verbal bullying. Over 17% of elementary school children were identified as bullies, 18.1% were identified as victims, and 5.8% were identified as bully-victims. Among middle school children, 28.9% were identified as bullies, 13.5% were identified as victims, and 4.9% were identified as bully-victims. Male elementary school children were significantly more likely to be identified as bullies, victims, and bully-victims than females. Among middle school students, males were significantly more likely to be identified as victims than females. Children between 8 and 18 years old spend more time engaged with electronic media (7.5 hours per day, seven days a week) than in any other activity, besides perhaps sleep (Rideout, Foehr, & Roberts, 2010). Each day, an estimated 64% of children aged 8-18 report using a computer for recreational purposes. Computer users reported staying on the computer for over 2 hours per day. Nearly 85% of young people have access to the internet at home, and in a typical day, 70% of children aged 8-18 go online. Each day, 40% of young people will visit a social networking site (e.g. Facebook, Twitter) and spend nearly an hour there (this estimate increases to 53% for 15-18 year olds) (Rideout, Foehr, & Roberts, 2010). Nearly two-thirds (66%) of all children between ages 8-18 own a cell phone, with 15-18 year olds reporting the most ownership (85%).On average, children spend slightly over 30 minutes talking on a cell phone each day and more than half (56%) report talking on a cell phone every day. Nearly half (46%) of children aged 8-18 report sending text messages via cell phone each day. Children who send text messages estimate sending 118 messages per day (Rideout, Foehr, & Roberts, 2010). 64
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality As electronic media becomes a more significant part of children s lives, so to do the dangers associated with such connectivity. A fairly new development in the bullying arena is the existence of cyberbullying. Patchin and Hinduja (2006) define cyberbullying as the willful and repeated harm inflicted through the medium of electronic text. Cyberbullying includes sending harassing text messages, instant messages, or emails, posting mean or untrue things about others on social media sites, like Facebook, and posting videos to sites like YouTube that make fun of others. Much less is known about the prevalence of and children s experiences with cyberbullying than traditional bullying. Estimates of the prevalence of cyberbullying vary greatly and are influenced by the age group in question and the definition of cyberbullying used. In their review of cyberbullying, Hinduja and Patchin (2009) found that estimates of cyberbullying victimization rates from 22 studies ranged from 6% to 42%.While traditional bullying behaviors peek in early middle school, research has found that cyberbullying behaviors occur most often in later middle and high school years (Williams & Guerra, 2007; Ybarra & Mitchell, 2007). Robers et al. (2012) found that in a nationally representative sample, 6% of students aged 12 18 reported being cyberbullied during the school year. Recent data from the Youth Risk Behavior Surveillance System (YRBS) study found that just over 16% of 9 th 12 th grade students reported being cyberbullied in the 12 months prior to the survey. Females (22.1%) reported higher rates of cyberbullying than males (10.8%) and white students (18.6%) were more likely to report being cyberbullied than black (8.9%) or Hispanic (13.6%) students. Using data from the Harris Poll On Line, Ybarra (2012) found that approximately 15% of children aged 10 to 15 reported being victims of cyberbullying in the past year. In their sample of 6 th through 10 th graders, Wang, Iannotti, and Nansel (2009) found that 8.3% reported engaging in cyberbullying and 9.8% reported being cyberbullying victims. Patchin and Hinduja (2010) reported that over 20% of children between ages 10 and 18 had been the victims of cyberbullying in their lifetime. Hinduja and Patchin (2009) reported that rates of cyberbullying victimization and perpetration are more consistent across gender than traditional forms of bullying.one study found that boys (18%) and girls (16%) reported similar rates of cyberbullying 65
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach perpetration (Hinduja & Patchin, 2008). In another investigation, Hinduja and Patchin (2009) reported that girls were more likely to be cyberbullied via email or social networking sites than boys. Robers et al. (2012) found that females were only slightly more likely to report being cyberbullied than males.several studies have found that white children are victimized by cyberbullying more often than children of other races (Centers for Disease Control and Prevention, 2012c; Robers et al., 2012; Hinduja & Patchin, 2009). Data from the YRBS indicated that 18.6% of white students reported being cyberbullied compared to 8.9% of black and 13.6% of Hispanic students (Centers for Disease Control and Prevention, 2012c). Cyberbullies and their victims tend to be older than traditional bullies and victims, as older children spend more time online and are more proficient with technology. Earlier in this chapter we reported on the characteristics of bullies, victims, and bully-victims. Researchers have found a relationship between those involved in bullying (as perpetrator or victim) and poorer behavioral health outcomes, including elevated levels of depression (Arseneault et al., 2006, Kumpulainen et al., 1998; Stevens, De Bourdeaudhuij, & Van Oost, 2002). This section presents a more in-depth look at the relationship between bullying, mental health, and suicide. Research has consistently shown that victims of bullying and cyberbullying report elevated levels of depressive symptoms compared to non-involved peers (Fekkes, Pijpers, & Verloove-Vanhorick, 2004; Kaltiala-Heino & Fröjd, 2011; Klomek et al., 2007; Kumpulainen et al., 1998; Kumpulainen & Räsänen, 2000; Slee, 1995; Wang, Nansel, &Iannotti, 2011). While both male and female victims report higher levels of depression than their peers, Craig (1998) found that female victims reported higher levels of depressive symptoms than did male victims. In a Dutch sample of elementary school children, Fekkes, Pijpers, & Verloove-Vanhorick (2004), found that victims of bullying were much more likely to report elevated levels of depression than non-involved peers. While 16% of non-involved children were classified as moderate on the depression inventory, 48.6% of victims fell 66
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality into the moderate category. Just over 2% of the non-involved children but 16.1% of the victimized children met criteria for strong indicators of depression. In a large study of high school students in New York, Klomek et al. (2007) found that frequent bullying victimization increased the risk for depression compared to children not involved in bullying behavior. The more often the child was bullied, the higher the risk of depressive symptoms. Children who reported frequent victimization were seven times more likely to be depressed compared to non-victims whereas infrequent bullying victims were two to three times more likely to be depressed than non-victims (Klomek et al., 2007). While any level of bullying victimization increased girls risk for depression compared to female non-victims, only boys who were frequently victimized were more likely to be depressed compared to non-victimized boys. As described earlier, victims of bullying are more likely to report elevated levels of depression and other internalizing behaviors. It is possible that these problems existed prior to the victimization and perhaps even facilitated the bullying and that the bullying itself did not independently contribute to the depression levels. A small number of studies have examined the temporal relationship between mental health issues and bullying victimization. Fekkes, Pijpers, Fredriks, Vogels and Verloove-Vanhorick. (2006) found that while depressed children were more likely to be victimized by bullies, victimization led to even higher levels of depression. Sweeting et al. (2006) found that depression both predicted and was caused by bullying victimization, leading to support for a bidirectional relationship between bullying victimization and depression (McLaughlin, Hatzenbuechler, & Hilt, 2009; Bond, Carlin, Thomas, Rubin & Pattion, 2001; Kim, Leventhal, Koh, Hubbard & Boyce, 2006). Arseneault et al. (2006) found that after controlling for prior mental health symptoms, victims of bullying demonstrated higher levels of internalizing problems than their non-involved peers. Elevated depression levels are not unique to victims of bullying. Researchers have found that both bullies and bully-victims report more depressive symptoms than their non-involved peers and sometimes more than the bullying victims. Austin and Joseph (1996) found that bully-victims reported similar depression levels as victims and higher levels than bullies, while bullies scored significantly higher on depressive symptoms than non-involved students. Additional studies have found elevated levels of depressive 67
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach symptoms for both bullies and bully-victims (Kaltiala-Heino, Rimpelä, Marttunen,Rimpelä, & Rantanen, 1999; Kaltiala-Heino, Rimpelä, Rantanen & Rimpelä, 2000; Klomek, et al., 2007; Swearer, Song, Paulette, Eagle & Mickelson, 2001). Not only does participating in bullying behavior increase the risk for reporting elevated levels of depressive and other internalizing symptoms as children, but research has shown that there are often long-term psychological effects from bullying behavior that last well into adulthood (Arseneault, Bowes, & Shakoor, 2010; Jordanova et al., 2007; Lund et al., 2009). Gladstone, Parker, and Malhi (2006) examined adult patients presenting at an outpatient depression clinic. Results indicated that childhood bullying victimization was a common trait among the clients and was associated with both anxiety and depressive disorders as adults. Klomek et al. (2008) examined bullying and depression among male Finnish children at age 8 and then again at age 18.Results indicated that frequent bullying at age 8 was significantly associated with elevated depressive symptoms 10 years later, but no relationship existed for less frequent bullying. Similar to bullying, suicide is a complex phenomenon with many risk and protective factors and represents a significant public health concern. The Centers for Disease Control and Prevention (CDC) report that suicide is the third leading cause of death for young people aged 15-24. In 2007, children aged 15-19 were much more likely to commit suicide (6.9 per 100,000) than children aged 10-14 (0.9 per 100,000) (Centers for Disease Control and Prevention, 2012a). While the single strongest predictor of a suicide attempt is a previous suicide attempt (Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Centers for Disease Control and Prevention, 2012b; Hatcher-Kay & King, 2003; Shaffer et al., 1996), mental health factors also play an important role. Researchers have found depression to be a risk factor for suicide ideation and suicide attempts (Balázs et al., 2006; Beautrais, Joyce, & Mulder, 1998; Bridge, Goldstein, & Brent, 2006; CDC, 2012b; Flannery, 2006; Gould et al., 1998; Hallfors et al., 2004; Hatcher-Kay & King, 2003; Kretschmar & Flannery, 2011; Rihmer, 2005; Rihmer & Kiss, 2002). As we have established, bullying behavior has been found to be related to elevated levels of depressive symptoms for both victims and perpetrators. Therefore, 68
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality many researchers have sought to understand the relationship between bullying, depression, and suicide ideation and attempts. Researchers have found a ubiquitous relationship between bullying behavior and suicide ideation and attempts. The association exists for elementary (van der Wal, de Wit, & Hirasing, 2003), middle (Ivarsson et al., 2005; Seals & Young, 2003), and high school students (Kaltiala-Heino et al., 1999; Klomek et al., 2007). Victims of bullying are more likely to report suicide ideation and suicide attempts compared to non-victims (Cleary, 2000; Kaltiala-Heino et al., 1999; Kaminski & Fang, 2009; Klomek, Sourander, & Gould, 2010; Meltzer, Vostanis, Ford, Bebbington & Dennis., 2011; Mills, Guerin, Lynch, Daly & Fitzpatrick, 2004; Rigby & Slee, 1999; Roland, 2002; van der Wal et al., 2003). Luukkonen, Räsänen, Hakko and Riala (2009) examined the relationship between childhood bullying behaviors, self-harm, and suicide behaviors among a sample of adolescents admitted into a psychiatric inpatient facility. Results indicated that bullying victims had a higher risk of suicide behaviors but were not more likely to engage in self-harm behaviors. While the relationship between bullying and suicide for perpetrators of bullying is less clear, researchers have found that bullies report elevated levels of suicide ideation and suicide attempts compared to those not involved in bullying (Kaltiala-Heino et al., 1999; Kaminski & Fang, 2009; Luukkonen et al., 2009; Roland, 2002; van der Wal, 2005). Researchers have also found that bully-victims were at greatest risk for increased suicide ideation and attempts (Juvonen, Graham, & Shuster, 2003; Kaltiala-Heino et al., 1999; Kim, Leventhal, Koh & Boyce, 2009; Klomek et al., 2007; Klomek et al., 2011). In a large sample of high school students in New York, Klomek et al. (2007) found that students involved in bullying behavior as a bully or victim were at significantly higher risk for depression, serious suicide ideation (SSI) and suicide attempts compared with non-involved peers. Additionally, frequency of bullying involvement was related to both SSI and suicide attempts. Children frequently involved in bullying behavior (as bully or victim) were most likely to have SSI and to have attempted suicide. Bully-victims were especially likely to report problems with SSI and suicide attempts. 69
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach The authors did find gender differences related to bullying frequency and SSI and suicide attempts. Girls involved in any bullying behavior (victim or perpetrator, frequent or infrequent involvement) were at greater risk for depression, SSI, and suicide attempts compared to non-involved peers. On the other hand, frequency of involvement was a significant factor for boys. Compared to non-victims, frequently victimized boys were significantly more likely to report depression, SSI, and suicide attempts. Boys who were victimized infrequently were more likely to attempt suicide but no more likely to have SSI than non-victims. Boys who bullied others frequently were more likely than non-bullies to report depression and SSI, but no more likely to attempt suicide. Boys who bullied others infrequently were no more likely to report depression, SSI, or suicide attempts than non-bullies (Klomek et al., 2007). Kaminski and Fang (2009) examined the impact of peer victimization and bullying on suicide ideation and behavior in three large national samples of adolescents in the US. Using data from the National Longitudinal Study of Adolescent Health (Add Health), the Youth Risk Behavior Surveillance System (YRBS), and a CDC survey of high-risk communities, the researchers found that after controlling for demographics and depressive symptomatology, adolescents who reported being victimized by peers were significantly more likely to report suicide ideation and suicide attempts. For example, in the YRBS sample, students who reported peer victimization had over two times the odds of reporting suicide ideation and over three times the odds of reporting suicide attempts than students who were not victimized. This general conclusion was supported in all three datasets. Kim et al. (2009) reviewed 16 studies conducted in various countries that examined the relationship between bullying and suicide. While these studies were conducted in different countries, with children of different ages, and controlled for different covariates, results indicated that there was a significant and positive relationship between bullying and suicide variables. Similar to previous research, this relationship was strongest for bully-victims. 70 In order to account for potential methodological limitations of the cross-sectional studies in their review (e.g. lack of consistent control variables, shared method va-
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality riance, etc.), Kim et al. (2009) conducted a prospective cohort study of Korean 7 th and 8 th graders. Baseline data collection occurred between October and November 2000 and follow-up data were collected between June and July 2001.Results indicated that victims and bully-victims showed increased risk for suicide ideation from baseline to follow-up, even after controlling for previously established suicide risk factors. Once again, this risk was highest for bully-victims. Of those students who experienced bullying at baseline, girls were at a significantly greater risk for persistent suicidal ideation than boys. Additionally, of the frequent bullies, only the girls demonstrated an increased risk for suicidal behaviors at a six-month follow-up. The researchers concluded that bullying is a significant and independent risk factor for adolescent suicide ideation and suicide behaviors and this risk appeared especially high for females. In a series of longitudinal investigations into the relationship between bullying and suicide, Klomek and colleagues examined data from a large cohort of Finnish children born in 1981. The cohort included children first interviewed at age 8 and followed until they were 25 years old. Boys were first followed up at age 18 when they were called for military service. The first study focused only on the boys and examined the relationship between bullying, depression, and suicide ideation over a 10 year period. Bullying behavior was found to be a risk factor for elevated depressive symptoms even after controlling for childhood depression. The relationship between bullying behavior at age 8 and suicide ideation at age 18 became non-significant after controlling for childhood depression (Klomek et al., 2008). Klomek et al. (2009) used the Finnish cohort dataset to examine the relationship between bullying behaviors at age 8 and suicide attempts and completed suicides for both boys and girls. Results indicated that for boys, bullying behaviors at age 8 were not related to subsequent suicide attempts and completed suicides after controlling for childhood conduct and depressive symptoms. The authors suggest that suicidal behaviors among boys who are bullies may be a function of pre-existing psychopathy rather than the actual bullying behaviors. Frequent victimization among girls at age 8 was significantly related to later suicide attempts and completed suicides, even after controlling for childhood conduct and depressive symptoms. Klomek et al. (2009) proposed that because girls are more often victimized by relational bullying, and previous research has found relational victimization to have a more profound impact on mental 71
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach health outcomes (Baldry, 2004; Crick & Grotpeter, 1996; Roland, 2002), the effects of bullying victimization on girls may be more significant than for boys. There have been several recent high-profile cases of adolescent suicide that have been largely attributed to cyberbullying. In their recent review of cyberbullying, Hinduja and Patchin (2009) provided several accounts of young people who were victims of cyberbullying and who eventually took their own lives. One of the most well-known cases involving cyberbullying involved Megan Meier, a 13-year-old girl from Missouri. Megan was in eighth grade when she received a message on MySpace from a 16-year-old boy named Josh. The two began exchanging messages, some of which were described as flirtatious. However, the tone of Josh s messages changed abruptly, as he wrote: I don t know if I want to be friends with you any longer because I hear you re not nice to your friends. He continued to send additional negative messages to Megan through an instant message client. In his final message to Megan, he reportedly wrote the world would be a better place without you. Reports indicate that Megan responded by writing: You re the kind of boy a girl would kill herself over and then, upset, retreated to her bedroom. Her mother would find her there, 20 minutes later, hanging from a belt in her closet. Despite efforts by paramedics, Megan died the following day. Soon after Megan s death, the Meier family learned that Josh never existed. Lori Drew, a 47-year-old woman, admitted creating the fake MySpace account with her daughter, who was formally friends with Megan, and another woman. They claimed they created the account to discover what, if anything, Megan was saying about her daughter and others. Several people had access to the fictitious account and contributed to the hoax. The story elicited national outrage, and many called for those involved to be held accountable for Megan s death. Local prosecutors announced they would not file charges against Drew in connection with Megan s death. However, in 2008, Lori Drew was indicted by a United States Grand Jury on four counts related to the Computer Fraud and Abuse Act (CFAA) (but not specifically related to Megan s death). While Drew was found guilty of a misdemeanor related to the CFAA, that decision was later overturned. 72
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality While stories like Megan s are tragic and heartbreaking, they alone do not provide empirical support for a relationship between cyberbullying and suicide. Similar to traditional forms of bullying, cyberbullying has been found to be related to elevated depressive symptoms (Hinduja & Patchin, 2009; Klomek et al., 2007; Wang, Nansel, & Iannotti, 2011). In a recent study of nearly 2000 middle school students, Hinduja and Patchin (2010) found that children who experienced cyberbullying as victims or perpetrators reported more suicidal thoughts and were more likely to attempt suicide than students not involved in cyberbullying. Cyberbullying victimization appeared to be a stronger predictor of suicidal ideation and behaviors than cyberbullying perpetration. The odds of an attempted suicide were nearly twice as high for cyberbullying victims and 1.5 times as high for cyberbullies compared to non-involved peers. In a cross-sectional sample, Klomek et al. (2007) found that involvement in cyberbullying was significantly related to depressive symptoms, suicide ideation, and suicide attempts. Girls who were frequently or infrequently bullied through the internet reported higher levels of depressive symptoms and suicide ideation. Girls who were frequent cyberbullying victims were also more likely to attempt suicide. Boys who were frequent or infrequent victims of cyberbullying were more likely to report suicide ideation. While more research is needed to elucidate the connection between cyberbullying and suicide, preliminary findings have established a link between cyberbullying, depressive symptoms, and suicide ideation and behaviors. Recently, Hinduja and Patchin (2010) reported that cyberbullying alone may not directly lead to youth suicide, but rather may exacerbate the daily pressures, stresses, and general hopelessness experienced by many children. Beginning with the Olweus Bullying Prevention Program, there has been a proliferation of school-wide approaches to bullying prevention to change the culture of schools in an attempt to reduce bullying behaviors. The Olweus approach begins with an assessment of the extent of the bullying problem and the establishment of a committee of faculty and staff members to devise a plan according to the basic features of 73
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach the Olweus approach. These features include clear and consistent disciplinary measures, raising school-wide awareness of bullying, and encouraging parental involvement paying particular attention to cultural and social issues specific to the student population in the school (Olweus, 1993a). Following some initially positive results of the program in Norway, attempts to replicate those results elsewhere have proven difficult (Smith, Schneider, Smith & Ananiadou, 2004). Results from several national and international large investigations of school-based bullying prevention programs have produced mixed results. While some researchers have found these programs had little to no success (Bauer, Lozano, & Rivara, 2007; Merrell, Gueldner, Ross & Isava, 2008; Smith et al., 2004), others have found these programs can produce positive outcomes (DeRosier, 2004; Farrington & Ttofi, 2009; Vreeman & Carroll, 2007; Ttofi, Farrington, & Baldry, 2008). In their meta-analysis examining 44 school-based bullying prevention programs, Ttofi and Farrington (2011) found that bullying and victimization were reduced by an average of approximately 20% post implementation. Research has generally shown that bullying prevention programs are most effective for children in elementary school and in high school (Hoglund, Hosan, & Leadbeater, 2012; Ttofi & Farrington, 2011). Preliminary evidence seems to suggest that in addition to a reduction in bullying behaviors and peer victimization, prevention programs may also be effective in reducing symptoms of depression and anxiety among elementary school children (Williford et al., 2012). A key feature of bullying prevention programs is the involvement of adults outside of the classroom. Particularly, bullying prevention programs that take a multi-pronged approach with cooperation with community leaders, school officials, parents, and peers have been found to be effective in bullying intervention (Swearer et al., 2006; Ttofi & Farrington, 2011; Vreeman & Carroll, 2007).Although there has been a concerted effort to increase peer involvement in bullying prevention (e.g. Polanin, Espelage, & Pigott, 2012), Ttofi and Farrington (2011) found that peer involvement is negatively associated with victimization. However, this may be in part due to not controlling for the bullying norms in these peer groups (Swearer, Espelage, Vaillancourt & Hymel, 2010). Peer involvement, including bystander intervention and peer monitoring may in fact be an integral aspect of bullying prevention programs. 74
Chapter 5 The Impact of Bullying and Cyberbullying on Depression and Suicidality Although research suggests a multi-pronged approach to bullying prevention is the most effective approach to reduce bullying and its consequences, it is nevertheless important to note that family dynamics play a key role in bullying behaviors (Bowers, Smith, & Binney, 1992; Oliver, Oaks, & Hoover, 1994; Rigby, 1994; Stevens, De Bourdeaudhuij, & Van Oost, 2002). Family members may be reticent to work with school officials and teachers on developing effective non-aggressive forms of discipline. In addition, it is often beyond the scope of school-based intervention programs to treat individuals for externalizing behaviors and hyperactivity that are often associated with bullying behaviors. Ultimately, the largest effect of prevention programs may be on increasing awareness among children with subsequent modest behavioral changes (Merrell et al., 2008). The goals of this chapter were to review the research related to bullying and its associated consequences, specifically its relationship to depressive symptoms and suicide ideation and attempts. Researchers have demonstrated a robust relationship between bullying behaviors and elevated depressive symptoms (Klomek et al., 2007; Kumpulainen et al., 1998; Kumpulainen & Rasanen, 2000; Slee, 1995; Fekkes, Pijpers, & Verloove-Vanhorick, 2004; Kaltiala-Heino & Fröjd, 2011; Wang, Nansel, & Iannotti, 2011). Increased depression levels are not unique to victims of bullying. Bullies and bully-victims report more depressive symptoms than their non-involved peers and sometimes more than the bullying victims (Austin & Joseph, 1996; Kaltiala-Heino et al., 1999; Kaltiala-Heino et al., 2000; Klomek et al., 2007; Swearer et al., 2001). Data from cross-sectional and longitudinal studies have also uncovered a positive and significant relationship between bullying behavior and suicide ideation and attempts. Bullying victims are more likely to report suicide ideation and suicide attempts compared to non-victims (Cleary, 2000; Kaltiala-Heino et al., 1999; Kaminski & Fang, 2009; Klomek, Sourander, & Gould, 2010; Mills et al., 2004; Rigby & Slee, 1999, Roland, 2002; van der Wal, de Wit & Hirasing, 2003). Bullies and bully-victims have also been found to demonstrate increased risk for suicide ideation and attempts (Juvonen, Graham, & Shuster, 2003; Kaltiala-Heino et al., 1999; Kaminski & Fang, 2009; Kim et al., 2009; Klomek et al., 2007; Klomek et al., 2011; Luukkonen et al., 2009; Roland, 2002; 75
Developmental and Public Health Perspectives on Suicide Prevention: An Integrated Approach van der Wal, 2005). The association between bullying, depression, and suicide ideation and attempts appears especially strong for females (Kim et al., 2009, 2007, 2008, 2009). The relationship between bullying behavior and suicide has also been found in research on cyberbullying (Hinduja & Patchin, 2010; Klomek et al., 2007). Hinduja and Patchin (2010) caution that cyberbullying alone may not directly lead to youth suicide, but rather may serve to exacerbate the daily pressures, stresses, and general hopelessness experienced by many children. While the general consensus is that a relationship between bullying, depression, and suicide ideation and attempts exists, additional research is needed to better understand the other variables that may weaken or strengthen this association. Advocates for Children, Inc. 2005. In harm s way: A survey oflesbian, gay, bisexual, and transgender students who speak about harassment and discrimination in New York City schools. New York: Advocates for Children, Inc. Arseneault, L., Bowes, L., & Shakoor, S.(2010). Bullying Victimization in Youths and Mental Health Problems: Much Ado About Nothing? Psychological Medicine, 40 (5),717-729. Arseneault, L., Walsh, E., Trzesniewski, K., Newcombe, R., Caspi, A., & Moffitt, T. E. (2006). Bullying Victimization Uniquely Contributes to Adjustment Problems in Young Children: A Nationally Representative Cohort Study. Pediatrics, 118 (1),130 138. Austin, S.& Stephen J. "Assessment of bully/victim problems in 8 to 11 year olds." British Journal of Educational Psychology 66.4 (1996): 447-456. Baldry, A. C. (2004). The Impact of Direct and Indirect Bullying on the Mental and Physical Health of Italian Youngsters. Aggressive Behavior, 30 (5), 343-355. Baldry, A. C. &Farrington, D. P. (2000). Bullies and Delinquents: Personal Characteristics and Parental Styles. Journal of Community and Applied Social Psychology, 10 (1), 17-31. Bauer, N. S., Lozano, P., & Rivara, F. P. (2007). The Effectiveness of the Olweus Bullying Prevention Program in Public Middle Schools: A Controlled Trial. Journal of Adolescent Health, 40 (3), 266-274. Beautrais, A. L., Joyce, P. R., &Mulder, R. T. (1998). Psychiatric Illness in a New Zealand Sample of Young People Making Serious Suicide Attempts. New Zealand Medical Journal, 111 (1060), 44 48. Balázs, J., Benazzi, F., Rihmer, Z., Rihmer, A., Akiskal, K. K., &Akiskal, H. S. (2006). The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention. Journal of affective disorders, 91(2), 133-138. Birkett, M., Espelage, D. L., & Koenig, B.(2009). LGB and Questioning Students in Schools: The Moderating Effects of Homophobic Bullying and School Climate on Negative Outcomes. Journal of Youth and Adolescence, 38 (7), 989-1000. 76
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